Tumor downstaging in muscle invasive bladder cancer with neoadjuvant systemic therapy—does it lead to prolonged survival?

It has been firmly established that cisplatin-based chemotherapy in the neoadjuvant setting prior to radical cystectomy improves overall survival in patients with muscle invasive bladder cancer (1). This study demonstrates and argues that improvement in overall survival with neoadjuvant chemotherapy (NACT) is not only related to a complete clinical response (pT0N0), but also to any pathologic downstaging, whether complete or a partial response from the initial clinical stage at diagnosis (2). Both the Retrospective International Study of Cancer of the Urothelial Tract (RISC) and National Cancer Database (NCDB) were queried in this study to identify a cohort of patients that had complete pathologic response or downstaging with NACT. Multivariable Cox proportional hazard models were used to demonstrate the effect of downstaging and complete pathologic response on overall survival in the data set. The analysis ultimately found that any pathologic response is associated with improved overall survival, but a couple caveats should be noted.