The association of salvage intravesical therapy following BCG with pathologic outcomes and survival after radical cystectomy for patients with high-grade non-muscle invasive bladder cancer: A multi-institution analysis

Long-term outcomes of bladder-sparing therapy vs radical cystectomy in BCG-unresponsive non-muscle-invasive bladder cancer

OBJECTIVE

To quantify the oncological risks of bladder-sparing therapy (BST) in patients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) compared to upfront radical cystectomy (RC).

PATIENTS AND METHODS

Pre-specified data elements were collected from retrospective cohorts of patients with BCG-unresponsive NMIBC from 10 international sites. After Institutional Review Board approval, patients were included if they had BCG-unresponsive NMIBC meeting United States Food and Drug Administration criteria. Oncological outcomes were collected following upfront RC or BST. BST regimens included re-resection or surveillance only, repeat BCG, intravesical chemotherapy, systemic immunotherapy, and clinical trials.

RESULTS

Among 578 patients, 28% underwent upfront RC and 72% received BST. The median (interquartile range) follow-up was 50 (20-69) months. There were no statistically significant differences in metastasis-free survival, cancer-specific survival, or overall survival between treatment groups. In the BST group, high-grade recurrence rates were 37% and 52% at 12 and 24 months and progression to MIBC was observed in 7% and 13% at 12 and 24 months, respectively. RC was performed in 31.7% in the BST group and nodal disease was found in 13% compared with 4% in upfront RC (P = 0.030).

CONCLUSION

In a selected cohort of patients, initial BST offers comparable survival outcomes to upfront RC in the intermediate term. Rates of recurrence and progression increase over time especially in patients treated with additional lines of BST.

Contemporary Treatment of NMIBC-Is It Time to Move on from BCG?

Non-muscle-invasive bladder cancer (NMIBC) encompasses approximately three-quarters of all bladder cancer (BC) diagnoses. Intravesical Bacillus Calmette-Guerin (BCG) has been the long-standing gold standard treatment for patients following endoscopic resection. However, despite reasonable efficacy, recurrence rates are still suboptimal, and this, combined with treatment tolerability and BCG shortages, has prompted an investigation into alternative treatment modalities. Advances in this landscape have been predominantly for patients with BCG-unresponsive disease, and there are currently four FDA-approved treatments for these patients. More recently, trials have emerged looking for alternatives to BCG for patients who are treatment-naïve. We performed a literature search via PubMed to find recent publications on alternatives to BCG, as well as a search on clinicaltrials.gov and recent conference presentations for ongoing clinical trials. Studies have shown that combination intravesical chemotherapy, combination intravesical therapy with BCG, and combination intravenous therapy with BCG preliminarily have good efficacy and safety profiles in this disease space. Ongoing trials are underway, and we anticipate as these studies mature, there will be a shift in NMIBC treatment regimens.

Transurethral resection of bladder tumor-based bladder preservation therapy for refractory high risk non-muscle invasive bladder cancer: Current landscape and future directions

Bladder cancer is the most common malignant tumor of urinary system worldwide. Approximately 75% of patients with bladder cancer present with non-muscle-invasive bladder cancer (NMIBC), which is effectively managed with transurethral resection of bladder tumor (TURBT). For refractory high risk NMIBC, patients are typically treated by radical cystectomy (RC). TURBT deserves further evaluation. Growing evidence suggests that repeated TURBT-based bladder-sparing approaches may improve oncological outcomes and quality of life in highly selected patients. Novel imaging techniques and biomarkers may aid in patients selection and postoperative surveillance. With growing interest in adding immunotherapy to refractory bladder cancer, TURBT based approaches enable the bladder preservation therapy for high risk NMIBC. Here we summarize the current landscape, biomarkers for surveillance, and future directions for applying TURBT-based bladder preservation therapy.

Intravesical Therapy Compared to Radical Cystectomy Among Patients With Non-Muscle Invasive Bladder Cancer Requiring Additional Treatment After Induction BCG

BACKGROUND

Many patients with recurrent high-risk non-muscle invasive bladder cancer after intravesical bacillus calmette-guerin (BCG) face a difficult decision between radical cystectomy (RC) or salvage intravesical therapy (IVT). We sought to determine if there is a difference in overall survival RC and IVT after previous treatment with BCG.

METHODS

We performed a retrospective cohort study of patients with Ta, T1, and Tis bladder cancer treated with induction BCG in the SEER-Medicare dataset from 2000 to 2015. We used a proportional hazards regression model to compare differences in survival between patients having RC and IVT. We adjusted for confounding using a propensity score and stratified our analysis according to timing of treatment and stage at diagnosis.

RESULTS

We identified 3940 patients who received either IVT (79%) or RC (21%) following induction BCG. Among patients treated within 12 months of BCG, there was no significant difference in survival between RC and IVT (HR 0.92, 95% CI 0.81-1.04) and 17% of patients having early IVT ultimately required RC. Among patients treated at least 12 months after BCG, RC was associated with worse survival than IVT (HR 1.19, 95% CI 1.06-1.35) and 10% of patients having late IVT ultimately required RC.

CONCLUSION

Among patients with bladder cancer who required additional treatments after induction BCG, we did not observe a difference in overall survival between IVT and RC within 12 months of starting BCG. While RC remains the gold-standard for high risk recurrent NMIBC after BCG, bladder preservation with IVT may be appropriate for well-selected patients.

A longitudinal single center analysis of T1HG bladder cancer: An 18 year experience

OBJECTIVES

To re-evaluate the treatment of T1HG bladder cancer by analyzing our experience over 18 years.

METHODS AND MATERIALS

An IRB-approved, single-institution retrospective review was performed of all patients with T1HG bladder cancer between August 1999 and July 2017. We assessed clinicopathologic characteristics, treatment history (including intravesical therapy, cystectomy, systemic chemotherapy, and radiation), and oncologic outcomes.

RESULTS

We identified 191 patients with T1HG. Five patients underwent cystectomy at diagnosis. The five-year recurrence-free survival (RFS) for the 186 patients who initially underwent bladder sparing treatments was 50% (95% CI: 41%-58%). There were 83 patients (45%) with disease recurrence; median time to recurrence was 6.7 months (IQR: 4.9-17.5). Disease characteristics at initial recurrence was T2 or greater in 8 patients (10%), T1HG in 19 (23%), CIS in 30 (36%), TaHG in 10 (12%), T1 low-grade (LG) in 1 (1%), and TaLG in 15 (18%). For patients with no prior recurrences, neither re-resection (P = 0.12), receipt of induction therapy (P = 0.81), prostatic urethra positivity (P = 0.51), or age (P = 0.34) were significantly associated with risk of recurrence. Similarly, patients with a single recurrence also fared well without identifiable risk factors. In fact, baseline hazard function analysis demonstrated no differences in RFS comparing patients stratified by 0, 1, and 2+ prior recurrences (P = 0.46). The five-year overall survival (OS) was 76% (95% CI: 68%-82%), and median OS was 127 months. The five-year cancer-specific survival was 86% (95% CI: 78%-91%) for the overall cohort. Five-year cystectomy-free survival for patients with BCG responsive disease and unresponsive disease was 95% (95% CI: 85%-98%) and 72% (95% CI: 52%-84%), respectively.

CONCLUSION

For patients who recurred after intravesical therapy, including those with recurrent T1 disease, additional induction courses of intravesical therapy did not negatively affect oncologic outcomes. Pathology of initial recurrence was not found to be a statistically significant risk factor for future recurrence. These findings suggest that BCG-unresponsive disease does not necessarily require immediate cystectomy. A multicenter, pragmatically designed evaluation in a contemporary cohort would more validly interrogate this important patient population.

Real-world treatment patterns and oncological outcomes in early relapse and refractory disease after bacillus Calmette-Guérin failure in non-muscle-invasive bladder cancer

OBJECTIVE

To assess real-world oncological outcomes between the radical cystectomy (RC) group and non-RC group for early relapse and refractory disease.

METHODS

We retrospectively analyzed 953 patients with recurrent non-muscle-invasive bladder cancer (NMIBC) who received bacillus Calmette-Guérin (BCG) at 31 affiliated hospitals from 2000 to 2019. Patients with missing data on the timing of failure were excluded and 871 patients remained eligible, of whom 447, 357, and 67 were classified as early relapse/refractory disease, intermediate/late relapse disease, and intolerant disease, respectively. For early relapse/refractory disease, patients were divided into two salvage treatment groups: RC and non-RC. The clinicopathological variables of each group were examined using Kaplan-Meier plots and proportional Cox hazard ratios with matched score analyses to compare oncological outcomes between the two groups.

RESULTS

Significantly worse progression-free survival and cancer-specific survival (CSS) were confirmed in the early relapse/refractory disease group compared to the intermediate/late relapse group. Of the 88 salvage patients in the RC group with early relapse/refractory disease, ≤pT1 was observed in 47, pT2 in 11, and ≥pT3 in 28 (two patients with unknown pT category). In early relapse/refractory disease, the RC group showed significantly high-risk tumor compared to the non-RC group. However, no significant difference was observed in CSS after matched score analyses (p = 0.45) between the RC and non-RC groups.

CONCLUSIONS

This study found that the RC group showed no significant superiority compared to the non-RC group in CSS for early relapse/refractory disease in terms of first salvage therapy.

Comparative Outcomes of Primary Versus Recurrent High-risk Non–muscle-invasive and Primary Versus Secondary Muscle-invasive Bladder Cancer After Radical Cystectomy: Results from a Retrospective Multicenter Study

Background

Radical cystectomy (RC) is indicated in primary or secondary muscle-invasive bladder cancer (primMIBC, secMIBC) and in primary or recurrent high- or very high-risk non–muscle-invasive bladder cancer (primHR-NMIBC, recHR-NMIBC). The optimal timing for RC along the disease spectrum of nonmetastatic urothelial carcinoma remains unclear.

Objective

To compare outcomes after RC between patients with primHR-NMIBC, recHR-NMIBC, primMIBC, and secMIBC.

Design, setting, and participants

This retrospective, multicenter study included patients with clinically nonmetastatic bladder cancer (BC) treated with RC.

Outcome measurements and statistical analysis

We assessed oncological outcomes for patients who underwent RC according to the natural history of their BC. primHR-NMIBC and primMIBC were defined as no prior history of BC, and recHR-NMIBC and secMIBC as previously treated NMIBC that recurred or progressed to MIBC, respectively. Log-rank analysis was used to compare survival outcomes, and univariable and multivariable Cox and logistic regression analyses were used to identify predictors for survival.

Results and limitations

Among the 908 patients included, 211 (23%) had primHR-NMIBC, 125 (14%) had recHR-NMIBC, 404 (44%) had primMIBC, and 168 (19%) had secMIBC. Lymph node involvement and pathological upstaging were more frequent in the secMIBC group than in the other groups (p < 0.001). The median follow-up was 37 mo. The 5-year recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were 77.9%, 83.2%, and 72.7% in primHR-NMIBC, 60.0%, 59%, and 48.9% in recHR-NMIBC, 60.9%, 64.5%, and 54.8% in primMIBC, and 41.3%, 46.5%, and 39% in secMIBC, respectively, with statistically significant differences across all survival outcomes except between recHR-NMIBC and primMIBC. On multivariable Cox regression, recHR-NMIBC was independently associated with shorter RFS (hazard ratio [HR] 1.64; p = 0.03), CSS (HR 1.79; p = 0.01), and OS (HR 1.45; p = 0.03), and secMIBC was associated with shorter CSS (HR 1.77; p = 0.01) and OS (HR 1.57; p = 0.006). Limitations include the biases inherent to the retrospective study design.

Conclusions

Patients with recHR-NMIBC and primHR-MIBC had similar survival outcomes, while those with sec-MIBC had the worst outcomes. Therefore, early radical intervention may be indicated in selected patients, and potentially neoadjuvant systemic therapies in some patients with recHR-NMIBC.

Patient summary

We compared cancer outcomes in different bladder cancer scenarios in a large, multinational series of patients who underwent removal of the bladder with curative intent. We found that patients who experienced recurrence of non–muscle-invasive bladder cancer (NMIBC) had similar survival outcomes to those with initial muscle-invasive bladder cancer (MIBC), while patients who experienced progression of NMIBC to MIBC had the worst outcomes. Selected patients with non–muscle-invasive disease may benefit from early radical surgery or from perioperative chemotherapy or immunotherapy.