Impact of intravesical chemotherapy versus BCG immunotherapy on recurrence of superficial transitional cell carcinoma of the bladder: metaanalytic reevaluation

Sequential intravesical gemcitabine and docetaxel for treatment-naïve and previously treated intermediate-risk nonmuscle invasive bladder cancer

INTRODUCTION

Adjuvant intravesical therapy is recommended for patients with intermediate-risk NMIBC. While intravesical gemcitabine-docetaxel (Gem/Doce) has demonstrated favorable outcomes for high-risk NMIBC, its utility in the intermediate-risk setting is not well described. We report outcomes of Gem/Doce as an adjuvant treatment for intermediate-risk NMIBC.

METHODS

We retrospectively identified patients with intermediate-risk NMIBC by AUA criteria treated with Gem/Doce following TURBT between 2012 and 2022. Patients received weekly sequential intravesical instillations of 1 g gemcitabine and 37.5 mg docetaxel for 6 weeks. Monthly maintenance of 2 years was initiated if disease-free at first surveillance. The primary outcome was recurrence-free survival (RFS), assessed using the Kaplan-Meier method.

RESULTS

The cohort included 77 patients with median follow-up of 26 (IQR 14-50) months. Prior to induction, 67 (87%) patients presented with Ta low-grade (LG) lesions, 3 (3.9%) with Ta high-grade (HG), 5 (6.5%) with TaLG plus focal TaHG, and 2 (2.6%) with T1LG. Thirty-three (43%) patients received previous intravesical therapy including BCG (23), mitomycin (13), and docetaxel monotherapy (12). The 2-year RFS was 71% among all patients. Treatment-naïve patients had superior RFS compared to previously treated patients (P = 0.04); 2-year estimates were 79% and 64%, respectively. Twenty-nine (38%) patients experienced adverse events; all were Grade 1 to 2 except 1 (1.3%) Grade 3 (acute oxygen desaturation). Three (3.9%) patients did not tolerate a full induction course.

CONCLUSIONS

In this retrospective review of a heterogenous population of patients with intermediate-risk NMIBC, Gem/Doce was an effective and well-tolerated adjuvant therapy. Further prospective evaluation in this setting is needed.

Analysis of sex-based differences to Bacillus Calmette-Guérin for non-muscle invasive bladder cancer

OBJECTIVE

To evaluate whether differences exist between men and women in response to intravesical BCG treatments. The incidence of urothelial carcinoma of the bladder is lower in women but they tend to present with more aggressive and advanced disease. Some prior studies also suggest there are sex-based differences in response to treatment for non-muscle invasive bladder tumors.

METHODS

In this retrospective study, we reviewed all consecutive patients who received BCG at the CHU de Québec - Laval University from 2009-2019. Men and women were treated with intravesical BCG therapy following pathologic confirmation of urothelial carcinoma. Outcomes evaluated include recurrence, progression, and treatment tolerability. Recurrence was defined as a pathology confirmed cancer whereas progression was the new development of high-grade (recurrence) pathology or an increase of stage. Tolerability was defined according to the proportion of prescribed BCG received. All clinical details were obtained through review of the medical records, collaborated by pharmacy records for BCG administration. Competing-risk analysis was used to compare outcomes.

RESULTS

Among 613 patients who received BCG at our institution between 2009-2019, 472 (77.0%) were men and 141 (23.0%) were women. The recurrence rate was not different between sexes, with a 5-year recurrence risk of 52% (95% CI: 36.93-65.4) among women compared to 57.5% (CI 95%: 51.9-62.6) among men. The overall non-progression rate at 1,3 and 5 years was 97.3% (95% CI: 95.6%-98.3%), 93.6% (95% CI: 91.2%-95.4%), and 91.7% (95% CI: 88.4%-94.1%), respectively. The completion of ≥5 induction BCG instillations and maintenance BCG use was similar in both genders.

CONCLUSIONS

We report a contemporary NMIBC cohort treated with BCG and find no clear evidence for sex-based differences in response to BCG treatment in regard of progression, recurrence, and tolerability.

Intravesical BCG: where do we stand? Past, present and future

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.

Are we following the guidelines on non-muscle invasive bladder cancer?

Objectives

To evaluate the clinical practice of non-muscle invasive bladder cancer (NMIBC) treatment in Brazil in relation to international guidelines: Sociedade Brasileira de Urologia (SBU), European Association of Urology (EAU) and American Urological Association (AUA).

Materials and Methods

Cross-sectional study using questionnaires about urological practice on treatment of NMIBC during the 32nd Brazilian Congress of Urology. A total of 650 question forms were answered.

Results

There were 73% of complete answers (total of 476 question forms). In total, 246 urologists (51.68%) lived in the southeast region and 310 (65.13%) treat 1 to 3 cases of NMIBC per month. Low risk cancer: Only 35 urologists (7.5%) apply the single intravesical dose of immediate chemotherapy with Mitomicin C recommended by the above guidelines. Adjuvant therapy with BCG 2 to 4 weeks after TUR is used by 167 participants (35.1%) and 271 urologists (56.9%) use only TUR. High risk tumors: 397 urologists (83.4%) use adjuvant therapy, 375 (78.8%) use BCG 2 to 4 weeks after TUR, of which 306 (64.3%) referred the use for at least one year. Intravesical chemotherapy with Mitomicin C (a controversial recommendation) was used by 22 urologists (4.6%). BCG dose raised a lot of discrepancies. Induction doses of 40, 80 and 120mg were referred by 105 (22%), 193 (40.4%) and 54 (11.3%) respectively. Maintenance doses of 40, 80 and 120mg were referred by 190 (48.7%), 144 (37.0%) and 32 (8.2%) urologists, respectively. Schemes of administration were also varied and the one cited by SWOG protocol was the most used: 142 (29.8%).

Conclusion

SBU, EAU and AUA guidelines are partially respected by Brazilian urologists, particularly in low risk tumors. In high risk tumors, concordance rates are comparable to international data. Further studies are necessary to fully understand the reasons of such disagreement.

Optimal treatment of non-muscle invasive urothelial carcinoma including perioperative management revisited

Non-muscle invasive urothelial carcinoma is a heterogeneous disease that requires the practicing urologist to implement a variety of surgical and non-surgical treatment strategies. The disease course can range from recurrent low grade papillary disease to aggressive disease concerning for progression from initial presentation. Depending on the particular patient and goals of care, treatments similarly span the range from minimally invasive fulgurations to immediate radical cystectomy. For most patients some form of intravesical therapy will bridge the gap between transurethral resections (TUR) and radical surgery. Recent advances in the field continue to emphasize the importance of quality TUR and its strong impact on outcomes. In addition, continued research to optimize intravesical therapies has provided more information about how, when, and in whom these agents should be utilized to enhance their efficacy. This review covers the current state of NMIBC and the standards of care for the management of this disease.

Perioperative chemotherapy: when to use it, what to use, and why

This article provides an overview of intravesical chemotherapy agents used for non-muscle invasive bladder cancer; summarizes the evidence on single-dose perioperative administration, induction therapy, and maintenance therapy; and briefly discusses ongoing research.

Oncolytic viruses in the treatment of bladder cancer

Bladder carcinoma is the second most common malignancy of the urinary tract. Up to 85% of patients with bladder cancer are diagnosed with a tumor that is limited to the bladder mucosa (Ta, T1, and CIS). These stages are commonly termed as non-muscle-invasive bladder cancer (NMIBC). Although the treatment of NMIBC has greatly improved in recent years, there is a need for additional therapies when patients fail bacillus Calmette-Guérin (BCG) and chemotherapeutic agents. We propose that bladder cancer may be an ideal target for oncolytic viruses engineered to selectively replicate in and lyse tumor cells leaving normal cells unharmed. In support of this hypothesis, here we review current treatment strategies for bladder cancer and their shortcomings, as well as recent advancements in oncolytic viral therapy demonstrating encouraging safety profiles and antitumor activity.

Surveillance and treatment of non-muscle-invasive bladder cancer in the USA

Seventy percent of newly diagnosed bladder cancers are classified as non-muscle-invasive bladder cancer (NMIBC) and are often associated with high rates of recurrence that require lifelong surveillance. Currently available treatment options for NMIBC are associated with toxicities that limit their use, and actual practice patterns vary depending upon physician and patient characteristics. In addition, bladder cancer has a high economic and humanistic burden in the United States (US) population and has been cited as one of the most costly cancers to treat. An unmet need exists for new treatment options associated with fewer complications, better patient compliance, and decreased healthcare costs. Increased prevention of recurrence through greater adherence to evidence-based guidelines and the development of novel therapies could therefore result in substantial savings to the healthcare system.

Update on the management of non-muscle invasive bladder cancer

Non-muscle invasive bladder cancer (NMIBC) is a heterogeneous population of tumours accounting for 80% of bladder cancers. Over the years, the management of this disease has been changing with improvements in results and outcomes. In this review, we focus on the latest updates on the management of NMIBC.

Management of BCG non-responders with fixed dose intravesical gemcitabine in superficial transitional cell carcinoma of urinary bladder

Aims and Objectives:

The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (WHO). Though intravesical adjuvant therapy with BCG is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon become BCG failure. Hence there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim was to study the efficacy, tolerability and safety of intravesical Gemcitabine in managing BCG-refractory superficial bladder malignancy.

Materials and Methods:

Thirty-five BCG failure patients, 26 males and nine females between 20-72 years of age were instilled with 2000 mg of Gemcitabine in 50 ml of normal saline intravesically two weeks post tumor resection, for six consecutive weeks. Mean follow-up was for 18 months with cystoscopies.

Results:

Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences while three patients (8.6%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated.

Conclusion:

Gemcitabine fulfils all requirements as an alternative agent, in treating BCG failure patients with low adverse events, is well tolerated and highly effective in reducing tumor recurrences.

Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer

BACKGROUND

Bladder cancer accounts for approximately 4.4% of adult malignancies, and approximately 80% of bladder cancer presents initially as transitional cell carcinoma that is confined to the urothelium (stage Ta) or lamina propria (stage T1). Intravesical administration of Bacillus Calmette-Guérin (BCG) and epirubicin (EPI) has been proven to reduce tumour recurrence and prevent or delay progression to muscle invasion and metastases. However, comparison of the effectiveness and safety of intravesical BCG and EPI in bladder cancer has yet to be explored.

OBJECTIVES

To compare the effectiveness and safety of BCG with EPI in the treatment of Ta and T1 bladder cancer.

SEARCH STRATEGY

A comprehensive search of MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), Health Services Technology, Administration, and Research (HealthSTAR), the Cochrane Central Register of Controlled Trials (CENTRAL), CancerLit, and Database of Abstracts of Reviews of Effectiveness (DARE), was performed, and handsearching of relevant journals was undertaken.

SELECTION CRITERIA

All randomised or quasi-randomised trials (in which allocation was obtained by alternation - e.g., alternate medical records, date of birth, or other predictable methods) in patients with Ta or T1 bladder cancer that compared intravesical BCG with EPI were included. No language restrictions were applied.

DATA COLLECTION AND ANALYSIS

Trial eligibility, methodological quality and data extraction were assessed independently by two reviewers. We compared dichotomous outcomes (frequency of tumour recurrence, progressive disease by stage, mortality, distant metastases, local and systemic adverse effects, treatment delayed or stopped due to adverse effects) using risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Five trials of 1111 participants were included in this review. For BCG, 549 patients were treated, and 562 with EPI. Of the evaluated patients, 35.5% (195/549) in the BCG group and 51.4% (289/562) in the EPI group had tumour recurrence (P < 0.05). For disease progression (BCG, 44/549; EPI, 58/562) and distant metastases (BCG, 23/487; EPI, 31/495), there were no significant differences (P = 0.19 and P = 0.29, respectively). Only two trials, including 769 patients, had sufficient data for us to analyze disease-specific (BCG, 22/383; EPI, 26/386) and overall mortality (BCG, 125/383; EPI, 147/386). Neither comparison was significant (P = 0.93 and P = 0.12, respectively). In four studies reporting toxicity, BCG was associated with significantly more drug-induced cystitis [BCG, 54.1% (232/429); EPI, 31.7% (140/441)] and haematuria [BCG, 30.8% (132/429); EPI, 16.1% (71/440)]. Similarly, in three studies reporting systemic toxicity, BCG had significantly higher toxicity than the EPI (34.8% (134/385) versus 1.3% (5/393), respectively). In a meta-analysis comparing 'treatment delayed or stopped' (BCG, 40/431; EPI, 33/441), there was no significant difference between BCG and EPI treatments (P = 0.82).

AUTHORS' CONCLUSIONS

The data from the present meta-analysis indicate that intravesical BCG treatment is more efficacious than EPI in reducing tumour recurrence for Ta and T1 bladder cancer. However, BCG appears to be associated with a higher incidence of adverse effects, such as drug-induced cystitis, haematuria and systemic toxicity, than EPI. The overall quality of the evidence is rather low. Well-designed, high quality randomised controlled trials with good allocation concealment are required.

Prognostic value of p53 and Ki-67 expression in intermediate-risk patients with nonmuscle-invasive bladder cancer receiving adjuvant intravesical mitomycin C therapy

OBJECTIVES

To analyze the prognostic values of p53 and Ki-67 expression in intermediate-risk patients with nonmuscle-invasive bladder cancer who were treated with adjuvant intravesical mitomycin C.

METHODS

From 2001 to 2006, 129 patients with nonmuscle-invasive bladder cancer who had undergone transurethral resection and adjuvant intravesical mitomycin C therapy. Patients with primary, single, Stage TaG1 lesions and those with T1G3 or carcinoma in situ lesions were excluded. The expression of p53 and Ki-67 was measured by immunohistochemistry on tissue sections after transurethral resection. The clinical and pathologic data were collected in a prospectively maintained bladder cancer database program.

RESULTS

The mean follow-up period was 48.6 months (range 6.1-96.0). Of the 129 patients, 61 (47.3%) developed recurrence and 15 (11.6%) developed progression to muscle-invasive disease. The expression of p53 was not associated with the patient outcomes, but Ki-67 overexpression was related to progression-free survival on univariate analysis (relative risk 4.38, 95% confidence interval 1.48-13.01, P = .006). On multivariate analysis, Ki-67 overexpression was significantly associated with progression-free survival (relative risk 3.40, 95% confidence interval 1.04-11.05, P = .042). In the patients with Ki-67 overexpression, the 1- and 5-year progression-free survival rate was 98.0% and 73.9%, respectively. When the combination of p53 and Ki-67 expression was assessed in the multivariate model, the simultaneous overexpression of p53 and Ki-67 did not predict for progression-free survival (adjusted relative risk 1.16; 95% confidence interval 0.21-6.20, P = .863).

CONCLUSIONS

These results suggest that Ki-67 expression can identify a subset of intermediate-risk patients with nonmuscle-invasive bladder cancer in whom intravesical mitomycin C therapy could be effective.

The effects of intravesical chemoimmunotherapy with gemcitabine and Bacillus Calmette-Guérin in superficial bladder cancer: a preliminary study

This prospective study investigated the long-term effects of intravesical chemoimmunotherapy with gemcitabine (GEM) and bacillus Calmette-Guérin (BCG; n = 36) versus BCG alone (n = 51) for the treatment of superficial bladder cancer. For the chemoimmunotherapy (GEM + BCG) group, GEM (1000 mg) was instilled immediately after transurethral resection of bladder tumour (TURBT) and again (2000 mg) 1 week later. From 2 to 7 weeks after TURBT, BCG was instilled into the bladder of all patients once weekly. The recurrence-free period of the GEM + BCG group (24.13 months) was significantly longer than that of the BCG monotherapy group (19.81 months). The overall recurrence rate was similar between the groups, although at 6 and 9 months post-TURBT, GEM + BCG produced a significantly lower rate of recurrence compared with BCG alone. This study suggests that intravesical chemoimmunotherapy with GEM + BCG is effective in reducing early tumour recurrence and in prolonging the recurrence-free period of superficial bladder cancer.

[Intravesical therapy in non-muscle-invasive bladder cancer: indications and practical considerations]

Intravesical treatment with various agents is an accepted standard for treating patients with non-muscle-invasive bladder cancer; all guidelines recommend its use. Depending on the agent and the instillation schedule, a reduction in recurrence and a decrease in the progression rate can be achieved.However, many of the recommendations in the various guidelines are currently under debate. Early instillation with a chemotherapeutic agent is probably overtreatment in patients requiring further induction or maintenance therapy because it adds no further benefit. The economic aspects of early instillations are also being discussed. Recent studies question the ability of bacillus Calmette-Guérin (BCG) instillations to reduce the progression of non-muscle-invasive bladder cancer. Furthermore, the superiority of maintenance therapies compared with induction schedules is under debate.There is a great body of evidence that the effectiveness of intravesical chemotherapy can be increased by simple measures. Reduction of BCG side effects without compromising the oncological outcome is possible.

[EAU guidelines on non-muscle-carcinoma of the bladder]

CONTEXT AND OBJECTIVE

To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer.

EVIDENCE ACQUISITION

A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned.

EVIDENCE SYNTHESIS

The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2-6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups-separately for recurrence and progression-represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org.

CONCLUSIONS

These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application.

An individual patient data meta-analysis of the long-term outcome of randomised studies comparing intravesical mitomycin C versus bacillus Calmette-Guérin for non-muscle-invasive bladder cancer

BACKGROUND

Patients with non-muscle-invasive bladder cancer with an intermediate or high risk need adjuvant intravesical therapy after surgery. Based largely on meta-analyses of previously published results, guidelines recommend using either bacillus Calmette-Guérin (BCG) or mitomycin C (MMC) in these patients. Individual patient data (IPD) meta-analyses, however, are the gold standard.

OBJECTIVE

To compare the efficacy of BCG and MMC based on an IPD meta-analysis of randomised trials.

DESIGN, SETTING, AND PARTICIPANTS

Trials were searched through Medline and review articles. The relevant trial investigators were contacted to provide IPD.

MEASUREMENTS

The drugs were compared with respect to time to recurrence, progression, and overall and cancer-specific death.

RESULTS AND LIMITATIONS

Nine trials that included 2820 patients were identified, and IPD were obtained from all of them. Patient characteristics were 71% primary, 54% Ta, 43% T1, 25% G1, 58% G2, and 16% G3, and 7% had prior intravesical chemotherapy. Based on a median follow-up of 4.4 yr, 43% recurred. Overall, there was no difference in the time to first recurrence (p=0.09) between BCG and MMC. In the trials with BCG maintenance, a 32% reduction in risk of recurrence on BCG compared to MMC was found (p<0.0001), while there was a 28% risk increase (p=0.006) for BCG in the trials without maintenance. BCG with maintenance was more effective than MMC in both patients previously treated and those not previously treated with chemotherapy. In the subset of 1880 patients for whom data on progression, survival, and cause of death were available, 12% progressed and 24% died, and, of those, 30% of the deaths were due to bladder cancer. No statistically significant differences were found for these long-term end points.

CONCLUSIONS

For prophylaxis of recurrence, maintenance BCG is required to demonstrate superiority to MMC. Prior intravesical chemotherapy was not a confounder. There were no statistically significant differences regarding progression, overall survival, and cancer-specific survival between the two treatments.

Sequential intravesical gemcitabine and mitomycin C chemotherapy regimen in patients with non-muscle invasive bladder cancer

OBJECTIVES

Currently, there are few options other than cystectomy for the management of BCG refractory non-muscle invasive bladder cancer. We report our experience with intravesical combination chemotherapy using gemcitabine and MMC in such patients.

MATERIALS AND METHODS

We identified all patients with non-muscle invasive bladder cancer who were BCG refractory or intolerant and had been treated with intravesical gemcitabine and MMC at our institution. Patients were treated with a combination of intravesical gemcitabine (1000 mg in 50 ml sterile water) followed sequentially by intravesical MMC (40 mg in 20 ml sterile water) every week for 6 weeks (induction). Induction therapy was followed by a maintenance regimen using the same dose of gemcitabine and MMC once a month for 12 months. Data regarding patient demographics and disease information such as previous intravesical therapy, previous cystoscopy, cytology results, time to recurrence, and side effect profile were collected.

RESULTS

A total of 10 patients (6 male and 4 female) aged 48 to 85 years (median 67 years) underwent treatment with a median follow-up of 26.5 months (4-34 months). Six patients were recurrence free and have maintained their response at a median of 14 months (4-34 months). Four patients had biopsy proven recurrence. Median time to recurrence was 6 months (range 4-13 months). The therapy was well tolerated in all patients. There were no major complications. Two patients experienced irritative lower urinary tract symptoms, which did not require cessation of therapy and one experienced a maculopapillary rash that improved with benadryl.

CONCLUSIONS

In patients with recurrent BCG refractory bladder cancer, intravesical combination chemotherapy with gemcitabine and MMC appears to be well tolerated and yields a response in a good proportion number of patients.

Advances in the management of superficial bladder cancer

Given its high tendency to recur, coupled with an ever-present possibility to progress to potentially life-threatening muscle-invasive disease, superficial bladder cancer remains a challenging clinical problem. Optimal management begins with early detection and accurate risk assessment through careful attention to clinical features, aided by an emerging array of urinary markers and molecular characterizations. Prevention of recurrence requires the sequential application of tools to completely remove all visible disease, avert reimplantation during surgical resection, ablate microscopic foci, and prevent the emergence of new primary tumors amidst a field of carcinogen-exposed urothelium. Previously standard adjunctive intravesical chemo- and immunotherapies are enjoying new vitality as optimization strategies, new drugs, and rational drug combinations provide the potential for improved efficacy with reduced toxicity. New technological advances such as fluorescence-aided cystoscopy, microwave chemothermotherapy, and electromotive chemotherapeutic drug delivery offer further hope for better outcomes even for disease previously refractory to conservative measures. Yet despite these advances, aggressive surgical management involving bladder removal continues to be an indispensable life-saving maneuver that must be considered in all high-risk cases that fail to promptly respond to other measures.

Actual experience and future development of gemcitabine in superficial bladder cancer

Gemcitabine has a molecular weight of 299 D, lower than that of commonly-used intravesical chemotherapeutic agents such as mitomycin C (389 D) and doxorubicin (589 D). This may enable gemcitabine to penetrate the bladder mucosa with beneficial effects in the treatment of early invasive bladder cancer (T1 disease). At the same time the molecular weight is high enough to prevent significant systemic absorption in an intact bladder. Based on the results of phase I studies, it appears that the 2000 mg dose of gemcitabine in 50/100 ml normal saline when administered intravesically for up to 2 h once a week for 6 weeks has unremarkable systemic and local side effects and therefore should be considered the most convenient schedule. The currently available phase II studies have assessed the activity of intravesical gemcitabine on a marker lesion in intermediate risk superficial bladder cancers (SBC), showing complete responses in up to 56% of cases. Few attempts have been made to test the activity of intravesical gemcitabine in high risk SBC achieving unexpected complete responses in BCG refractory CIS. Gemcitabine seems to have fulfilled the requirements to be a promising new candidate for standard intravesical therapy in SBC so far. Further phase II trials exploring the activity of gemcitabine on highly-recurrent intermediate risk or high risk SBC would provide additional information to foresee its efficacy in clinical practice and thus constitute the framework for large comparative phase III trials.

Low-grade Ta (noninvasive) urothelial carcinoma of the bladder

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.

[Cell cycle and apoptosis mechanisms implicated in intravesical chemotherapy resistances in superficial bladder cancer]

It is well documented the effectiveness of intravesical chemotherapy following transurethral resection to prevent recurrences of superficial bladder cancer. But it is also known that efficacy may be limited by tumour cell resistance to one or several of the drugs available for instillation. In addition to the genetically determined unicellular mechanisms classically described in the literature such as glycoprotein P-170 expression (mdr-1), overexpression of Bcl-2 or glutation S-transferase activity, it has been recently shown that multicellular mechanisms may also be involved in drug resistance. Multicellular resistance can only be demonstrated in three-dimensional cultures and fails to be shown in monolayers or cell suspensions. This is explained by the fact that cell-to-cell and cell-to-stroma adhesion limits drug penetration and by the variable susceptibility to cytotoxicity determined by oxygen and tissue proliferation gradients. A better understanding of the molecular mechanisms involved in drug resistance is necessary to increase intravesical chemotherapy effectiveness. Current research includes improving drug penetration, searching resistance reversing agents and developing in vitro chemosensitivity tests to identify drug resistance.

Superficial Bladder Cancer Therapy: A Review

Most bladder cancers present as a superficial disease, confined to the bladder mucosa or submucosal layer, without muscle invasion. Most superficial tumors have a propensity for recurrence after transurethral resection; some have a high risk for progression to muscle invasion. The treatment aim in superficial bladder cancer with intravesical therapy is three-fold: (1) eradicate existing disease, (2) prevention of recurrence, (3) prevention of tumor progression. The prognostic factors (tumor stage, grade, size, number and recurrence pattern) allow the stratification of tumors in different risk groups to plan treatment. Studies on pharmacokinetics have proved the efficacy of optimized drug delivery. Comparing resection with and without intravesical chemotherapy, a short-term reduction, approximately 15%, in tumor recurrence with chemotherapy can be obtained, but no effect on progression was proven. No agent has proved to be more effective than the others. A single instillation of chemotherapy immediately after transurethral resection has proven to be effective, but the role of maintenance therapy is controversial. Immunotherapy, in the form of Bacillus Calmette-Guerin, is generally shown to be more effective than chemotherapy, even if the results in comparison to mitomycin C do not result conclusive. Several new approaches are being explored to improve the efficacy of this therapy.

Practical Applications of Intravesical Chemotherapy and Immunotherapy in High-risk Patients with Superficial Bladder Cancer

The following steps are practical in the treatment of intermediate-to-high risk patients with superficial bladder cancer: Resect all visible tumor at the time of first TUR of bladder tumor. Strongly consider re-resection, especially for high-risk, large, multifocal, stage T1 tumors. Apply one dose of cytotoxic chemotherapy perioperatively within 6 hours of TUR (ideally immediately). Once histopathology is available, consider intravesical induction chemotherapy for intermediate-risk patients and BCG for intermediate- or high-risk patients and those having failed prior chemotherapy. At least 1 year of maintenance therapy should be planned for all intermediate-to-high risk BCG-treated patients. Chemotherapy maintenance may be useful if perioperative chemotherapy was omitted. For patients failing standard therapy, a thorough discussion of the risks (including progression and metastasis) and expected benefits should take place before the initiation of salvage therapy. The radical cystectomy option should be openly entertained. Consider BCG plus interferon or gemcitabine-based salvage programs if appropriate. Explore clinical trial options. Contact urologic cancer experts for guidance and advice.

The Influence of Intravesical Therapy on Progression of Superficial Transitional Cell Carcinoma of the Bladder

OBJECTIVE

Currently, the true impact of intravesical chemotherapy or immunotherapy (bacilli Calmette-Guerin [BCG]) on the rate of progression of superficial transitional cell carcinoma of the bladder to muscle invasive disease is unclear. A metaanalysis was performed to statistically compare the efficacy of these treatments in preventing tumor progression in this disease setting.

METHODS

A prospective protocol outlining the metaanalysis noted here was developed followed by a thorough search of the existing published literature using strict eligibility criteria. Eight randomized, controlled trials were found that met protocol specifications. These reports contained data on 2427 patients who were statistically pooled using a fixed-effects model (Peto). The outcome of interest was the proportion of patients progressing to muscle invasive or metastatic disease expressed as a summary odds ratio (ORp). An ORp greater than unity favored BCG versus chemotherapy.

RESULTS

Initial pooling of these 8 trials gave a nonstatistically significant summary odds ratio of 1.24 (0.95-1.61) without evidence of statistical heterogeneity. Analysis by drug type showed significant attenuation of the ORp when the effects of mitomycin C were compared with BCG, ie, 1.04 (0.76-1.42) suggesting that: 1) mitomycin is probably more active than the other chemotherapeutics used in the available trials and 2) BCG is not clearly superior to mitomycin C. Sensitivity analyses also demonstrated that failure to control for prior intravesical drug treatment in all but 2 of the analyzed studies produces a spurious result favoring BCG over intravesical chemotherapy.

CONCLUSION

The available data fail to support a clear superiority of intravesical BCG over intravesical chemotherapy in preventing progression of superficial transitional cell carcinoma of the bladder. Mitomycin C appears more effective than the other commonly used drugs, and failure to control for prior intravesical chemotherapy in most of available studies results in a spurious finding of greater clinic effect of BCG over chemotherapy.

Phase II Study to Investigate the Ablative Efficacy of Intravesical Administration of Gemcitabine in Intermediate-Risk Superficial Bladder Cancer (SBC)

OBJECTIVE

Phase I studies have so far demonstrated that intravesical Gemcitabine up to a 40 mg/ml concentration is well tolerated and has a substantial ablative activity on high-risk BCG refractory SBC. New treatment options are needed for intermediate-risk SBC recurring after conventional intravesical treatments. The purpose of the present study was to investigate the ablative efficacy of intravesical Gemcitabine on intermediate-risk SBC.

METHODS

The study was designed as a two-stage phase II trial, with a sample size of 39 patients. The efficacy of intravesical Gemcitabine at a concentration of 40 mg/ml (2000 mg in 50 ml saline solution) administered weekly for 6 weeks was assessed on a single marker tumour left in the bladder after a complete TUR of all other lesions. Patients underwent TUR or biopsy at the site of the marker lesion 2 weeks after completion of the treatment.

RESULTS

Complete response was observed in 22 out of 39 patients (56%). No progression was observed among the 17 non-responders. Neither systemic nor local side effects generally exceeded grade I toxicity.

CONCLUSION

The ablative effect of Gemcitabine produced a higher number of responses than the minimum required by the protocol to indicate a significant probability of drug efficacy. It is worth testing the drug in phase III trials to assess for durability of response.