Impact of suboptimal neoadjuvant chemotherapy on peri‐operative outcomes and survival after robot‐assisted radical cystectomy: a multicentre multinational study

Objectives To evaluate the effect of suboptimal dosing on the outcomes of patients who received neoadjuvant chemotherapy (NAC) and robot-assisted radical cystectomy (RARC). Patients and Methods We retrospectively reviewed 336 consecutive patients with urothelial carcinoma of the bladder who were treated with NAC and RARC at three academic institutions. Outcomes were compared between 3 groups: patients who received optimal NAC; patients who received suboptimal NAC; and those who did not receive NAC. To adjust for potential baseline differences between the three groups, propensity-score-based matching was performed. The suboptimal dose group was defined as those who received fewer than three cycles of cisplatin-based chemotherapy, received decreased dosage, or one's not treated with cisplatin. Primary outcomes analyzed were recurrence-free survival (RFS) and overall survival (OS). Secondary outcomes were perioperative complications and readmissions after RARC. Results Within the cohort after propensity-score matching, 69 patients received optimal dose NAC, 41 received suboptimal NAC and 69 did not receive NAC. Complication rates and readmission rates between the 3 groups did not differ significantly. On multivariable analysis, suboptimal dosing and no NAC were independent predictors of worse RFS (HR: 2.5, 95%CI: 1.2-5.7, p=0.01 and HR 2.4, 95%CI 1.28-5.16, p=0.01) and worse OS (HR 4.5, 95%CI 1.6-15.0, p<0.01 and HR 4.9, 95%CI 1.9-15.6, p<0.01) in patients who received NAC and RARC. Failure to achieve pathological complete response (ypT0N0) was also an independent predictor of worse RFS (HR 6.6, 95%CI 1.3-20.9, p=0.02) and OS (HR 4.9, 95%CI: 1.8-15.3, p=0.02). Conclusion Optimal NAC resulted in a better RFS and OS when compared to suboptimal or no NAC. Suboptimal and no NAC were associated with worse OS and RFS. These findings will allow for improved patient counseling and treatment selection. This article is protected by copyright. All rights reserved.