Comparative efficacy of adjuvant chemotherapy and immunotherapy after radical surgery for upper tract urothelial carcinoma: A systematic review and meta-analysis.

Abstract

To evaluate the effects of adjuvant chemotherapy (AC) and adjuvant immunotherapy (AI) on the prognosis of patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU). A systematic review and meta-analysis was conducted using studies identified from PubMed, Cochrane Library, Embase, CENTRAL, and ClinicalTrials.gov up to September 2024. We performed pair-wise and network meta-analyses to evaluate survival outcomes, focusing on overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), recurrence-free survival, and metastasis-free survival. A total of 43 studies involving 13,132 patients were included. Pair-wise meta-analysis showed that AC significantly improved OS (HR 0.74, 95% CI 0.63-0.86, P = 0.0001), CSS (HR 0.74, 95% CI 0.60-0.90, P < 0.00001), and DFS (HR 0.61, 95% CI 0.51-0.75, P < 0.00001). A pooled analysis of three RCTs with 384 UTUC patients showed that AI did not significantly improve DFS (HR 1.19, 95% CI 0.87-1.64, P = 0.28) or OS (HR 1.28, 95% CI 0.81-2.03). Network meta-analysis suggested that combining AC with AI could offer better DFS than AC alone, with AC outperforming AI. Ranking analysis indicated that MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) was the most effective for OS and CSS improvement, followed by GC (gemcitabine and cisplatin). AC improves the prognosis of UTUC patients, whereas the results with AI are less promising. AC shows better outcomes than AI after RNU. Preliminary evidence suggests that combining AC with AI may enhance DFS, but further research is needed to confirm its effectiveness.