Aim: This study provides a critical literature review on state-of-the-art and novel strategies
in the field of neoadjuvant treatments for muscle-invasive bladder cancer (MIBC). Methods: A nonsystematic
literature review was performed using PubMed, Scopus and Clinical Trials.gov to retrieve
papers related to neoadjuvant treatments for MIBC over the past 15 years. Prospective and retrospective
studies were included.
Results: Platinum-based treatment is the gold standard and mainly consists of a combination of cisplatin
with vinblastine, methotrexate, doxorubicin, gemcitabine, adriamycin or even epirubicin. The 5-
year absolute overall survival benefit of MVAC is 5% and the absolute disease-free survival improves
by 9%. CMV treatment is associated with a 10-year overall survival improving from 30% to 36% and
a 16% reduction in mortality. Gemcitabine and cisplatin regimen provides complete response in 20%
of cases, with non-inferior oncological outcomes compared to MVAC regimen. Recent prospective trials
investigating neoadjuvant immunotherapy show a high rate of complete response, from 29% with
atezolizumab to 39.5% with pembrolizumab. The tyrosine kinase inhibitor pathway is being explored
and could offer an interesting strategy to improve survival outcomes.
Conclusion: Available evidence suggests better oncological outcomes for MIBC patients receiving
neoadjuvant treatment before radical cystectomy. While MVAC remains the standard of care in cisplatin
eligible patients, novel strategies are under development for cisplatin-ineligible patients, whereby
immunotherapy seems to hold great promise.