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Gontero P, Birtle A, Capoun O, Compérat E, Dominguez-Escrig JL, Liedberg F, Mariappan P, Masson-Lecomte A, Mostafid HA, Pradere B, Rai BP, van Rhijn BWG, Seisen T, Shariat SF, Soria F, Soukup V, Wood R, Xylinas EN. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ)-A Summary of the 2024 Guidelines Update. Eur Urol 2024:S0302-2838(24)02514-4. [PMID: 39155194 DOI: 10.1016/j.eururo.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND OBJECTIVE This publication represents a summary of the updated 2024 European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ. The information presented herein is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation. METHODS For the 2024 guidelines on NMIBC, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS Key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with NMIBC. The guidelines stress the importance of defining patients' risk stratification and treating them appropriately. CONCLUSIONS AND CLINICAL IMPLICATIONS This overview of the 2024 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, prognostic factors, treatment, and follow-up of NMIBC. These guidelines are designed for effective integration into clinical practice.
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Affiliation(s)
- Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy.
| | - Alison Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Eva Compérat
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Fredrik Liedberg
- Institute of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Western General Hospital, The University of Edinburgh, Edinburgh, UK
| | | | - Hugh A Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Benjamin Pradere
- Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thomas Seisen
- Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University Vienna, Vienna, Austria
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Robert Wood
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Evanguelos N Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, Paris, France
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Llano A, Chan A, Kuk C, Kassouf W, Zlotta AR. Carcinoma In Situ (CIS): Is There a Difference in Efficacy between Various BCG Strains? A Comprehensive Review of the Literature. Cancers (Basel) 2024; 16:245. [PMID: 38254736 PMCID: PMC10813486 DOI: 10.3390/cancers16020245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Introduction: Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is the standard of care for high-risk and intermediate-risk non-muscle-invasive bladder cancer (NMIBC) as well as for Carcinoma in situ (CIS). Evidence supports that the different BCG strains, despite genetic variability, are equally effective clinically for preventing the recurrence and progression of papillary NMIBC. The available evidence regarding possible differences in clinical efficacy between various BCG strains in CIS is lacking. Methods: We reviewed the literature on the efficacy of different BCG strains in patients with CIS (whether primary, secondary, concomitant, or unifocal/multifocal), including randomized clinical trials (RCTs), phase II/prospective trials, and retrospective studies with complete response rates (CRR), recurrence-free survival (RFS), or progression-free survival (PFS) as endpoints. Results: In most studies, being RCTs, phase II prospective trials, or retrospective studies, genetic differences between BCG strains did not translate into meaningful differences in clinical efficacy against CIS, regardless of the CIS subset (primary, secondary, or concurrent) or CIS focality (unifocal or multifocal). CRR, RFS, and PFS were not statistically different between various BCG strains. None of these trials were designed as head-to-head comparisons between BCG strains focusing specifically on CIS. Limitations include the small sample size of many studies and most comparisons between strains being indirect rather than head-to-head. Conclusions: This review suggests that the clinical efficacy of the various BCG strains appears similar, irrespective of CIS characteristics. However, based on the weak level of evidence available and underpowered studies, randomized studies in this space should be encouraged as no definitive conclusion can be drawn at this stage.
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Affiliation(s)
- Andres Llano
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Amy Chan
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Cynthia Kuk
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, QU H4A 3J1, Canada;
| | - Alexandre R. Zlotta
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Heath Network, University of Toronto, Toronto, ON M5G 2C4, Canada
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Busetto GM, Finati M, Chirico M, Cinelli F, D’Altilia N, Falagario UG, Sanguedolce F, Del Giudice F, De Berardinis E, Ferro M, Crocetto F, Porreca A, Di Gianfrancesco L, Calo’ B, Mancini V, Bettocchi C, Carrieri G, Cormio L. Conservative treatment for high-risk NMIBC failing BCG treatment: who benefits from adding electromotive drug administration (EMDA) of mitomycin C (MMC) to a second BCG induction cycle? World J Urol 2023; 41:1329-1335. [PMID: 36971825 DOI: 10.1007/s00345-023-04372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023] Open
Abstract
Abstract
Purpose
Radical cystectomy (RC) is the standard treatment for high-risk non muscle-invasive bladder cancer (NMIBC) failing first BCG treatment. A second BCG course is an option for those patients who refuse RC or are not eligible for it, but its success rate is quite low. Aim of the present study was to determine whether the addition of intravesical electromotive drug administration of mytomicin-C (EMDA-MMC) improved the efficacy of second BCG course.
Methods
Patients with high-risk NMIBC having failed first BCG treatment and having refused RC were offered a second BCG induction course either alone (group A) or combined with EMDA-MMC (group B). Recurrence-free survival (RFS), progression-free survival (PFS) and cancer-specific survival (CSS) were tested.
Results
Of the 80 evaluable patients, 44 were in group A and 36 in group B; median follow-up was 38 months. RFS was significantly worse in group A whereas there was no difference in PFS and CSS between the two groups. Stratifying by disease stage, Ta patients receiving combined treatment had statistically better RFS and PFS survival than those receiving BCG only; this difference did not apply to T1 patients. Multivariable analysis confirmed that combined treatment was a significant predictor of recurrence and was close to predict progression. No tested variable was predictive of recurrence or progression in T1 tumours. Among those who underwent RC, CSS was 61.5% in those who had progression and 100% in those who remained with NMIBC.
Conclusion
Combined treatment improved RFS and PFS only in patients with Ta disease.
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4
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BCG-unresponsive high-grade non-muscle invasive bladder cancer: what does the practicing urologist need to know? World J Urol 2021; 39:4037-4046. [PMID: 33772322 PMCID: PMC7997797 DOI: 10.1007/s00345-021-03666-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Bacille Calmette-Guérin (BCG) is a well-established treatment for preventing or delaying tumour recurrence following high-grade nonmuscle invasive bladder cancer (NMIBC) resection. However, many patients will experience recurrence or progression during or following BCG. This scenario has been one of the most challenging in urologic oncology for several decades since BCG implementation. Finally, significant progress has occurred lately. The aim of this review was to summarize for the practising urologist the current treatment options available in 2020 or expected to be ready for routine use in the near future for patients with high-risk NMIBC who experience BCG failure. Methods Narrative review using data through the end of 2020. Results First, the definition of BCG unresponsive disease which is critical in counseling and managing patients has finally reached a consensus. Second, some promising options other than radical cystectomy are finally available and many other should be in a near future. The options can be categorized as chemotherapy, device-assisted therapy, check-point inhibitors, new intravesical and systemic agents and sequential combinations of these newer modalities with conventional therapy. Conclusions Considering the options that are currently under scrutiny, many of which in phase III trials, clinicians should have at their disposal several new treatment options in the next five years.
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Moussa M, Papatsoris AG, Dellis A, Abou Chakra M, Saad W. Novel anticancer therapy in BCG unresponsive non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2020; 20:965-983. [PMID: 32915676 DOI: 10.1080/14737140.2020.1822743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Many patients with non-muscle-invasive bladder cancer (NMIBC) failed intravesical BCG therapy. Currently, radical cystectomy is the recommended standard of care for those patients. There is unfortunately no effective other second-line therapy recommended. AREAS COVERED In this review, we present the topics of BCG unresponsive NMIBC; definition, prognosis, and further treatment options: immunotherapy, intravesical chemotherapy, gene therapy, and targeted individualized therapy. EXPERT OPINION There are major challenges of the management of NMIBC who failed BCG therapy as many patients refuse or are unfit for radical cystectomy. Multiple new modalities currently under investigation in ongoing clinical trials to better treat this category of patients. Immunotherapy, especially PD-1/PD-L1 inhibitors, offers exciting and potentially effective strategies for the treatment of BCG unresponsive NMIBC. As the data expands, it is sure that soon there will be established new guidelines for NMIBC.
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Affiliation(s)
- Mohamad Moussa
- Head of Urology Department, Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
| | - Athanasios G Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens , Athens, Greece
| | - Athanasios Dellis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens , Athens, Greece
| | - Mohamed Abou Chakra
- Faculty of Medical Sciences, Department of Urology, Lebanese University , Beirut,Lebanon
| | - Wajih Saad
- Head of Oncology Department, Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
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Kamat AM, Lerner SP, O'Donnell M, Georgieva MV, Yang M, Inman BA, Kassouf W, Boorjian SA, Tyson MD, Kulkarni GS, Chang SS, Konety BR, Svatek RS, Balar A, Witjes JA. Evidence-based Assessment of Current and Emerging Bladder-sparing Therapies for Non-muscle-invasive Bladder Cancer After Bacillus Calmette-Guerin Therapy: A Systematic Review and Meta-analysis. Eur Urol Oncol 2020; 3:318-340. [PMID: 32201133 DOI: 10.1016/j.euo.2020.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/15/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Currently, there is no standard of care for patients with non-muscle-invasive bladder cancer (NMIBC) who recur despite bacillus Calmette-Guerin (BCG) therapy. Although radical cystectomy is recommended, many patients decline to undergo or are ineligible to receive it. Multiple agents are being investigated for use in this patient population. OBJECTIVE To systematically synthesize and describe the efficacy and safety of current and emerging treatments for NMIBC patients after treatment with BCG. EVIDENCE ACQUISITION A systematic literature search of MEDLINE, Embase, and the Cochrane Controlled Register of Trials (period limited to January 2007-June 2019) was performed. Abstracts and presentations from major conference proceedings were also reviewed. Randomized controlled trials were assessed using the Cochrane risk of bias tool. Data for single-arm trials were pooled using a random-effect meta-analysis with the proportions approach. Trials were grouped based on the minimum number of prior BCG courses required before enrollment and further stratified based on the proportion of patients with carcinoma in situ (CIS). EVIDENCE SYNTHESIS Thirty publications were identified with data from 23 trials for meta-analysis, of which 17 were single arm. Efficacy and safety outcomes varied widely across studies. Heterogeneity across trials was reduced in subgroup analyses. The pooled 12-mo response rates were 24% (95% confidence interval [CI]: 16-32%) for trials with two or more prior BCG courses and 36% (95% CI: 25-47%) for those with one or more prior BCG courses. In a subgroup analysis, inclusion of ≥50% of patients with CIS was associated with a lower response. CONCLUSIONS The variability in efficacy and safety outcomes highlights the need for consistent endpoint reporting and patient population definitions. With promising emerging treatments currently in development, efficacious and safe therapeutic options are urgently needed for this difficult-to-treat patient population. PATIENT SUMMARY We examined the efficacy and safety outcomes of treatments for non-muscle-invasive bladder cancer after bacillus Calmette-Guerin therapy. Outcomes varied across studies and patient populations, but emerging treatments currently in development show promising efficacy.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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7
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Abstract
PURPOSE OF REVIEW To give an overview of current options for conservative treatment of patients failing intravesical bacillus Calmette-Guerin (BCG) and to discuss emerging approaches with potential future clinical applications. RECENT FINDINGS Radical cystectomy is the standard-of-care for patients failing BCG therapy. In patients unfit or unwilling to undergo surgery, salvage therapy options could be proposed with the aim to offer local cancer control and prevent progression to muscle-invasive disease. Salvage treatments have been conducted using intravesical chemotherapy regimens, chemoradiation or chemohyperthermia. Intravesical agents such as valrubicin, gemcitabine or docetaxel showed response rates varying between 16 and 40%, whereas combination treatments of gemcitabine with docetaxel or mitomycin reported response rates in up to 50% of all patients with durable responses in about one out of three patients. For chemohyperthermia, 2-year recurrence rates between 41 and 56% have been reported. Ongoing clinical trials are evaluating chemoradiation as well as novel approaches such as systemic immunotherapy, viral gene therapy, targeted therapy or vaccination strategies with promising preliminary outcomes. SUMMARY Salvage therapeutic bladder-sparing strategies for BCG failure such as intravesical chemotherapy or chemoradiation should currently only be considered in patients unfit for or refusing surgery. Innovative concepts such as chemohyperthermia, checkpoint inhibitors, targeted therapy or viral gene therapy could lead to major changes in clinical management of BCG failures in the future.
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8
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Hobbs C, Bass E, Crew J, Mostafid H. Intravesical BCG: where do we stand? Past, present and future. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818817120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High and intermediate risk non-muscle invasive bladder cancer poses a real challenge for treatment. Approximately 70% of bladder cancer presents as non-muscle invasive and 20–25% will progress to muscle invasive disease. Recurrences occur in up to 70% but treatment options are limited. Intravesical bacillus Calmette–Guérin is still considered the bladder sparing treatment of choice despite its well documented pitfalls. This review considers how bacillus Calmette–Guérin has become the recommended treatment, its benefits and risks and the alternative options for treatment. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Edward Bass
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
| | - Jeremy Crew
- Department of Urology, Churchill Hospital, UK
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
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9
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Urothelial Carcinoma In Situ and Treatment of Bacillus Calmette-Guérin Failures. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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10
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Werntz RP, Adamic B, Steinberg GD. Emerging therapies in the management of high-risk non-muscle invasive bladder cancer (HRNMIBC). World J Urol 2018; 37:2031-2040. [DOI: 10.1007/s00345-018-2592-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/28/2018] [Indexed: 01/19/2023] Open
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11
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Treatment for Carcinoma In Situ. Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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D’Andrea D, Witjes F, Soria F, Shariat SF. Urothelial Carcinoma In Situ and Treatment of Bacillus Calmette-Guérin Failures. Urol Oncol 2018. [DOI: 10.1007/978-3-319-42603-7_21-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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13
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Impact of age on outcomes of patients with non-muscle-invasive bladder cancer treated with immediate postoperative instillation of mitomycin C. Urol Oncol 2017; 36:89.e1-89.e5. [PMID: 29221642 DOI: 10.1016/j.urolonc.2017.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 11/06/2017] [Accepted: 11/12/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate whether age affects the clinical benefit afforded by immediate postoperative intravesical instillation of mitomycin C in a contemporary cohort of patients with NMIBC. PATIENTS AND METHODS A total of 4,258 patients with NMIBC treated with transurethral resection of the bladder with (n = 2,605, 61%) or without (n = 1,652, 39%) one immediate instillation of mitomycin C from 5 institutions (study period: 2000-2007) were included. No patients received adjuvant instillations. A multivariable Cox proportional hazards regression model adjusting for standard clinical and pathological features tested the potential interaction term between age and administration of mitomycin C with regard to disease recurrence. RESULTS A total of 2,063 patients experienced disease recurrence with a median follow-up of 48 months for those who did not recur. In multivariable Cox regression analysis, immediate postoperative instillation of mitomycin C (HR: 0.62; 95% CI: 0.56-0.68; P<0.0001) and age (HR: 1.04; 95% CI: 1.00-1.09; P = 0.036) were associated with disease recurrence. We observed only slight decreases in recurrence-free survival with age irrespective of treatment administration of mitomycin C or not. CONCLUSION We confirmed reduced disease recurrence rates associated with 1 immediate postoperative intravesical instillation of mitomycin C in NMIBC patients. The benefit on recurrence-free survival of a postoperative intravesical instillation was preserved across all ages and therefore age by itself should not be taken into consideration when deciding to use it.
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14
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Kamat AM, Bellmunt J, Galsky MD, Konety BR, Lamm DL, Langham D, Lee CT, Milowsky MI, O'Donnell MA, O'Donnell PH, Petrylak DP, Sharma P, Skinner EC, Sonpavde G, Taylor JA, Abraham P, Rosenberg JE. Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of bladder carcinoma. J Immunother Cancer 2017; 5:68. [PMID: 28807024 PMCID: PMC5557323 DOI: 10.1186/s40425-017-0271-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/25/2017] [Indexed: 12/21/2022] Open
Abstract
The standard of care for most patients with non-muscle-invasive bladder cancer (NMIBC) is immunotherapy with intravesical Bacillus Calmette-Guérin (BCG), which activates the immune system to recognize and destroy malignant cells and has demonstrated durable clinical benefit. Urologic best-practice guidelines and consensus reports have been developed and strengthened based on data on the timing, dose, and duration of therapy from randomized clinical trials, as well as by critical evaluation of criteria for progression. However, these reports have not penetrated the community, and many patients do not receive appropriate therapy. Additionally, several immune checkpoint inhibitors have recently been approved for treatment of metastatic disease. The approval of immune checkpoint blockade for patients with platinum-resistant or -ineligible metastatic bladder cancer has led to considerations of expanded use for both advanced and, potentially, localized disease. To address these issues and others surrounding the appropriate use of immunotherapy for the treatment of bladder cancer, the Society for Immunotherapy of Cancer (SITC) convened a Task Force of experts, including physicians, patient advocates, and nurses, to address issues related to patient selection, toxicity management, clinical endpoints, as well as the combination and sequencing of therapies. Following the standard approach established by the Society for other cancers, a systematic literature review and analysis of data, combined with consensus voting was used to generate guidelines. Here, we provide a consensus statement for the use of immunotherapy in patients with bladder cancer, with plans to update these recommendations as the field progresses.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, 1515 Pressler Unit 1373, Houston, TX, 77030, USA.
| | | | - Matthew D Galsky
- Tisch Cancer Institute at Mount Sinai Medical Center, New York, NY, 10029, USA
| | | | | | - David Langham
- Bladder Cancer Advocacy Network, North Carolina Triangle Chapter, Chapel Hill, NC, 27517, USA
| | - Cheryl T Lee
- The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | | | | | | | | | - Padmanee Sharma
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | | | - John A Taylor
- University of Kansas Cancer Center, Kansas City, KS, 66160, USA
| | - Prasanth Abraham
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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15
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Aoun F, Rassy EE, Assi T, Albisinni S, Katan J. Advances in urothelial bladder cancer immunotherapy, dawn of a new age of treatment. Immunotherapy 2017; 9:451-460. [PMID: 28357911 DOI: 10.2217/imt-2017-0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Urothelial bladder cancer displays a high number of somatic mutations that render these tumors more responsive to immunotherapy. Several immunotherapeutic agents were examined in patients with advanced stage urothelial bladder cancer and recently atezolizumab - an (PDL-1) immune checkpoint inhibitor antibody - was approved for the treatment of patients with metastatic disease progressing after platinum combination therapy. Despite the great success, there are still some unanswered questions and ongoing trials that are in progress to define the role of combination therapy and sequencing strategies. The objective of our manuscript is to summarize the most recent data on immunotherapy in advanced urothelial cancer. Current challenges and future perspectives of immunotherapy as a monotherapy or in combination strategies will also be analyzed.
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Affiliation(s)
- Fouad Aoun
- Department of Urology, Hotel Dieu de France, Saint Joseph University, Beirut, Lebanon.,Department of Urology, Jules Bordet Institute, 1 Rue Héger Bordet, 1000 Brussels, Belgium
| | - Elie El Rassy
- Department of Oncology, Hotel Dieu de France, Saint Joseph University, Beirut, Lebanon
| | - Tarek Assi
- Department of Oncology, Gustave Roussy Institute, Paris, France
| | - Simone Albisinni
- Department of Urology, Jules Bordet Institute, 1 Rue Héger Bordet, 1000 Brussels, Belgium
| | - Joseph Katan
- Department of Oncology, Hotel Dieu de France, Saint Joseph University, Beirut, Lebanon
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16
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Woldu SL, Şanli Ö, Lotan Y. Tackling non-muscle invasive bladder cancer in the clinic. Expert Rev Anticancer Ther 2017; 17:467-480. [PMID: 28359179 DOI: 10.1080/14737140.2017.1313119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Non-muscle invasive bladder cancer (NMIBC) is a common disease process with a high propensity for recurrence and risk of progression to muscle-invasive or systemic disease. Optimal management of NMIBC depends on appropriate resection and staging, risk-based use of intravesical therapy and tailored surveillance. Current challenges include compliance with guideline recommendations and cancers which are refractory to standard therapies. Areas covered: This review summarizes the conventional management of NMIBC - which relies on strict cystoscopic surveillance and intravesical therapies with chemotherapy and/or immunotherapy in the form of bacillus Calmette-Guerin (BCG). As many patients will be resistant to conventional treatment, investigational therapies and novel prognostic models will also be discussed. Expert commentary: For decades, the management of NMIBC has been predicated on intravesical therapies, most often through the instillation of BCG which has proven clinical efficacy over transurethral resection alone. Despite this, many patients will recur or progress after BCG therapy. While radical cystectomy remains the standard for such patients, suitable alternatives are being actively investigated. An increased interest in immunotherapy for malignancy has reinvigorated this field and on-going advances in disease prognostication are likely to improve upon the existing treatment paradigms for NMIBC.
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Affiliation(s)
- Solomon L Woldu
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Öner Şanli
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA.,b Department of Urology, Istanbul Faculty of Medicine , Istanbul University , Istanbul , Turkey
| | - Yair Lotan
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
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BCG-unresponsive non-muscle-invasive bladder cancer: recommendations from the IBCG. Nat Rev Urol 2017; 14:244-255. [DOI: 10.1038/nrurol.2017.16] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Intravesical immunotherapy with bacille-Calmette-Guerin (BCG) is indicated in the treatment of high-risk and intermediate-risk non-muscle invasive bladder cancer (NMIBC). Our goal is to describe the various disease states following induction and maintenance BCG and to describe contemporary treatment options and the current and projected clinical trial landscape for patients who recur following BCG therapy.
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Affiliation(s)
- Friedrich-Carl von Rundstedt
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
| | - Seth P Lerner
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
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Kamat AM, Sylvester RJ, Böhle A, Palou J, Lamm DL, Brausi M, Soloway M, Persad R, Buckley R, Colombel M, Witjes JA. Definitions, End Points, and Clinical Trial Designs for Non-Muscle-Invasive Bladder Cancer: Recommendations From the International Bladder Cancer Group. J Clin Oncol 2016; 34:1935-44. [PMID: 26811532 DOI: 10.1200/jco.2015.64.4070] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide recommendations on appropriate clinical trial designs in non-muscle-invasive bladder cancer (NMIBC) based on current literature and expert consensus of the International Bladder Cancer Group. METHODS We reviewed published trials, guidelines, meta-analyses, and reviews and provided recommendations on eligibility criteria, baseline evaluations, end points, study designs, comparators, clinically meaningful magnitude of effect, and sample size. RESULTS NMIBC trials must be designed to provide the most clinically relevant data for the specific risk category of interest (low, intermediate, or high). Specific eligibility criteria and baseline evaluations depend on the risk category being studied. For the population of patients for whom bacillus Calmette-Guérin (BCG) has failed, the type of failure (BCG unresponsive, refractory, relapsing, or intolerant) should be clearly defined to make comparisons across trials feasible. Single-arm designs may be relevant for the BCG-unresponsive population. Here, a clinically meaningful initial complete response rate (for carcinoma in situ) or recurrence-free rate (for papillary tumors) of at least 50% at 6 months, 30% at 12 months, and 25% at 18 months is recommended. For other risk levels, randomized superiority trial designs are recommended; noninferiority trials are to be used sparingly given the large sample size required. Placebo control is considered unethical for all intermediate- and high-risk strata; therefore, control arms should comprise the current guideline-recommended standard of care for the respective risk level. In general, trials should use time to recurrence or recurrence-free survival as the primary end point and time to progression, toxicity, disease-specific survival, and overall survival as potential secondary end points. Realistic efficacy thresholds should be set to ensure that novel therapies receive due review by regulatory bodies. CONCLUSION The International Bladder Cancer Group has developed formal recommendations regarding definitions, end points, and clinical trial designs for NMIBC to encourage uniformity among studies in this disease.
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Affiliation(s)
- Ashish M Kamat
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
| | - Richard J Sylvester
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Andreas Böhle
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Joan Palou
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Donald L Lamm
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Maurizio Brausi
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Mark Soloway
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Raj Persad
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Roger Buckley
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Marc Colombel
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - J Alfred Witjes
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Tang DH, Chang SS. Management of carcinoma in situ of the bladder: best practice and recent developments. Ther Adv Urol 2015; 7:351-64. [PMID: 26622320 DOI: 10.1177/1756287215599694] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Management of carcinoma in situ of the bladder remains a complex and challenging endeavor due to its high rate of recurrence and progression. Although it is typically grouped with other nonmuscle invasive bladder cancers, its higher grade and aggressiveness make it a unique clinical entity. Intravesical bacillus Calmette-Guérin is the standard first-line treatment given its superiority to other agents. However, high rates of bacillus Calmette-Guérin failure highlight the need for additional therapies. Radical cystectomy has traditional been the standard second-line therapy, but additional intravesical therapies may be more appealing for non-surgical candidates and patients refusing cystectomy. The subject of this review is the treatment strategies and available therapies currently available for carcinoma in situ of the bladder. It discusses alternative intravesical treatment options for patients whose condition has failed to respond to bacillus Calmette-Guérin therapy and who are unfit or unwilling to undergo cystectomy.
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Affiliation(s)
- Dominic H Tang
- Department of Urologic Surgery, Vanderbilt University Medical Center, MCN A-1302, Nashville, TN 37027, USA
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Steinberg RL, Thomas LJ, O'Donnell MA. Bacillus Calmette-Guérin (BCG) Treatment Failures in Non-Muscle Invasive Bladder Cancer: What Truly Constitutes Unresponsive Disease. Bladder Cancer 2015; 1:105-116. [PMID: 27376112 PMCID: PMC4927833 DOI: 10.3233/blc-150015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bacillus Calmette-Guérin (BCG) remains the most effective intravesical therapy for non-muscle invasive bladder cancer but will fail in up to 40% of patients. The ability to identify patients who are least likely to respond to further BCG therapy allows urologists to pursue secondary treatments more likely to convey a recurrence or survival benefit to the patient. We examined the literature to determine what constitutes BCG unresponsive disease. After review, we believe that BCG unresponsive disease should be defined as (1) patients with recurrent high grade T1 disease within 6 months of their primary tumor after at least one course of BCG or patients who have failed at least 2 courses of BCG with either (2) persistent or recurrent pure papillary (Ta) disease within 6 months or (3) persistent or recurrent carcinoma in situ (CIS) within 12 months.
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Affiliation(s)
| | - Lewis J Thomas
- University of Iowa Department of Urology, Iowa City, IA, USA
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The Role of Interferon in the Management of BCG Refractory Nonmuscle Invasive Bladder Cancer. Adv Urol 2015; 2015:656918. [PMID: 26550012 PMCID: PMC4621325 DOI: 10.1155/2015/656918] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/20/2015] [Indexed: 12/02/2022] Open
Abstract
Background. Thirty to forty percent of patients with high grade nonmuscle invasive bladder cancer (NMIBC) fail to respond to intravesical therapy with bacillus Calmette-Guerin (BCG). Interferon-α2B plus BCG has been shown to be effective in a subset of patients with NMIBC BCG refractory disease. Here we present a contemporary series on the effectiveness and safety of intravesical BCG plus interferon-α2B therapy in patients with BCG refractory NMIBC. Methods. From January of 2005 to April of 2014 we retrospectively found 44 patients who underwent induction with combination IFN/BCG for the management of BCG refractory NMIBC. A chart review was performed to assess initial pathological stage/grade, pathological stage/grade at the time of induction, time to IFN/BCG failure, pathological stage/grade at failure, postfailure therapy, and current disease state. Results. Of the 44 patients who met criteria for the analysis. High risk disease was found in 88.6% of patients at induction. The 12-month and 24-month recurrence-free survival were 38.6% and 18.2%, respectively. 25 (56.8%) ultimately had disease recurrence. Radical cystectomy was performed in 16 (36.4%) patients. Conclusion. Combination BCG plus interferon-α2B remains a reasonably safe alternative treatment for select patients with BCG refractory disease prior to proceeding to radical cystectomy.
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Spaliviero M, Dalbagni G, Nielsen M. What to do when bacillus Calmette-Guérin fails. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Casey RG, Catto JW, Cheng L, Cookson MS, Herr H, Shariat S, Witjes JA, Black PC. Diagnosis and Management of Urothelial Carcinoma In Situ of the Lower Urinary Tract: A Systematic Review. Eur Urol 2015; 67:876-88. [DOI: 10.1016/j.eururo.2014.10.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/24/2014] [Indexed: 12/28/2022]
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Prasad SM, Eyre S, Loughlin KR. Salvage combination intravesical immunotherapy with Bacillus Calmette-Guérin and interferon-α2B: impact on recurrence, progression, and survival. Hosp Pract (1995) 2014; 41:31-9. [PMID: 24145587 DOI: 10.3810/hp.2013.10.1078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The population of patients with bladder cancer who have recurrence following an initial instillation of Bacillus Calmette-Guérin (BCG) is critical to study, as treatment delay with repeated courses of intravesical therapy may yield poor prognosis in patients with disease progression. OBJECTIVE To evaluate our institution's experience with use of BCG alone and in combination with interferon (INF)-α2B in regard to the rates of bladder cancer recurrence, disease progression, need for eventual cystectomy, and survival in patients with initial BCG failure. STUDY DESIGN We identified a combined series of 139 patients who had undergone intravesical instillations of BCG alone (n = 114) or in combination with INF-α2B (n = 25) performed at Brigham and Women's Hospital, Boston, between 2002 and 2007. All patients previously received an initial 6-week course of BCG therapy and subsequently had BCG failure on follow-up cystoscopy. Study outcome measures included: time to cancer recurrence in patients, progression of disease, eventual cystectomy, and patient mortality. RESULTS At a median follow-up of 64.7 months from initial BCG administration, 84% of patients treated with BCG + INF-α2B had disease recurrence. The average time to recurrence was < 1 year, and 63% of patients had recurrence on the first post-treatment biopsy. Among patients with a positive first biopsy, 52% had disease progression on initial surveillance. Overall, disease progression was seen in 48% of patients receiving BCG + INF-α2B therapy, and 28% of all patients eventually underwent radical cystectomy. All outcomes occurred more frequently in patients undergoing combination intravesical therapy compared with patients given BCG monotherapy. CONCLUSIONS Patients with bladder cancer undergoing salvage intravesical BCG + INF-α2B at our institution had a > 50% chance of disease recurrence and progression, and > 25% of patients eventually proceeded to radical cystectomy. Randomized trials are needed to clarify the issues present in our findings and to determine the appropriate role for concomitant INF therapy in patients when BCG monotherapy has failed.
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Affiliation(s)
- Sandip M Prasad
- Division of Urologic Surgery, Medical University of South Carolina, Charleston, SC
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Lamm D, Brausi M, O'Donnell MA, Witjes JA. Interferon alfa in the treatment paradigm for non-muscle-invasive bladder cancer. Urol Oncol 2013; 32:35.e21-30. [PMID: 23628309 DOI: 10.1016/j.urolonc.2013.02.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 01/01/2023]
Abstract
OBJECTIVES In this article, we review the various options for and the potential role of interferon alfa (IFN-α) in the treatment of non-muscle-invasive bladder cancer (NMIBC). METHODS PubMed was searched for journal articles on IFN-α use in treating bladder cancer. The references listed in the National Comprehensive Cancer Network guidelines were used as a guide to identify relevant publications on treatments for NMIBC. RESULTS Transurethral resection with adjuvant intravesical chemotherapy or immunotherapy is the standard treatment option for NMIBC. Adjuvant IFN-α therapy has limited efficacy in preventing recurrences in intermediate-risk and high-risk patients; bacillus Calmette-Guérin (BCG) monotherapy is the recommended first-line treatment in these patients. Unfortunately, cancer progression or recurrence is a common outcome; radical cystectomy, which is often the lifesaving approach in such a scenario, is associated with significant morbidity, mortality, and decreased quality of life. Current alternatives to cystectomy include repeat intravesical immunotherapy, conventional instillation chemotherapy, and device-assisted intravesical chemotherapy. The efficacy of any chemotherapy after BCG failure, either conventional or device assisted, has not been established. BCG and IFN-α combination intravesical therapy has not been investigated thoroughly; based on available data, combination therapy appears to be most effective in patients with carcinoma in situ and may be preferentially considered as an alternative to radical cystectomy for patients with intermediate-risk or high-risk NMIBC who do not tolerate the standard BCG dose or experience BCG failure after 1 year of therapy. However, this approach requires close follow-up and should only be chosen after careful consideration of all risk factors. CONCLUSIONS There is a lack of efficacious treatment options for patients with NMIBC recurrence or progression after initial BCG treatment. There is a need for well-designed clinical trials investigating the safety and efficacy of available therapies, including BCG and IFN-α2b combination therapy.
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Affiliation(s)
| | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Yates DR, Brausi MA, Catto JW, Dalbagni G, Rouprêt M, Shariat SF, Sylvester RJ, Witjes JA, Zlotta AR, Palou-Redorta J. Treatment Options Available for Bacillus Calmette-Guérin Failure in Non–muscle-invasive Bladder Cancer. Eur Urol 2012; 62:1088-96. [DOI: 10.1016/j.eururo.2012.08.055] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/27/2012] [Indexed: 11/17/2022]
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Current world literature. Curr Opin Urol 2012; 22:432-43. [PMID: 22854603 DOI: 10.1097/mou.0b013e3283572fe1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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[Recurrent bladder cancer after BCG instillation therapy. Local therapy options?]. Urologe A 2012; 51:1209-19. [PMID: 22580923 DOI: 10.1007/s00120-012-2875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Patients with a so-called BCG failure (Bacillus Calmette-Guérin) constitute an inhomogeneous group of patients. Patients with BCG recurrence or BCG refractive tumors are real BCG failures. Therapeutic options are radical cystectomy and a conservative approach, depending on the individual risk of recurrence and progression. Intravesical chemotherapy with docetaxel or gemcitabine after BCG failure shows some promise whereas second line immunotherapy, the combination of BCG and interferon (INF)-α, is an effective regimen but results need to be confirmed. Device-assisted intravesical strategies, such as mitomycin-EMDA or chemohyperthermia are candidates to keep in mind for the near future. Finally, cystectomy results in the best disease-specific survival in patients with BCG failure.
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Response to the rebuttal letter of Kountouras and colleagues regarding the paper by Codolo et al. ‘HP-NAP inhibits the growth of bladder cancer in mice by activating a cytotoxic Th1 response’. Cancer Immunol Immunother 2012. [DOI: 10.1007/s00262-011-1144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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