Background: NAC improves survival in pts with MIBC eligible to receive cisplatin-based chemotherapy. Prospective data supports the use of aMVAC, however concerns about toxicity limits usage compared to gemcitabine and cisplatin, especially in the elderly. We investigated the safety and efficacy of aMVAC as a function of age. Methods: We conducted a retrospective analysis of pts with MIBC at Fox Chase Cancer Center who received NAC with aMVAC from 2008-2017. Pts were excluded for non-urothelial histology, non-muscle-invasive or primary upper tract disease, or if final pathology was not available. Clinicopathologic variables were extracted from charts and pts were grouped into 3 cohorts by age ( < 65, 65-74, ≥75). Associations between age group (gp) and categorical/continuous factors were evaluated using Fisher’s exact/Wilcoxon rank sum tests. Results: A total of 90 pts ( < 65: 40; 65-74: 28; ≥75: 22) were evaluable for safety and 84 for efficacy. The majority of pts were male (72%), PS 0 ( < 65: 85%; 65-74: 85%; ≥75: 68%) and Caucasian (90%). Baseline clinical staging was cT2 in 50%, cT3 in 27% and > cT3 in 14%, with 9% lacking clinical staging. Mean number of aMVAC cycles delivered was numerically similar between age gps, though statistically different (3.1 v 2.8 v 2.6; p = 0.01). There were no statistically significant differences in dose reductions, treatment interruptions, or time to surgery (10.7 v 10.7 v 10.1 wks, p = 0.91) by age. Grade ≥3 AEs were most frequent in the youngest age gp (14.4% v 2.2% v 8.9%, p = 0.018). Split-dose cisplatin was increasingly used in advanced age (2.5% v 17.9% v 31.8%, p = 0.003). Although glomerular filtration rate (GFR) at baseline inversely correlated with age (105 v 93 v 63 ml/min, p < 0.0001), there was no difference in % GFR decline at 90 days or 1 year. The downstaging rate to < pT2N0 disease was similar in all age gps (41.0% v 29.6% v 38.9%; p = 0.41). At median follow-up of 20 months, recurrence rates were 30.0% v 25.9% v 28.6% (p = 0.95). Conclusions: NAC with aMVAC yields similar safety and efficacy outcomes regardless of age, thus age should not be a factor in determining treatment eligibility.