Refining the use of neoadjuvant chemotherapy in locally advanced bladder cancer: from conviction to optimization

Radical cystectomy (RC) remains the standard of care as local treatment of muscle-invasive bladder cancer (MIBC). However, the cancer-specific survival is approximately 50%, depending on the presence of extravesical extension and lymph node metastases. In other words, nearly 50% of patients develop metastases within 2 years after RC, implying the presence of micro-metastases at the time of surgery. Neoadjuvant chemotherapy (NAC) has been shown to improve survival of patients and international guidelines recommend NAC based on the available level I evidence (1,2).