Timing of treatment for muscle-invasive bladder cancer in the neo-adjuvant chemotherapy era

Muscle-invasive bladder cancer (MIBC) is a potentially lethal disease and radical cystectomy (RC) remains the gold standard for its treatment. Neoadjuvant chemotherapy (NAC) followed by RC can improve OS and is currently approved by international guidelines. In the setting of patients undergoing primary RC, several studies have shown that a delay from the time of diagnosis to surgery greater than 3 months could negatively impact oncological outcomes. It remains to be determined how timing impact patients undergoing NAC. Time to initiation of NAC represents an important time course which is poorly reported; two studies investigating it failed to demonstrate an association between delay of NAC and prognosis. After the completion of chemotherapy, there is no clear indication on how much recovery time is needed before performing surgery and how much delay is acceptable without affecting oncological outcomes. Single-center experiences suggest that surgery could be safely delayed up to approximately 10 weeks or that earlier RC does not affect perioperative morbidity. However, these results could not be reproduced by population-based studies.