Background historical views of systemic treatment for muscle invasive bladder cancer.

OBJECTIVES Bladder cancer is a frequent, chemosensitive disease and has shown good outcomes on several chemotherapy regimens over last 60 years. However, very little improvement has been shown in terms of overall survival and side-effects decrease. EVIDENCE ACQUISITION A review on manuscripts published in English and Spanish from 1949 including the terms chemotherapy and bladder cancer has been performed. EVIDENCE SYNTHESIS Locally advanced or metastatic bladder cancer chemotherapy was initially introduced for metastasis management. The utilization of cisplatin base regimens has shown superiority over single therapy. The most commonly used regimens are cisplatine-metotrexate-vinblastine, metotrexate-vinblatine-adriamicine-cisplatin y gemcitabine-cisplatin. Neoadjuvant chemotherapy has shown to provide a minimal overall survival advantage, based on level 1 evidence. Neoadjuvant chemotherapy utilizes the same cisplatin-based regimens. Neoadjuvant chemotherapy is underutilized due to the inability to identify non-responders. Adjuvant chemotherapy is more controversial due to the lack of strong evidence. It is used when neoadjuvant chemotherapy has been utilized and the cystectomy pathology report is locally advanced. The best outcomes are for low-volume node positive patients.In bladder preservation protocols (aiming to decreased morbidity associated with cystectomy and chemotherapy), several regimens have been utilized in combination with radiation therapy. No standardized treatmentis available as no comparisons with cystectomy have been done. CONCLUSION Chemotherapy has been utilized for several decades in muscle invasive bladder cancer without any major survival improvements or decreaseon side-effects. That is the rational why the treatment regimen are widely different amongst groups without a standard treatment.