Comment on “The role of adjuvant chemotherapy after radical surgery in patients with lymph node-positive bladder cancer or locally advanced (pT3, pT4a) bladder cancer: a meta-analysis and systematic review”

Dear Editor, In 2022, approximately 600 000 new cases of bladder cancer were diagnosed worldwide, making it the ninth most prevalent cancer globally[1,2]. In 2024, the United States recorded approximately 84 870 cases of bladder cancer. The cancer might manifest as advanced-stage or aggressive disease or as recurrent noninvasive tumors. For individuals with diseases that can be cured, surgical excision is the only recognized treatment option. Recurrence rates are still significant, nevertheless, especially in cases of positive surgical margins or lymph node involvement. The necessity of adjuvant therapy even following radical operation is shown by the high recurrence rate[3,4]. Chen et al.[5] carried out a meta-analysis of 21 trials to identify the role of adjuvant chemotherapy following radical surgery in individuals with locally advanced bladder cancer or lymph node-positive bladder cancer. There were 12 888 patients in all. This meta-analysis demonstrated that postoperative adjuvant chemotherapy improves cancer-specific survival, recurrence-free survival, as well as overall survival in individuals with locally advanced bladder cancer. Additionally, it was established that individuals with bladder cancer benefited more from a chemotherapy treatment based on cisplatin. Delaying treatment for chemotherapy-resistant patients carries drawbacks, even though neoadjuvant chemotherapy enables early treatment initiation and aids in assessing in vivo chemotherapy sensitivity. Thus, the majority of professionals continue to choose postoperative chemotherapy as their course of treatment. For patients who have lymph nodes-positive, the most recent European Association of Urology guidelines from 2023 strongly advise administering platinum-based adjuvant combination chemotherapy. The period from the start of surgery to disease recurrence or death caused by disease progression is referred to as recurrence-free survival. At the moment, decreased survival rates and increased rates of postoperative progression are linked to lymph node metastases. In order to lower surgical metastasis rates and increase patient disease-free survival rates, it is crucial to determine which patients should get more aggressive postoperative adjuvant chemotherapy. Lymph node positivity (LND) is a novel method for classifying pelvic lymph node-positive patients, which is computed as the ratio of positive lymph nodes to the total number of resected lymph nodes. According to reports, LND is a valuable predictive tool because it captures the severity of nodal clearance and the disease load of nodal disease following radical cystectomy. Furthermore, LND is better in predicting post-radical cystectomy survival rates than TNM lymph node staging. In line with other studies, pathological N stage was unable to predict prognosis, but LND emerged as an independent predictor of total mortality. There are several limitations on this study: (1) there is no consistent postoperative chemotherapy throughout the included research; (2) a meta-analysis was not feasible because the number of lymph node metastases in the current studies was defined differently; (3) there was only one randomized controlled trial, which may have introduced potential bias; and (4) the follow-up periods were relatively short, leading to an underestimation of mortality rates. This letter was conducted according to Transparency in the reporting of Artificial Intelligence-the TITAN guideline[6].