Chemotherapy for Metastatic Disease

Bladder cancer occurs with a relatively high incidence in industrial nations. For example, bladder cancer is the fourth most common type of cancer in American men. The estimated U.S. incidence in 2008 was 68,810 cases and the mortality was 14,100 cases (Jemal et al., 2008). Of newly diagnosed bladder cancer cases, approximately 70% 80% will present with non muscle-invasive disease. Among such cases, 50% 70% will recur, and 10% 30% will progress to muscle-invasive disease (Soloway et al., 2002; Saad et al., 2002). Radical cystectomy with or without chemotherapy is the standard therapy for muscle-invasive disease; however, some patients will experience metastatic relapse after radical surgery. A few patients present with metastatic disease upon their initial presentation at the hospital. Such advanced bladder cancer remains an incurable terminal disease, and accounts for 3% of the cancer-related mortality in the United States. Deaths from bladder cancer are mainly related to distant spread; hence, prevention of metastatic disease remains a crucial goal in this disease. Systemic chemotherapy achieves palliation, survival benefit, and occasional long-term remissions. For the last two decades, cisplatin-based combination therapies have evolved as the standard. The MVAC regimen (Sternberg et al., 1988) was reported to demonstrate an impressive complete remission rate of 37% in advanced urothelial carcinoma (UC), and in a subsequent comparative study was found to be superior to the single agent cisplatin (Saxman et al., 1997). In this chapter, we review the recent progress in chemotherapeutic regimens not only for advanced bladder cancer, but also for advanced UC in the upper urinary tract. We also show current data on the efficacy of combination therapy with gemcitabine and platinum anti-cancer drugs, which is mainly used as a second-line treatment in our institution.