radical cystectomy ( rc ) is the standard surgical treatment for clinically localized muscle - invasive bladder cancer ( mibc ) .
however , nearly 50% of patients with mibc develop metastases and die of bc . such a high failure rate
there are several factors to consider while offering perioperative chemotherapy to a patient undergoing rc .
the advantages and disadvantages of neoadjuvant chemotherapy ( nac ) and adjuvant chemotherapy ( ac ) are discussed in table 1 .
neoadjuvant versus adjuvant chemotherapy for bladder cancer : advantages and disadvantages after a decision is made to administer chemotherapy , to achieve maximum benefit the planned regimen should be initiated and the planned number of cycles must be completed at an optimal dosage . however , due to various reasons chemotherapy is often not initiated or it is initiated but not completed . the aim of our study is to evaluate and compare the likelihood of initiating and completing neoadjuvant and adjuvant chemotherapy in patients with mibc .
upon obtaining an institutional review board approval , we performed a retrospective analysis of patients who underwent rc and urinary diversion ( ud ) by a single surgical team between 1992 and 2011 .
data on whether nac or ac was recommended , initiated , discontinued , or completed was obtained and analyzed . prior to 2004 ,
nac was recommended for patients with clinical stage t3 or higher stage , hydronephrosis , extensive lymphovascular invasion ( lvi ) , or prostatic stromal invasion . since 2004 ,
the typical chemotherapy regimens were gemcitabine plus cisplatin or methotrexate , vinblastine , doxorubicin , and cisplatin ( mvac ) . on occasions
, carboplatin was substituted for cisplatin at the discretion of the oncologist . at any given instance ,
both ac and nac were not recommended to patients who were unlikely to tolerate chemotherapy due to renal impairment or other debilitating morbidities .
a total of 363 patients underwent rc and ud and were considered for perioperative chemotherapy141 for nac and 222 for ac .
the mean age was 66 years in nac group and 67.5 years in ac group ( p = 0.13 ) . of these patients , 79% were men and 21% were women .
completion of chemotherapy was defined as receiving the planned number of cycles predetermined by the medical oncologist . among
further , 98 patients ( 78.4% ) completed at least 3 cycles , 20 ( 16% ) completed 2 cycles as planned , and 7 ( 5.6% ) did not complete the planned number of cycles .
from the 222 patients recommended to receive ac , 151 ( 68.0% ) initiated the treatment . of patients who initiated ac , 79 ( 52.7% ) completed at least 4 cycles and 72 ( 47.3% )
overall , only 79 ( 35.5% ) of patients who are candidates for ac received the prescribed number of cycles , while 118 ( 83.5% ) of nac candidates received the planned number of cycles .
patients who were offered nac were more likely to initiate ( p < 0.001 ) and complete ( p < 0.001 ) chemotherapy [ figure 1 ] .
the reason for not initiating nac was patient preference , while for ac the reasons were either patient preference or presence of medical condition or surgical complication interfering with chemotherapy initiation .
the reasons for discontinuing nac or ac were patient preference , chemotherapy intolerability , or development of complications [ table 2 ] .
initiation and completion rates for nac vs ac reasons for not initiating / completing the chemotherapy
there are several difficulties in administering chemotherapy in the adjuvant setting . the typical patient undergoing
rc is in his / her sixth or seventh decade of life and has significant associated comorbidities .
moreover , rc and ud are associated with complications in approximately 30% of patients . in a study by donat et al .
, 83% of patients who experienced complications following rc and ud had significant complications ( grade 2 - 5 , modified clavien system ) , which prevented or delayed the use of adjuvant chemotherapy .
the psychological impact of a major surgery may further impede adjuvant therapy , and thus fewer patients receive ac . our study shows that 32% of the patients who were recommended to receive ac rejected the treatment and elected to be monitored instead .
patients who undergo a curative treatment for mibc in the form of rc might be more reluctant to receive additional treatment .
the associated morbidity brought by such a major surgery alone would interfere with the initiation of ac . on the other hand ,
patients who were offered nac were more willing to initiate treatment to improve their chance for a cure as well as survival ( 88.6% ) .
furthermore , among patients who initiated perioperative chemotherapy , nac patients were more likely to complete the number of planned cycles ( 94.4% ) , while only 52.7% completed the ac treatment .
currently , nac followed by rc is an established approach for mibc . supported by several randomized trials ,
nac is associated with a survival benefit of 6.5% and a lower risk of bc - specific mortality . on the other hand ,
our study shows that patients are more likely to accept and complete nac , and this further supports the administration of nac for mibc .
chemotherapy protocols were not the same throughout the study period as novel chemotherapy regimens with less toxicity became available .
however , the protocols offered were the same in the nac and ac setting at a specific time .
this study is limited to the likelihood of initiation and completion of nac and ac .
patients with mibc are more likely to initiate and complete the planned number of cycles of neoadjuvant chemotherapy as compared to adjuvant chemotherapy . therefore , we advocate administration of chemotherapy in the neoadjuvant setting in patients who are likely to benefit from chemotherapy .
 introduction : chemotherapy was shown to improve survival in patients undergoing radical cystectomy ( rc ) for muscle - invasive bladder cancer ( mibc ) . the initiation and completion rates for perioperative chemotherapy are variable . 
 our aim is to compare the likelihood of initiating and completing neoadjuvant ( nac ) and adjuvant chemotherapy ( ac ) in patients who underwent of rc for mibc.materials and methods : we performed a retrospective analysis of patients who underwent rc between 1992 and 2011 . 
 nac was advised for patients with clinical stage t2 , hydronephrosis , extensive lymphovascular invasion ( lvi ) , or prostatic stromal invasion . 
 patients with pt3 or lymph node metastases were considered for ac.results:a total of 363 patients were considered for perioperative chemotherapy . among 
 the 141 patients who were offered nac , 125 ( 88.6% ) initiated nac . 
 a total of 222 were considered for ac , and 151 ( 68.0% ) initiated ac ( p < 0.001 ) . in the nac group , 118 ( 83.5% ) 
 completed planned number of cycles of chemotherapy and 7 ( 5.6% ) did not complete the planned chemotherapy . in the ac group , 79 ( 35.5% ) completed at least four cycles and 72 ( 47.3% ) could not complete the planned cycles ( p < 0.001).conclusions : patients with mibc are more likely to initiate and complete nac than ac . 