Editorial Comment

Abstract

In this issue of Urology, we are provided with provocative additional evidence that should further inform the discussion regarding use of perioperative chemotherapy for muscle-invasive urothelial cancer. Despite level I evidence demonstrating a survival benefit for patients who receive cisplatin-based neoadjuvant chemotherapy compared with those who do not, 1 Grossman H.B. et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003; 349: 859-866 Crossref PubMed Scopus (1958) Google Scholar it is believed that adoption of the use of neoadjuvant chemotherapy, in widespread practice, has been limited. 2 Donat S.M. Integrating perioperative chemotherapy into the treatment of muscle-invasive bladder cancer: strategy versus reality. J Natl Compr Cancer Netw. 2009; 7: 40-47 PubMed Google Scholar , 3 David K.A. et al. Low incidence of perioperative chemotherapy for stage III bladder cancer 1998-2003: a report from the national cancer database. J Urol. 2007; 178: 451-454 Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar Multiple factors, reflecting perhaps a hesitance by both patients and surgeons, have been cited as reasons for omission of neoadjuvant chemotherapy. 4 Black P. So A. Perioperative chemotherapy for muscle-invasive bladder cancer. Cancer Urol Assoc J. 2009; 3: S223-S227 PubMed Google Scholar The current article provides a characterization of the most objectively measurable limitation to neoadjuvant cisplatin-based chemotherapy: unfitness of the patient because of poor baseline renal function. The authors found that, in a consecutive cohort of 194 patients, up to 40% would be deemed inappropriate for cisplatin-based therapy using either of the most widely used cutoffs (creatinine clearance <60 mL/min or glomerular filtration rate (GFR) <60 mL/min/1.73 m2). 5 Raj G.V. et al. Formulas calculating creatinine clearance are inadequate for determining eligibility for cisplatin-based chemotherapy in bladder cancer. J Clin Oncol. 2006; 24: 3095-3100 Crossref PubMed Scopus (61) Google Scholar , 6 Dash A. et al. Impact of renal impairment on eligibility for adjuvant cisplatin-based chemotherapy in patients with urothelial carcinoma of the bladder. Cancer. 2006; 107: 506-513 Crossref PubMed Scopus (289) Google Scholar Notably, the authors also found that, in most patients, renal function did not decline after cystectomy and, in some patients, especially those younger than 65 years, it may even improve. This conclusion is supported by similar evidence from Dash et al. in an even larger series of patients. 6 Dash A. et al. Impact of renal impairment on eligibility for adjuvant cisplatin-based chemotherapy in patients with urothelial carcinoma of the bladder. Cancer. 2006; 107: 506-513 Crossref PubMed Scopus (289) Google Scholar Baseline Renal Function Status Limits Patient Eligibility to Receive Perioperative Chemotherapy for Invasive Bladder Cancer and Is Minimally Affected by Radical CystectomyUrologyVol. 77Issue 1PreviewTo evaluate the proportion of patients with muscle-invasive urothelial carcinoma (UC) who would be eligible to receive cisplatin-based chemotherapy before and after radical cystectomy based on renal function. Full-Text PDF