Rationale / arguments for adjuvant treatment (cf. neoadjuvant):
- Avoids over-treatment of those who don’t need chemo – i.e., pathology of cystectomy allows better selection
- Avoids treating those with chemo-resistant tumours
- Allows expedient cystectomy
Trade-off is that many patients have prolonged recovery from cystectomy and therefore may be a delay or unable to tolerate chemotherapy.
High level evidence is difficult with problems recruiting and meeting end points – all RCTs have been underpowered and some use ancient chemotherapy regimes.
Retrospective analyses has shown a trend for overall survival and PFS benefits with adjuvant chemo in high risk groups.
EAU “from the currently available evidence it is still unclear whether immediate adjuvant chemo or chemo at time of relapse is superior”.
- Recommends offering adjuvant cisplatin based chemo for pT3/4 or pN+ (as does AUA).
Same regime and issues as neoadjuvant (although no evidence ddMVAC vs gem-cis).