Advances in Urology

For years patients with high-grade non-muscle invasive bladder cancer have received intravesical Bacillus Calmette-Guerin (BCG) as the treatment of choice. Some patients may undergo additional rounds of BCG if their cancer recurs. However, patients are considered BCG unresponsive if they present with persistent T1 disease after a single course of BCG, have a recurrence within six months of receiving BCG, or have a recurrent carcinoma in situ within 12 months of BCG treatment. For these individuals, further treatment with BCG is not advised, leaving them at high risk of disease progression and metastasis.

Radical cystectomy, an approach that offers a high rate of cure when performed early in the disease, has been the gold-standard treatment for these patients. Nevertheless, radical cystectomy brings with it short- and long-term risks. Due to the significant morbidity associated with this surgery, some patients are either ineligible or prefer to seek a bladder-sparing approach. Cancer specialists in the Department of Urology at NewYork-Presbyterian/Columbia University Irving Medical Center led by James M. McKiernan, MD, Urologist-in-Chief, are exploring options for this patient population that extend their survival while minimizing the adverse effects of radical treatment.

Dr. Christopher Anderson

While bladder preservation using salvage intravesical therapy (IVT) has been widely studied, few patients experience durable disease control with currently available agents. Research has shown that 10 to 50 percent of patients treated with salvage IVT will eventually require a radical cystectomy, and that patients with BCG unresponsive non-muscle invasive bladder cancer who have an immediate radical cystectomy have a higher cure rate compared to those who progress to muscle-invasive bladder cancer and require a delayed radical cystectomy. Patients with BCG unresponsive bladder cancer have a difficult choice between a radical cystectomy or bladder preservation with salvage IVT and there is little research to inform this decision. Christopher B. Anderson, MD, MPH, a urologic oncologist in the Department of Urology at NewYork-Presbyterian/Columbia, performed a study of IVT following induction of BCG to determine if this approach reduced survival compared to immediate radical cystectomy.

Dr. Anderson and his colleagues conducted a retrospective cohort study using the SEER-Medicare dataset, identifying 3,940 patients aged 65 and older who were diagnosed with urothelial carcinoma of the bladder (stages Ta, T1, and Tis) from 2000 to 2015. All patients were treated with induction BCG within six months of their bladder cancer diagnosis. They observed that among patients who required additional cancer treatments after induction BCG, 21 percent of patients had an immediate radical cystectomy and 79 percent had IVT.

Ultimately, they reported that among patients requiring additional cancer treatments within 12 months of BCG, there was no significant difference in survival between radical cystectomy and IVT, and 17 percent of patients having early IVT ultimately required radical cystectomy. Their results were published in the July 11, 2022, issue of Clinical Genitourinary Cancer.

The Columbia researchers concluded, “While upfront radical cystectomy remains the gold-standard treatment for high-risk recurrent non-muscle invasive bladder cancer after induction BCG, salvage intravesical therapy and bladder preservation may be appropriate for well-selected patients.”