Cisplatin-Based Neoadjuvant Chemotherapy for Elderly Patients with Muscle-Invasive Bladder Cancer: Is It Feasible?

Cisplatin-based neoadjuvant chemotherapy (C-NAC) has been the standard of care in localized muscle-invasive bladder cancer (MIBC). However, the feasibility and benefit of C-NAC in elderly patients remain uncertain since this population has always been underrepresented in pivotal trials and is often barred from chemotherapy in routine practice because of their perceived frailty. Therefore, in order to evaluate the effectiveness of C-NAC in elderly patients with MIBS, we retrospectively reviewed the medical files of patients (cT2-4, N0-3, and M0) treated at our institution and aged 75 or older at the time of the first chemotherapy cycle. From May 2012 to March 2020, 51 patients aged 75 to 90 received C-NAC. Among them, 38 patients received methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) and 13 patients received gemcitabine and cisplatin (GC). In this study, the primary endpoint was the feasibility of C-NAC, evaluated as the percentage of patients who underwent at least four chemotherapy cycles. Overall feasibility of a complete four-cycle chemotherapy course was 75% (dose-dense MVAC [dd-MVAC]: 76%; GC: 69%). Incidence of grade 3-4 adverse events was 57%, mostly driven by hematological toxicity from dd-MVAC, and the incidence of febrile neutropenia was 6%. These results indicate the feasibility of C-NAC in elderly patients without any contraindication to cisplatin. A coordinated multidisciplinary approach, including a geriatric oncologist, may help to identify patients at increased risk for chemotherapy-induced toxicity, especially in patients aged 85 or older.