1
|
Messing EM, Tangen CM, Lerner SP, Sahasrabudhe DM, Koppie TM, Wood DP, Mack PC, Svatek RS, Evans CP, Hafez KS, Culkin DJ, Brand TC, Karsh LI, Holzbeierlein JM, Wilson SS, Wu G, Plets M, Vogelzang NJ, Thompson IM. Effect of Intravesical Instillation of Gemcitabine vs Saline Immediately Following Resection of Suspected Low-Grade Non-Muscle-Invasive Bladder Cancer on Tumor Recurrence: SWOG S0337 Randomized Clinical Trial. JAMA 2018; 319:1880-1888. [PMID: 29801011 PMCID: PMC6583489 DOI: 10.1001/jama.2018.4657] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/05/2018] [Indexed: 01/14/2023]
Abstract
Importance Low-grade non-muscle-invasive urothelial cancer frequently recurs after excision by transurethral resection of bladder tumor (TURBT). Objective To determine whether immediate post-TURBT intravesical instillation of gemcitabine reduces recurrence of suspected low-grade non-muscle-invasive urothelial cancer compared with saline. Design, Setting, and Participants Randomized double-blind clinical trial conducted at 23 US centers. Patients with suspected low-grade non-muscle-invasive urothelial cancer based on cystoscopic appearance without any high-grade or without more than 2 low-grade urothelial cancer episodes within 18 months before index TURBT were enrolled between January 23, 2008, and August 14, 2012, and followed up every 3 months with cystoscopy and cytology for 2 years and then semiannually for 2 years. Patients were monitored for tumor recurrence, progression to muscle invasion, survival, and toxic effects. The final date of follow-up was August 14, 2016. Interventions Participants were randomly assigned to receive intravesical instillation of gemcitabine (2 g in 100 mL of saline) (n = 201) or saline (100 mL) (n = 205) for 1 hour immediately following TURBT. Main Outcomes and Measures The primary outcome was time to recurrence of cancer. Secondary end points were time to muscle invasion and death due to any cause. Results Among 406 randomized eligible patients (median age, 66 years; 84.7% men), 383 completed the trial. In the intention-to-treat analysis, 67 of 201 patients (4-year estimate, 35%) in the gemcitabine group and 91 of 205 patients (4-year estimate, 47%) in the saline group had cancer recurrence within 4.0 years (hazard ratio, 0.66; 95% CI, 0.48-0.90; P<.001 by 1-sided log-rank test for time to recurrence). Among the 215 patients with low-grade non-muscle-invasive urothelial cancer who underwent TURBT and drug instillation, 34 of 102 patients (4-year estimate, 34%) in the gemcitabine group and 59 of 113 patients (4-year estimate, 54%) in the saline group had cancer recurrence (hazard ratio, 0.53; 95% CI, 0.35-0.81; P = .001 by 1-sided log-rank test for time to recurrence). Fifteen patients had tumors that progressed to muscle invasion (5 in the gemcitabine group and 10 in the saline group; P = .22 by 1-sided log-rank test) and 42 died of any cause (17 in the gemcitabine group and 25 in the saline group; P = .12 by 1-sided log-rank test). There were no grade 4 or 5 adverse events and no significant differences in adverse events of grade 3 or lower. Conclusions and Relevance Among patients with suspected low-grade non-muscle-invasive urothelial cancer, immediate postresection intravesical instillation of gemcitabine, compared with instillation of saline, significantly reduced the risk of recurrence over a median of 4.0 years. These findings support using this therapy, but further research is needed to compare gemcitabine with other intravesical agents. Trial Registration clinicaltrials.gov Identifier: NCT00445601.
Collapse
Affiliation(s)
| | - Catherine M. Tangen
- SWOG Statistical Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Guan Wu
- University of Rochester, Rochester, New York
| | - Melissa Plets
- SWOG Statistical Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | |
Collapse
|
2
|
Zhou DH, Zhang G, Yu QS, Gan ZH. Folic Acid Modified Polymeric Micelles for Intravesical Instilled Chemotherapy. CHINESE JOURNAL OF POLYMER SCIENCE 2017. [DOI: 10.1007/s10118-018-2009-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
3
|
Intravesical Therapy for the Treatment of Nonmuscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. J Urol 2017; 197:1189-1199. [DOI: 10.1016/j.juro.2016.12.090] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/15/2022]
|
4
|
Systematic Review and Individual Patient Data Meta-analysis of Randomized Trials Comparing a Single Immediate Instillation of Chemotherapy After Transurethral Resection with Transurethral Resection Alone in Patients with Stage pTa–pT1 Urothelial Carcinoma of the Bladder: Which Patients Benefit from the Instillation? Eur Urol 2016; 69:231-44. [DOI: 10.1016/j.eururo.2015.05.050] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/28/2015] [Indexed: 11/21/2022]
|
5
|
Chamie K, Saigal CS, Lai J, Hanley JM, Setodji CM, Konety BR, Litwin MS. Compliance with guidelines for patients with bladder cancer: variation in the delivery of care. Cancer 2011; 117:5392-401. [PMID: 21780079 DOI: 10.1002/cncr.26198] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 03/22/2011] [Accepted: 03/24/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. In the current study, the authors sought to characterize practice patterns in patients with high-grade non-muscle-invasive bladder cancer in relation to established guidelines. METHODS Surveillance, Epidemiology and End Results (SEER)-Medicare-linked data were used to identify subjects diagnosed with high-grade non-muscle-invasive bladder cancer between 1992 and 2002 who survived at least 2 years without undergoing definitive treatment (n = 4545). The authors used mixed-effects modeling to estimate the association and partitioned variation of patient sociodemographic, tumor, and provider characteristics with compliance measures. RESULTS Of the 4545 subjects analyzed, only 1 received all the recommended measures. Approximately 42% of physicians have not performed at least 1 cystoscopy, 1 cytology, and 1 instillation of immunotherapy for a single patient nested within their practice during the initial 2-year period after diagnosis. After 1997, only use of radiographic imaging (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.03-1.37) and instillation of immunotherapy (OR, 1.67; 95% CI, 1.39-2.01) were found to be significantly increased. Surgeon-attributable variation for individual guideline measures (cystoscopy, 25%; cytology, 59%; radiographic imaging, 10%; intravesical chemotherapy, 45%; and intravesical immunotherapy, 26%) contributes to this low compliance rate. CONCLUSIONS There is marked underuse of guideline-recommended care in this potentially curable cohort. Unexplained provider-level factors significantly contribute to this low compliance rate. Future studies that identify barriers and modulators of provider-level adoption of guidelines are critical to improving care for patients with bladder cancer.
Collapse
Affiliation(s)
- Karim Chamie
- Department of Urology, Health Services Research Group, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA.
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Arakawa M, Nakamura K, Yamada Y, Kato K, Katsuda R, Tobiume M, Zennami K, Watanabe M, Kato Y, Nishikawa G, Yoshizawa T, Aoki S, Taki T, Mitsui K, Honda N, Saito H, Hasegawa T. Intravesical administration of pirarubicin against superficial bladder cancer: Relationship between tumor tissue concentration and exposure time in the bladder or therapeutic effect. Exp Ther Med 2011; 2:901-905. [PMID: 22977595 DOI: 10.3892/etm.2011.315] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 06/30/2011] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to investigate the relationship between tissue concentrations and exposure times or therapeutic effect of an anthracycline anticancer drug, pirarubicin, in bladder cancer tissue after single intravesical administration against superficial bladder cancer. The concentrations of pirarubicin in tumor tissues and serum were measured at designated collection times after a single intravesical administration of pirarubicin (30 mg) in 22 patients with superficial bladder cancer. A wide range of concentrations of pirarubicin in bladder cancer tissue was observed (2.3-125 μg/g of tissue), although serum pirarubicin concentrations were not detected in any of the patients. Recurrence of superficial bladder cancer after transurethral resection of the bladder tumor (TUR-BT) was observed in 2 patients (9%). The concentration of pirarubicin in the tumor tissue tended to be higher as the exposure time increased. There was a weak relationship between the pirarubicin tissue concentration and tumor size. However, no significant relationship between tissue pirarubicin concentrations and the prophylactic effect against intravesical recurrence of bladder cancer after TUR-BT was observed. All patients had no adverse events, such as bladder irritation and local toxicity, caused by the treatment with pirarubicin. These findings suggest that prior to single intravesical administration of pirarubicin to patients with superficial bladder cancer the exposure time and tumor size should be considered.
Collapse
|
7
|
Madeb R, Golijanin D, Noyes K, Fisher S, Stephenson JJ, Long SR, Knopf J, Lyman GH, Messing EM. Treatment of nonmuscle invading bladder cancer: do physicians in the United States practice evidence based medicine? The use and economic implications of intravesical chemotherapy after transurethral resection of bladder tumors. Cancer 2009; 115:2660-70. [PMID: 19455607 DOI: 10.1002/cncr.24311] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Phase 3 clinical trials performed primarily outside the US demonstrate that intravesical instillation of chemotherapy immediately after transurethral resection of the bladder (TURB) decreases cancer recurrence rates. The authors sought to determine whether US urologists have adopted this practice, and its potential effect on costs of bladder cancer (BC) care. METHODS By using 1997-2004 MEDSTAT claims data, the authors identified patients with newly diagnosed BC who underwent cystoscopic biopsy or TURB, and those who received intravesical chemotherapy within 1 day after TURB. Economic consequences of this treatment compared with TURB alone were modeled using published efficacy estimates and Medicare reimbursements. The authors used a time horizon of 3 years and assumed that this treatment was given for all newly diagnosed low-risk BC patients. RESULTS Between 1997 and 2004, the authors identified 16,748 patients with newly diagnosed BC, of whom 14,677 underwent cystoscopic biopsy or TURB. Of these, only 49 (0.33%) received same-day intravesical instillation of chemotherapy. From 1997 through 2004, there has been little change in the use of this treatment. The authors estimated a 3-year savings of $538 to $690 (10% to 12%) per patient treated with TURB and immediate intravesical chemotherapy compared with TURB alone, reflecting a yearly national savings of $19.8 to $24.8 million. CONCLUSIONS Instillation of intravesical chemotherapy immediately after TURB has not been embraced in the US. Adopting this policy would significantly lower the cost of BC care.
Collapse
Affiliation(s)
- Ralph Madeb
- Department of Urology, University of Rochester School of Medicine, Rochester, New York, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Dobruch J, Herr H. Should all patients receive single chemotherapeutic agent instillation after bladder tumour resection? BJU Int 2009; 104:170-4. [PMID: 19493266 DOI: 10.1111/j.1464-410x.2009.08654.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jakub Dobruch
- Department of Urology, Postgraduate Medical Education Center, Bursztynowa 2, Warsaw, Poland.
| | | |
Collapse
|
9
|
Holmäng S. Early Single-Instillation Chemotherapy Has No Real Benefit and Should Be Abandoned in Non–Muscle-Invasive Bladder Cancer. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.eursup.2008.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
10
|
Rao PK, Stephen Jones J. Routine perioperative chemotherapy instillation with initial bladder tumor resection. Cancer 2009; 115:997-1004. [DOI: 10.1002/cncr.24104] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
11
|
Bartoletti R, Cai T. Endocavitary Prophylaxis of Superficial Urothelial Bladder Tumours: New Compounds. Urologia 2009. [DOI: 10.1177/039156030907600101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bladder urothelial carcinoma is the fourth most frequent cancer among European men, accounting for about 7% of the total cancers. Transurethral resection (TUR) is usually indicated as the standard treatment for non-muscle invasive bladder cancer (NMIBC). However, TUR is unable to guarantee a complete eradication of Ta, T1 tumors with a recurrence rate ranging from 50 to 70%, and a progression rate to muscle invasive disease ranging from 10 to 15%. Methods The European Association of Urology guidelines recommend adjuvant intravesical chemotherapy after definitive diagnosis of intermediate/high risk NMIBC to reduce both recurrence and progression of the disease. To provide a comprehensive review of intravesical treatment options for NMIBC, we performed a search of the PubMed database for articles between 1980 and 2009 that reported on intravesical agents for treating this disease. Results A critical analysis of the findings resulting from large multicenter trials, phase I, II, III studies for pertinent novel agents and from review articles was carried out. We focused on the following issues: 1) the role of the treatment with Bacillus Calmette-Guérin (BCG) and the need of maintaining the drug schedule (with or without interferon-alpha); 2) the correct timing of adjuvant immuno- and chemotherapy; 3) the use of the novel chemotherapeutic agents; 4) the use of the novel technique of chemotherapeutic agents administration, with a particular interest on electromotive administration of mitomycin.
Collapse
Affiliation(s)
- R. Bartoletti
- Dipartimento di Area Critica Medico Chirurgica, Università degli Studi di Firenze
| | - T. Cai
- Dipartimento di Area Critica Medico Chirurgica, Università degli Studi di Firenze
| |
Collapse
|
12
|
Madeb R, Messing E. Perioperative Intravesical Therapy. Bladder Cancer 2009. [DOI: 10.1007/978-1-59745-417-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
13
|
Hendricksen K, Witjes WP, Idema JG, Kums JJ, van Vierssen Trip OB, de Bruin MJ, Vergunst H, Caris CT, Janzing-Pastors MH, Witjes JA. Comparison of Three Schedules of Intravesical Epirubicin in Patients with Non–Muscle-Invasive Bladder Cancer. Eur Urol 2008; 53:984-91. [DOI: 10.1016/j.eururo.2007.12.033] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 12/14/2007] [Indexed: 11/26/2022]
|
14
|
Berrum-Svennung I, Granfors T, Jahnson S, Boman H, Holmäng S. A single instillation of epirubicin after transurethral resection of bladder tumors prevents only small recurrences. J Urol 2007; 179:101-5; discussion 105-6. [PMID: 17997459 DOI: 10.1016/j.juro.2007.08.166] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We studied whether a single instillation of epirubicin after transurethral bladder tumor resection would influence the interval to and size of the first recurrence. MATERIALS AND METHODS A total of 404 patients from 13 hospitals were randomized to 1 instillation of 50 mg epirubicin or placebo within 6 hours after transurethral resection of bladder tumors. RESULTS Of 155 evaluable patients in the epirubicin group 79 (51.0%) had recurrence compared to 95 of 152 (62.5%) in the placebo group (p = 0.04). Of the recurrences 63.3% were small (1 to 5 mm). Tumor size was unknown in 5 patients. Of 79 patients with recurrence in the epirubicin arm 33 (42.9%) vs 29 (31.5%) of 95 in the placebo arm had larger (more than 5 mm) first recurrences (p = 0.12). Approximately half of the patients with first recurrences were treated as outpatients and the other half spent a total of 145 days in the hospital with no difference between the groups. CONCLUSIONS We confirmed the results of previous studies showing that 8.5 patients must be treated with a single instillation to prevent 1 recurrence. Furthermore, our data may indicate that only small recurrences are prevented, which could easily be fulgurated using local anesthesia at followup cystoscopy. The benefit of single instillations can be questioned if this finding is confirmed by others.
Collapse
|
15
|
Liu B, Wang Z, Chen B, Yu J, Zhang P, Ding Q, Zhang Y. Randomized study of single instillation of epirubicin for superficial bladder carcinoma: long-term clinical outcomes. Cancer Invest 2006; 24:160-3. [PMID: 16537185 DOI: 10.1080/07357900500524405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Intravesical instillation of epirubicin (EPI) is one of the most effective adjuvant therapies for nonmuscle-invasive bladder cancer postoperation. We evaluated the long-term efficacy of single dose intravesical epirubicin for superficial bladder carcinoma recurrence. METHODS Between June 1997 and May 1998, a total of 47 patients with resectable superficial bladder carcinoma (Ta-1, Grade 1-2), primary or recurrent with no recurrence during last one year, were enrolled in this study. All patients were randomized into 3 study groups: Group A-single epirubicin (80 mg/40 mL of normal saline) was administered into the bladder within 6 hours postoperation; Group B-40 mg Epirubicin consecutively; Group C-40 mg mitomycin C, consecutively. In Group B and C, instillation were given every week for 6- 8 weeks and then every one month for 10 months. Patients were followed up at 3, 6, 9, 12, 18, 24, 36, 48, and 60 months of treatment. The analyzed background factors were the therapeutic method, tumor recurrence, and side effects. RESULTS Of the 47 patients, 43 (91.5 percent) were eligible and were followed up for 5 years postoperation. The disease free intervals of the three groups were found to have no significant differences (F = 10.28, p > 0.05). The recurrence rates were 35.7 percent (5/14), 33.3 percent (5/15), and 40 percent (6/15), respectively (chi(2)= 0.83, p > 0.05). Side effects of group A (13.6 percent) was lower than that of Group B or C (53.3 percent and 46.7 percent, respectively) significantly (chi(2) test, p < 0.01). CONCLUSIONS These data indicate that single dose of epirubicin instillation postoperation can reduce the recurrence of superficial bladder carcinoma and has low side effects.
Collapse
Affiliation(s)
- Benchun Liu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China.
| | | | | | | | | | | | | |
Collapse
|
16
|
Oosterlinck W, Solsona E, Akaza H, Busch C, Goebell PJ, Malmström PU, Ozen H, Sved P. Low-grade Ta (noninvasive) urothelial carcinoma of the bladder. Urology 2006; 66:75-89. [PMID: 16399417 DOI: 10.1016/j.urology.2005.07.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2005] [Accepted: 07/06/2005] [Indexed: 10/25/2022]
Abstract
This article discusses the development of international guidelines for the diagnosis, treatment, follow-up, and prevention of low-grade Ta urothelial carcinoma of the bladder. The authors, who are experts in this field from 3 continents and 7 countries, reviewed the English language literature through September 2004. The results of the authors' deliberations are presented here as a consensus document. The objective of this study was to determine the optimal diagnostic workup, treatment, follow-up, and prevention of low-grade, Ta urothelial carcinoma of the bladder. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review the literature on the diagnosis and treatment of low-grade Ta urothelial carcinoma of the bladder. Research was conducted using Medline; this search engine also was used to identify additional works not detected at the initial search. Evidence-based recommendations for diagnosis and management of the disease were made with reference to a 4-point scale. Low-grade Ta urothelial carcinoma of the bladder is a well-studied subject with many level 1 and 2 evidence references that support clinical practice. Findings from 135 reviewed citations are summarized. Many grade A and B recommendations on the diagnostic workup and management of this disease can be given with level 1 and 2 evidence based on prospective randomized clinical trials of sufficient statistical power. This should improve the quality of the treatment of this disease.
Collapse
|
17
|
Chung D, Hersey K, Fleshner N. Differences between urologists in United States and Canada in approach to bladder cancer. Urology 2005; 65:919-25. [PMID: 15882724 DOI: 10.1016/j.urology.2004.11.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Revised: 10/19/2004] [Accepted: 11/18/2004] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To determine the Canada-United States differences with respect to the detection, diagnosis, surveillance, and treatment of bladder cancer. METHODS A multiple-choice questionnaire was developed and mailed to 760 American and 516 Canadian urologists between November and December 2002. The areas assessed by the questionnaire included demographics, screening, superficial disease and recurrence, surveillance, muscle-invasive disease, advanced disease, and adjuvant systemic chemotherapy. RESULTS The survey was adequately completed by 32.3% of American urologists and 40.0% of Canadian urologists (overall response rate 36.2%). Canadian urologists tended to be older and had larger practices than U.S. urologists (P <0.05). With respect to bladder cancer detection, U.S. urologists were more likely to use intravenous urography and cystoscopy than were Canadian urologists (P <0.0001). For patients with superficial disease, a significant proportion of urologists in both countries did not routinely use adjuvant chemotherapy. For surveillance, Canadian urologists performed cystoscopy (P <0.0001) and upper tract imaging (P <0.0001) less frequently than U.S. urologists. Striking differences were noted in the approach to Stage T2a disease, with U.S. urologists advocating radical cystectomy more frequently (P <0.0001). With respect to the type of urinary diversion, Canadian urologists tended to favor conduits (P <0.0001, male and P = 0.002, female). Canadian urologists were also less likely to use adjuvant chemotherapy among patients with advanced disease. CONCLUSIONS The results of our study have shown that the trend of urologists in the United States is toward more aggressive screening, closer surveillance, an earlier trigger for cystectomy, and more common indications for intravenous chemotherapy.
Collapse
Affiliation(s)
- Doreen Chung
- Department of Surgery, Division of Urology, Princess Margaret Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | | |
Collapse
|
18
|
Perabo FGE, Müller SC. Current and new strategies in immunotherapy for superficial bladder cancer. Urology 2005; 64:409-21. [PMID: 15351555 DOI: 10.1016/j.urology.2004.04.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Accepted: 04/19/2004] [Indexed: 11/30/2022]
MESH Headings
- Adjuvants, Immunologic/administration & dosage
- Adjuvants, Immunologic/therapeutic use
- Administration, Intravesical
- Administration, Oral
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Phytogenic/therapeutic use
- Bacterial Vaccines/administration & dosage
- Bacterial Vaccines/therapeutic use
- Carcinoma, Transitional Cell/drug therapy
- Carcinoma, Transitional Cell/pathology
- Carcinoma, Transitional Cell/therapy
- Clinical Trials, Phase I as Topic
- Clinical Trials, Phase II as Topic
- Cytosine/administration & dosage
- Cytosine/adverse effects
- Cytosine/analogs & derivatives
- Cytosine/therapeutic use
- Exotoxins/administration & dosage
- Exotoxins/therapeutic use
- Heart Diseases/chemically induced
- Hemocyanins/administration & dosage
- Hemocyanins/therapeutic use
- Humans
- Immunologic Factors/administration & dosage
- Immunologic Factors/therapeutic use
- Immunotherapy/methods
- Immunotherapy/trends
- Interferons/administration & dosage
- Interferons/therapeutic use
- Interleukins/administration & dosage
- Interleukins/therapeutic use
- Randomized Controlled Trials as Topic
- Recombinant Proteins/administration & dosage
- Recombinant Proteins/therapeutic use
- Transforming Growth Factor alpha/administration & dosage
- Transforming Growth Factor alpha/therapeutic use
- Treatment Outcome
- Tumor Necrosis Factor-alpha/administration & dosage
- Tumor Necrosis Factor-alpha/therapeutic use
- Urinary Bladder Neoplasms/drug therapy
- Urinary Bladder Neoplasms/pathology
- Urinary Bladder Neoplasms/therapy
Collapse
|
19
|
Abstract
The high recurrence rate in superficial bladder cancer (>70%) is caused by the adhesion of free floating tumor cells during transurethral treatment, by incomplete resections, and by overlooked and new tumors. Frequent follow-ups and reoperations are necessary. A single immediate instillation after TUR shows positive effects in reducing recurrence rates and is therefore recommended in the European Guidelines from 2001. The amount, concentration, instillation time, and substances have not yet been standardized. By analyzing the literature we found many different techniques of early instillation therapy. Different substances, concentrations, varying instillation times, and application times make a comparison of these studies very difficult. Further studies are needed to standardize early postoperative instillation therapy.
Collapse
Affiliation(s)
- S Langbein
- Urologische Universitätsklinik Mannheim.
| | | | | | | | | |
Collapse
|
20
|
Sylvester RJ, Oosterlinck W, van der Meijden APM. A SINGLE IMMEDIATE POSTOPERATIVE INSTILLATION OF CHEMOTHERAPY DECREASES THE RISK OF RECURRENCE IN PATIENTS WITH STAGE Ta T1 BLADDER CANCER: A META-ANALYSIS OF PUBLISHED RESULTS OF RANDOMIZED CLINICAL TRIALS. J Urol 2004; 171:2186-90, quiz 2435. [PMID: 15126782 DOI: 10.1097/01.ju.0000125486.92260.b2] [Citation(s) in RCA: 466] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE We determined if 1 immediate instillation of chemotherapy after transurethral resection (TUR) decreases the risk of recurrence in patients with stage Ta T1 single and multiple bladder cancer overall and separately. MATERIALS AND METHODS A meta-analysis was performed of the published results of randomized clinical trials comparing TUR alone to TUR plus 1 immediate instillation of chemotherapy. RESULTS Our study included 7 randomized trials with recurrence information on 1476 patients. Based on a median followup of 3.4 years and a maximum of 14.5 years, 267 of 728 patients (36.7%) receiving 1 postoperative instillation of epirubicin, mitomycin C, thiotepa or (2'R)-4'-O-tetrahydropyranyl-doxorubicin (pirarubicin) had recurrence compared to 362 of 748 patients (48.4%) with TUR alone, a decrease of 39% in the odds of recurrence with chemotherapy (OR 0.61, p <0.0001). Patients with a single tumor (OR 0.61) and those with multiple tumors (OR 0.44) benefited. However, after 1 instillation 65.2% of patients with multiple tumors had recurrence compared to 35.8% of patients with single tumors, showing that 1 instillation alone is insufficient treatment for patients with multiple tumors. CONCLUSIONS One immediate intravesical instillation of chemotherapy significantly decreases the risk of recurrence after TUR in patients with stage Ta T1 single and multiple bladder cancer. It is the treatment of choice in patients with a single, low risk papillary tumor and is recommended as the initial treatment after TUR in patients with higher risk tumors.
Collapse
Affiliation(s)
- Richard J Sylvester
- European Organization for the Research and Treatment of Cancer Data Center, Brussels, the Universitair Ziekenhuis Gent, Gent, Belgium.
| | | | | |
Collapse
|
21
|
Perioperative Single Dose Instillation of Epirubicin or Interferon-?? After Transurethral Resection for The Prophylaxis of Primary Superficial Bladder Cancer Recurrence: A Prospective Randomized Multicenter Study???Finnbladder III Long-Term Results. J Urol 2002. [DOI: 10.1097/00005392-200209000-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Rajala P, Kaasinen E, Raitanen M, Liukkonen T, Rintala E. Perioperative single dose instillation of epirubicin or interferon-alpha after transurethral resection for the prophylaxis of primary superficial bladder cancer recurrence: a prospective randomized multicenter study--FinnBladder III long-term results. J Urol 2002; 168:981-5. [PMID: 12187204 DOI: 10.1016/s0022-5347(05)64556-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE We evaluated the long-term efficacy of a single dose of interferon or epirubicin administered immediately after transurethral resection compared with transurethral resection alone for primary superficial bladder cancer recurrence. MATERIAL AND METHODS A total of 200 patients with primary superficial stages Ta to T1, grades 1 to 3 bladder cancer were randomized into 3 treatment groups, including transurethral resection alone, transurethral resection plus 50 milliunits interferon-alpha2b and transurethral resection plus 100 mg. epirubicin. The primary end point was time to first recurrence. RESULTS At a median followup of 72 months we observed a sustained effect of a single epirubicin instillation compared with other treatments. To date only 46% of the patients in group 3 have experienced recurrence in contrast to 73% and 68% in groups 1 and 2, respectively (p = 0.002). At 72 months the Kaplan-Meier disease-free estimates were 24%, 31% and 51% in groups 1 to 3, respectively (p = 0.002). The Cox multivariate model revealed a more than 2-fold relative risk of recurrence in group 1 versus group 3 (p <0.001). Other significant variables predicting recurrence were grade and the number of tumors. CONCLUSIONS A single perioperative instillation of 100 mg. epirubicin causes a significant and sustained decrease in primary superficial bladder cancer recurrence, whereas a single dose of 50 milliunits interferon-alpha2b is ineffective for prophylaxis.
Collapse
Affiliation(s)
- Pertti Rajala
- Divisions of Urology, Turku University Hospital, Turku, Finland
| | | | | | | | | |
Collapse
|
23
|
Kaasinen E, Rintala E, Hellström P, Viitanen J, Juusela H, Rajala P, Korhonen H, Liukkonen T. Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma. Eur Urol 2002; 42:167-74. [PMID: 12160589 DOI: 10.1016/s0302-2838(02)00260-9] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To study the factors determining new recurrences in patients with frequently recurring superficial bladder tumors. METHODS Of all 205 eligible patients, each received 5 weekly intravesical instillations of mitomycin C (MMC), with the first instillation given perioperatively. This was followed, according to randomization, by BCG instillations alone or by alternating instillations of interferon-alpha and BCG monthly for up to 1 year. Impact of 12 variables on time to first recurrence was retrospectively studied with the Cox multiple hazards regression and Kaplan-Meier analysis. RESULTS Type of regimen was the most significant factor determining new recurrences, with preceding recurrence rate being the most important prognostic factor. Timing of the first MMC was the third significant predictor in the main multivariate analysis, with more than a two-fold relative risk for a new recurrence if the first MMC instillation was given later than on day 0. CONCLUSION Preceding recurrence rate, most accurately reflects, in patients with frequently recurring tumors, the inherent risk for new recurrences. This risk can be considerably reduced by use of an effective chemoimmunotherapy regimen, and in addition, by inclusion of an early perioperative chemotherapy instillation in such a regimen.
Collapse
|
24
|
Malmström PU. A randomized comparative dose-ranging study of interferon-alpha and mitomycin-C as an internal control in primary or recurrent superficial transitional cell carcinoma of the bladder. BJU Int 2002; 89:681-6. [PMID: 11966624 DOI: 10.1046/j.1464-410x.2002.02734.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare, in a phase II study, the activity and toxicity of three dose levels of interferon-alpha, and of mitomycin-C given intravesically (as an internal control to validate the results), the primary objective being to investigate the percentage of complete responses (complete disappearance of a marker lesion) induced by the three interferon-alpha dose levels on a marker lesion; a secondary objective was to compare the interferon-alpha doses for toxicity. PATIENTS AND METHODS In all, 115 patients were enrolled, with the inclusion criteria being multiple grade 1 or 2, stage Ta or T1, primary or recurrent transitional cell carcinoma of the bladder. Interferon-alpha (30, 50 and 80 MU) and mitomycin-C (40 mg) intravesical treatments were given as follows. Patients randomized to one of three interferon-alpha dose levels were treated weekly for 12 weeks. However, in week 9 (first cystoscopy after baseline) interferon-alpha treatment was stopped if there was a complete response or disease progression. Patients randomized to mitomycin-C were treated weekly for 8 weeks only and in week 9 underwent follow-up cystoscopy. RESULTS Interferon-alpha at doses of 30, 50 and 80 MU gave response rates at 13 weeks of 19%, 33% and 41%, respectively. Although the response rates were higher for 50 and 80 MU than for 30 MU, the differences were not statistically significant. All three interferon-alpha groups had significantly lower response rates than the internal control, mitomycin-C (72%). The safety analysis showed that most of the adverse events were of mild to moderate severity. Adverse events were experienced by 37%, 37% and 48% of patients receiving 30, 50 and 80 MU interferon-alpha, respectively, and by 55% of patients receiving mitomycin-C. The corresponding rates for severe adverse events related to treatment were 9% for interferon-alpha and 10% for mitomycin-C. CONCLUSION Ablative therapy with interferon-alpha was less effective than mitomycin-C in patients with superficial bladder cancer. Both drugs were well tolerated, although interferon-alpha appeared to have a slightly better overall safety profile.
Collapse
Affiliation(s)
- Per-Uno Malmström
- Department of Urology, University Hospital, Uppsala University, Akademiska sjukhuset, SE-75185 Uppsala, Sweden.
| |
Collapse
|
25
|
Okamura K, Ono Y, Kinukawa T, Matsuura O, Yamada S, Ando T, Fukatsu T, Ohno Y, Ohshima S. Randomized study of single early instillation of (2"R)-4'-O-tetrahydropyranyl-doxorubicin for a single superficial bladder carcinoma. Cancer 2002; 94:2363-8. [PMID: 12015761 DOI: 10.1002/cncr.10496] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although transurethral resection of a bladder tumor (TUR-Bt) alone has been standard treatment for single superficial bladder carcinoma, some authors reported a certain prophylactic effect of a single immediate intravesical instillation of chemotherapeutic agent after TUR-Bt. A prospective randomized study was conducted to determine whether a single (2"R)-4'-O-tetrahydropyranyl-doxorubicin (THP) instillation immediately after TUR-Bt is beneficial to patients with a single superficial bladder carcinoma. METHODS One hundred seventy patients with a single resectable superficial bladder carcinoma (Ta-1, primary or recurrent with no recurrence during the last 1 year) were enrolled in this study. THP (30 mg/30 mL of normal saline) was administered into the bladder within 6 hours after TUR-Bt in arm A, while TUR-Bt alone was done in arm B. RESULTS Of the 170 patients, 160 (94.1%) were eligible and were followed up for a median time of 40.8 months. There was a significant difference in the recurrence free curve between the 2 arms (log-rank test; P = 0.0026), with 92.4% recurrence free rate at 1 year, 82.7% at 2 years, and 78.8% at 3 years in arm A (84 patients) and 67.0%, 55.7%, and 52.6%, respectively, in arm B. The recurrence rate per year was 0.11 +/- 0.22 in arm A and 0.24 +/- 0.36 in arm B, with a significant difference (P = 0.007). Toxicity included pain with micturition in 9 patients (10.7%), urinary frequency/urgency in 5 patients (6.0%), and macroscopic hematuria in 7 patients (8.3%). CONCLUSIONS These data indicate that a single THP instillation immediately after TUR reduces the recurrence of superficial bladder carcinoma.
Collapse
Affiliation(s)
- Kikuo Okamura
- Department of Urology, Chubu National Hospital, Gengo, Morioka-cho, Obu, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
INHIBITION OF BLADDER CARCINOMA CELL ADHESION BY OLIGOPEPTIDE COMBINATIONS IN VITRO AND IN VIVO. J Urol 2002. [DOI: 10.1097/00005392-200201000-00101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
|
28
|
Abstract
The primary role of immunotherapy for bladder cancer is to treat superficial transitional cell carcinomas (ie, carcinoma in situ, Ta, and T1). Immunotherapy in the form of bacille Calmette-Guérin (BCG), interferon, bropirimine, keyhole limpet hemocyanin, and gene therapy is intended to treat existing or residual tumor, to prevent recurrence of tumor, to prevent progression of disease, and to prolong survival of patients. Presently, BCG is commonly used and is the most effective immunotherapeutic agent against superficial transitional cell carcinoma. Data support that BCG has a positive impact on tumor recurrence, disease progression, and survival. Proper attention to maintenance schedules, route of administration, dosing, strains, and viability is essential to obtain the maximum benefits of BCG immunotherapy. This review highlights and summarizes the recent advances concerning immunotherapy, with special emphasis on BCG therapy for transitional cell carcinoma.
Collapse
Affiliation(s)
- A M Kamat
- Department of Urology, PO Box 9251, Health Sciences Center, West Virginia University, Morgantown, WV 26506, USA
| | | |
Collapse
|
29
|
Abstract
Transitional cell carcinoma (TCC) of the bladder makes up 90% of bladder cancers. The approach to the management of localized TCC includes accurate clinical and histologic diagnosis and staging with pathologic material obtained through endoscopy. Once the diagnosis of superficial TCC has been established, histologically based prognostic factors guide which therapy or combination of therapies is indicated in the management of individual patients. Surgery alone (transurethral resection) is appropriate initial therapy for noninvasive papillary TCC. For lamina propria invasive tumors and carcinoma in situ, intravesical immunotherapy with bacille Calmette-Guérin (BCG) is often the first line of treatment to decrease tumor recurrence and to possibly decrease progression and improve survival. Intravesical chemotherapy and interferon are alternative therapies that can also decrease recurrence rates. For BCG-refractory TCC, durable response rates with alternative intravesical therapies are low. For superficial TCC that is refractory to endoscopic procedures and intravesical agents or for disease progression, radical cystectomy with neobladder formation or other forms of urinary diversion is the treatment of choice.
Collapse
Affiliation(s)
- J I Izawa
- Department of Urology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 110, Houston, TX 77030, USA
| | | |
Collapse
|
30
|
Yamamoto Y, Nasu Y, Saika T, Akaeda T, Tsushima T, Kumon H. The absorption of pirarubicin instilled intravesically immediately after transurethral resection of superficial bladder cancer. BJU Int 2000; 86:802-4. [PMID: 11069404 DOI: 10.1046/j.1464-410x.2000.00911.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess the validity of the prophylactic use of pirarubicin ([2'R]-4-O-tetrahydropyranyl-doxorubicin) immediately after transurethral resection of bladder tumour (TURBT), using pharmacodynamic studies. PATIENTS AND METHODS The study included 20 consecutive patients with superficial bladder cancer. Pirarubicin (30 mg/50 mL or 30 mg/100 mL, 10 patients each) was instilled immediately after TURBT and retained in the bladder for 1 h. Blood samples were obtained before and at 15, 30, 60 and 120 min after the instillation. After retaining the drug for 1 h all the intravesical fluid was collected and assayed for pirarubicin. RESULTS The plasma pirarubicin concentration in those receiving either dose was below detectable levels at any time after instillation. The mean recovery rate of pirarubicin in the drained fluid was 73%. CONCLUSION The intravesical instillation of pirarubicin immediately after TURBT caused no detectable plasma concentration and few systemic side-effects.
Collapse
Affiliation(s)
- Y Yamamoto
- Department of Urology, Okayama University Medical School, Okayama, Japan
| | | | | | | | | | | |
Collapse
|
31
|
Patterson AL, Greenberg RE, Weems L, Bahnson R, Wajsman Z, Israel M, Sweatman T, Webber D, Gulfo J. Pilot study of the tolerability and toxicity of intravesical valrubicin immediately after transurethral resection of superficial bladder cancer. Urology 2000; 56:232-5. [PMID: 10925084 DOI: 10.1016/s0090-4295(00)00654-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess in a pilot study the safety, tolerability, and technical feasibility of administering intravesical valrubicin immediately after transurethral resection of bladder tumors (TURBT) in patients with superficial bladder cancer and to evaluate the optimal dose of valrubicin and its systemic absorption. METHODS Twenty-two patients with recurrent or newly diagnosed Stage Ta or T1 transitional cell tumors received a single dose of 400 mg, 600 mg, or 800 mg of intravesical valrubicin immediately after TURBT. Four patients thought to be at high risk of recurrence were followed up with five additional doses of 800 mg valrubicin, given weekly. RESULTS The use of valrubicin after TURBT was generally well tolerated. Little evidence was found to suggest a direct relationship among the dose of valrubicin, the time between the end of TURBT and drug instillation, and the occurrence of most bladder symptoms. The most commonly reported adverse events included dysuria (77%), hematuria (59%), and urgency/frequency (23%). Pharmacokinetic analyses revealed that the mean systemic exposure to valrubicin and its metabolites depended on the extent of the TURBT and the damage to the bladder wall. CONCLUSIONS The results of this study indicated that administration of valrubicin immediately after TURBT is feasible.
Collapse
Affiliation(s)
- A L Patterson
- Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Affiliation(s)
- A M Kamat
- Department of Urology, West Virginia University School of Medicine, Morgantown, USA
| | | |
Collapse
|
33
|
Onrust SV, Wiseman LR, Goa KL. Epirubicin: a review of its intravesical use in superficial bladder cancer. Drugs Aging 1999; 15:307-33. [PMID: 10582777 DOI: 10.2165/00002512-199915040-00006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
UNLABELLED The anthracycline epirubicin has been investigated for intravesical use in patients with superficial bladder cancer. In multicentre, randomised trials, prophylaxis with intravesical epirubicin 30 to 80 mg after transurethral resection (TUR) was more effective than no prophylaxis in the prevention of disease recurrence. Intravesical prophylaxis with epirubicin was as effective as that with equivalent dosages of doxorubicin after TUR. Data are conflicting concerning the relative efficacy of intravesical epirubicin and bacillus Calmette-Guerin (BCG) in patients at intermediate risk of recurrence after TUR, but epirubicin was less effective than BCG in those at high risk. The efficacy and tolerability of prophylaxis with epirubicin relative to that with mitomycin is not yet established. The efficacy of epirubicin as prophylaxis after TUR in combination with BCG or interferon-alpha-2b, or as treatment in patients with superficial bladder cancer has been evaluated in small, noncomparative trials, but requires clarification. Adverse events associated with intravesical epirubicin were generally mild and transient. The most common adverse events were localised to the bladder (cystitis, haematuria and urinary tract infection). Systemic adverse events (cardiac, haematological or related to hypersensitivity) were not reported in many trials of intravesical epirubicin, and when reported generally occurred in < or =5% of patients who received the drug. Intravesical epirubicin was generally tolerated as well as intravesical doxorubicin and was associated with a lower incidence of mild chemical cystitis in 1 clinical trial. The incidence of adverse events associated with intravesical epirubicin was markedly lower than that associated with intravesical BCG. CONCLUSIONS Intravesical epirubicin has shown efficacy in preventing disease recurrence after TUR of superficial bladder cancer. In comparison with equivalent dosages of doxorubicin, the efficacy of epirubicin for this indication is generally similar, and the tolerability profile may be more favourable. Epirubicin is less effective than BCG as intravesical prophylaxis in patients at high risk of recurrence after TUR; the relative efficacy of epirubicin and BCG after TUR in patients at intermediate risk is not yet clear. Intravesical epirubicin is generally tolerated better than BCG. Intravesical epirubicin may be used as prophylaxis after TUR in patients who are at low or intermediate risk of recurrence of superficial bladder cancer.
Collapse
Affiliation(s)
- S V Onrust
- Adis International Limited, Mairangi Bay, Auckland, New Zealand.
| | | | | |
Collapse
|