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What Is the Ideal Number of Neoadjuvant Chemotherapy Cycles for Muscle-Invasive Bladder Cancer?

By: Julia Fiederlein
Posted: Thursday, January 27, 2022

According to Hiten D. Patel, MD, MPH, of Loyola University Medical Center, Maywood, Illinois, and colleagues, in patients with muscle-invasive bladder cancer, the ideal number of neoadjuvant chemotherapy cycles is uncertain; however, three or four cycles is considered the standard of care. The results of this retrospective cohort study, which were published in The Journal of Urology, demonstrated that patients treated with three cycles of neoadjuvant chemotherapy experienced similar pathologic response and short-term survival rates compared with those treated with four cycles.

“Patients initially planned to receive four cycles who stop after three cycles due to significant toxicity can be reassured that they maintain a similar level of benefit from neoadjuvant chemotherapy,” the investigators commented.

Patients with cT2–4 N0 M0 urothelial carcinoma were identified and received standard-of-care cisplatin-based neoadjuvant chemotherapy (four cycles: n = 157; three cycles: n = 114) or a non–standard-of-care neoadjuvant chemotherapy regimen (one or two cycles/non–cisplatin-based: n = 47) followed by radical cystectomy. The rate of ypT0 responses was 26.8% with four cycles, 33.3% with three cycles, and 12.8% with the non–standard of care (P = .03); a total of 54.8%, 62.3%, and 27.7% of patients, respectively, achieved a pathologic stage less than or equal to ypT1 (P < .01). Due to toxicities, pathologic responses seemed to occur more frequently with three cycles (ypT0: 37.7%; ≤ ypT1: 66.2%); however, this finding did not reach statistical significance.

Toxicities such as thrombocytopenia (32.1%), neutropenia (27.2%), renal insufficiency (22.2%), and constitutional symptoms (18.5%) led to treatment modifications in this study population. Kaplan-Meier survival probabilities seemed to be lower with the non–standard-of-care regimens (cT2–cT4 N0 M0: log-rank P = .07; cT2 N0 M0: log-rank P = .02). Patient survival outcomes did not seem to significantly differ after treatment with three or four cycles (hazard ratio = 1.00; P = .99).

Disclosure: For full disclosures of the study authors, visit

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