Combination Chemotherapy in Treating Patients With Bladder Cancer

OBJECTIVES: I. Compare the recurrence rates and overall survival of patients treated with
postoperative adjuvant methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) to those
treated with combination paclitaxel and carboplatin for muscle invasive bladder cancer at
particularly high risk of relapse. II. Compare the relative toxicities of postoperative M-VAC
versus those encountered with postoperative paclitaxel and carboplatin. III. Compare the
quality of life scores during and following completion of treatment of patients in these two
treatment arms.

OUTLINE: This is a randomized study. Patients are stratified by N stage (N0 vs N+) and
performance status (0-1 vs 2). Patients are randomized to receive methotrexate, vinblastine,
doxorubicin, and cisplatin (arm I) or paclitaxel and carboplatin (arm II). Arm I: Patients
receive methotrexate IV push on days 1, 15, and 22; vinblastine IV push on days 2, 15, and
22; doxorubicin IV push on day 2; and cisplatin IV over 2 hours on day 2. Treatment repeats
every 28 days for 4 courses. Arm II: Patients receive paclitaxel IV over 3 hours on days 1
followed by carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for 4
courses. Quality of life assessments are completed pretreatment, prior to course 3, 6 weeks
after the last dose of chemotherapy, and at 6, 12, and 24 months from the end of therapy.
Patients are followed every 3 months until year 2, every 6 months for years 2-5, and then
annually thereafter.

PROJECTED ACCRUAL: There will be 490 patients accrued into this study within 2.6 years.

DISEASE CHARACTERISTICS: Histologically confirmed transitional cell carcinoma of the
bladder or mixed histologies containing a component of transitional cell carcinoma Must
have undergone radical cystectomy and pelvic lymph node dissection within 12 weeks prior to
randomization No evidence of distant metastatic disease on pre- or postoperative
radiographic scans No positive surgical margins in the cystectomy specimen and no known
macroscopic residual disease left at time of cystectomy No bladder sparing surgery May have
undergone continent urinary diversion or neobladder procedure but must have recovered
completely from the effects of surgery Must have muscle-invasive disease on final
pathologic staging and have a primary tumor stage of pT4, any N, M0, or any pT, N+, M0, or
pT3b, any N, any M, and following a pelvic lymph node dissection have a pathologic nodal
stage of pN0 (only if pT3b or pT4), pN1, or pN2 Clinically unsuspected organ confined
prostate cancer found during cystoprostatectomy allowed

PATIENT CHARACTERISTICS: Age: Any age Performance status: ECOG 0-2 Life expectancy: Not
specified Hematopoietic: WBC at least 3,500/mm3 Platelet count at least 100,000/mm3
Hepatic: Bilirubin no greater than 1.5 times upper limit of normal (ULN) SGOT no greater
than 2 times ULN Renal: Creatinine no greater than 1.7 mg/dL OR Creatinine clearance at
least 60 mL/min Cardiovascular: No second degree atrioventricular block or bundle branch
block Other: No history of prior malignancy in the past 5 years except basal or squamous
cell carcinoma of the skin or carcinoma in situ of the cervix No active infection requiring
antibiotics No history of allergic reaction to drugs utilizing the vehicle Cremophor Not
pregnant or nursing Fertile patients must use effective contraception

PRIOR CONCURRENT THERAPY: Recovered from all prior therapies Biologic therapy: No prior
biologic response modifier therapy No filgrastim (G-CSF) 24 hours pre- or post-chemotherapy
administration Chemotherapy: No prior systemic chemotherapy Endocrine therapy: Not
specified Radiotherapy: No prior radiotherapy as a component of bladder sparing therapy No
prior adjuvant radiotherapy for locally advanced disease with positive margins Surgery: See
Disease Characteristics Other: Prior intravesical therapy for superficial bladder cancer
allowed and recovered