Neoadjuvant versus adjuvant chemotherapy for muscle-invasive bladder cancer: A propensity matched analysis

Background: We compared survival outcomes among patients who received either NAC or AC and RC. Methods: We identified patients in the National Cancer Data Base (NCDB) diagnosed with clinical T2-T4, N0, M0 urothelial carcinoma who underwent RC. Patients who received NAC were propensity matched by age, race, ethnicity, sex, insurance type, academic/research program, comorbidity, and clinical stage to patients receiving AC within 90 days of RC. Median survival was calculated using Kaplan-Meier analysis. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated from multivariable Cox regression models to compare overall survival (OS), downstaging to non-MIBC (NMIBC), and N upstaging. Results: A total of 417 patients treated with NAC and 272 patients treated with AC were identified from 2004-2013. Patients who received NAC had better 5-year OS (46.2%, 95% CI: 39.2-53.0%) compared to patients who received AC (37.6%, 95% CI: 31.5-43.7%). NAC was a significant predictor of decreased mortality, decreased progression to node positivity, and downstaging to NMIBC (0.76, 0.60-0.96, P=0.023; 0.19, 0.13-0.28, P<0.001; 23.96, 8.91-64.42, P<0.001). Conclusions: The use of NAC+RC was associated with improved OS compared to RC+AC for patients diagnosed with T2-T4, N0, M0 bladder cancer. The increased survival benefit associated with NAC compared to AC among patients undergoing RC may be due to decreased progression to node positivity and pathological downstaging.