The role of adjuvant chemotherapy after radical surgery in patients with lymph node-positive bladder cancer or locally advanced (pT3, pT4a) bladder cancer: a meta-analysis and systematic review.

Objective: This study aims to evaluate the impact of adjuvant chemotherapy (AC) on survival outcomes in patients with lymph node-positive bladder cancer or locally advanced (pT3, pT4a) bladder cancer after surgery. The authors also seek to identify which patients with pN+ bladder cancer are most likely to benefit from AC after radical cystectomy (RC).

Methods: The authors searched databases including Embase, PubMed, Cochrane, and ClinicalTrials.gov to identify relevant literature published in English up to February 2024. The authors used Stata to compare various parameters. The study has been registered in PROSPERO.

Results: A total of 21 studies were analyzed, including 1 randomized controlled trial, 6 prospective studies, and 14 retrospective studies, encompassing 12 888 patients. The meta-analysis showed that for patients with lymph node-positive bladder cancer, the AC group had higher overall survival (OS) [ I2 =58.2%, hazard ratio (HR) 0.69; 95% CI: 0.57-0.83; P =0.019] and recurrence-free survival ( I2 =66.6%, HR 0.71; 95% CI: 0.57-0.89; P =0.006) compared to the RC group. For patients with pT3 and pT4a bladder cancer, the AC group had higher OS ( I2 =57.3%, HR 0.77; 95% CI: 0.67-0.89; P =0.022) and cancer-specific survival ( I2 =47.2%, HR 0.75; 95% CI: 0.64-0.88; P =0.0048) compared to the RC group. At the same time, according to the different chemotherapy regimens, the authors divided the cisplatin-based chemotherapy regimen and carboplatin-based chemotherapy or other regimens into two subgroups for analysis, and found that the OS ( I2 =41.4%, HR 0.64; 95% CI: 0.51-0.80; P =0.000) was better than carboplatin and other chemotherapy regimens ( I2 =64.1%, HR 0.77; 95% CI: 069-0.86; P =0.000); lymph node density was found to be an independent predictor of OS (HR=1.6; 95% CI: 1.31-1.95; P =0.0000).

Conclusions: This study found that postoperative AC improves OS, cancer-specific survival, and recurrence-free survival in patients with pT3, pT4a. It was also confirmed that cisplatin-based chemotherapy regimen was more beneficial for patients with bladder cancer; and lymph node-positive bladder cancer. Additionally, our analysis revealed that patients with lymph node-positive bladder cancer benefit more from postoperative AC. It was further demonstrated that cisplatin-based chemotherapy regimens are more beneficial than other regimens for patients with locally advanced bladder cancer.