Should we spare neoadjuvant chemotherapy in low-risk muscle-invasive bladder cancer patients scheduled for radical cystectomy?

There is an ongoing debate whether every eligible patient suffering from muscle-invasive bladder cancer should undergo cisplatin-based neoadjuvant chemotherapy (NAC) before definitive treatment by radical cystectomy. Supporters of this approach refer to level 1 evidence given by high quality meta-analyses indicating a survival benefit of at least 5% improvement in 5-year overall survival by NAC (Table 1) (1-5). Given that most patients relapsing from bladder cancer will present with distant metastases rather than local recurrence (6,7), NAC is thought to tackle micrometastatic disease.