Neoadjuvant therapy in invasive bladder cancer. Problems and pitfalls.

It is clear that some transitional-cell tumors of the bladder will respond to combined therapy. However, in the absence of randomized controlled trials, the impact of repeated transurethral resections versus the effect of chemotherapy cannot be assessed adequately, and such trials are urgently needed before neoadjuvant therapy can be considered standard. In addition, newer chemotherapy agents or the combination of currently available drugs with the addition of hematopoietic growth factors such as granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor to reduce toxicity and permit dose intensification in an attempt to increase overall response rates offer fruitful avenues for clinical research. Although cisplatin-based chemotherapy obviously does not have the same impact on bladder cancer that it does on testicular cancer, the initial results are encouraging. The "wall" has been breached, and the demonstration that urothelial tumors can be added to the list of chemotherapeutically responsive tumors should encourage urologic, radiologic, and medical oncologists to combine efforts in randomized, controlled studies of integrated approaches to therapy.