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Llano A, Chan A, Kuk C, Kassouf W, Zlotta AR. Carcinoma In Situ (CIS): Is There a Difference in Efficacy between Various BCG Strains? A Comprehensive Review of the Literature. Cancers (Basel) 2024; 16:245. [PMID: 38254736 PMCID: PMC10813486 DOI: 10.3390/cancers16020245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Introduction: Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is the standard of care for high-risk and intermediate-risk non-muscle-invasive bladder cancer (NMIBC) as well as for Carcinoma in situ (CIS). Evidence supports that the different BCG strains, despite genetic variability, are equally effective clinically for preventing the recurrence and progression of papillary NMIBC. The available evidence regarding possible differences in clinical efficacy between various BCG strains in CIS is lacking. Methods: We reviewed the literature on the efficacy of different BCG strains in patients with CIS (whether primary, secondary, concomitant, or unifocal/multifocal), including randomized clinical trials (RCTs), phase II/prospective trials, and retrospective studies with complete response rates (CRR), recurrence-free survival (RFS), or progression-free survival (PFS) as endpoints. Results: In most studies, being RCTs, phase II prospective trials, or retrospective studies, genetic differences between BCG strains did not translate into meaningful differences in clinical efficacy against CIS, regardless of the CIS subset (primary, secondary, or concurrent) or CIS focality (unifocal or multifocal). CRR, RFS, and PFS were not statistically different between various BCG strains. None of these trials were designed as head-to-head comparisons between BCG strains focusing specifically on CIS. Limitations include the small sample size of many studies and most comparisons between strains being indirect rather than head-to-head. Conclusions: This review suggests that the clinical efficacy of the various BCG strains appears similar, irrespective of CIS characteristics. However, based on the weak level of evidence available and underpowered studies, randomized studies in this space should be encouraged as no definitive conclusion can be drawn at this stage.
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Affiliation(s)
- Andres Llano
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Amy Chan
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Cynthia Kuk
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, QU H4A 3J1, Canada;
| | - Alexandre R. Zlotta
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Heath Network, University of Toronto, Toronto, ON M5G 2C4, Canada
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Ostrowski DA, Chelluri RR, Herzig M, Xia L, Cortese BD, Roberson DS, Guzzo TJ, Lee DJ, Malkowicz SB. Diminished Short-Term Efficacy of Reduced-Dose Induction BCG in the Treatment of Non-Muscle Invasive Bladder Cancer. Cancers (Basel) 2023; 15:3746. [PMID: 37509407 PMCID: PMC10377836 DOI: 10.3390/cancers15143746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
The ongoing Bacillus Calmette-Guérin (BCG) shortage has created challenges for the treatment of non-muscle invasive bladder cancer (NMIBCa). Our objective was to evaluate the efficacy of reduced-dose induction BCG (RD-iBCG) compared to full-dose induction BCG (FD-iBCG) regarding recurrence rates. We hypothesized that patients receiving RD-iBCG may recur at a higher rate compared to those who received FD-iBCG therapy. A retrospective review of all patients with NMIBCa treated with intravesical therapy at our institution between 2015-2020 was conducted. Inclusion criteria consisted of having a diagnosis of AUA intermediate or high-risk NMIBCa with an indication for a six-week induction course of FD or RD-BCG with at least 1 year of documented follow up. The data were censored at one year. Propensity score matching for age, sex, tumor pathology, and initial vs. recurrent disease was performed. The primary endpoint was bladder cancer recurrence, reported as recurrence-free survival. A total of 254 patients were reviewed for this study. Our final cohort was 139 patients after exclusion. Thirty-nine percent of patients had HGT1 disease. 38.6% of patients receiving RD-BCG developed a recurrence of bladder cancer within a one-year follow-up as compared to 33.7% of patients receiving FD therapy. After propensity matching, this value remained statistically significant (p = 0.03). In conclusion, RD-iBCG for NMIBCa is associated with a significantly greater risk of recurrence than full-dose induction therapy, suggesting that RD-iBCG may not be equivalent or non-inferior to full-dose administration in the short term.
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Affiliation(s)
- David A. Ostrowski
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - Raju R. Chelluri
- Division of Urology and Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Matthew Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Leilei Xia
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - Brian D. Cortese
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - Daniel S. Roberson
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - Thomas J. Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - Daniel J. Lee
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
| | - S. Bruce Malkowicz
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA; (D.A.O.)
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Kawada T, Yanagisawa T, Bekku K, Laukhtina E, von Deimling M, Chlosta M, Pradere B, Teoh JYC, Babjuk M, Araki M, Shariat SF. The efficacy and safety outcomes of lower dose BCG compared to intravesical chemotherapy in non-muscle-invasive bladder cancer: A network meta-analysis. Urol Oncol 2023:S1078-1439(23)00118-7. [PMID: 37137745 DOI: 10.1016/j.urolonc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/01/2023] [Indexed: 05/05/2023]
Abstract
This study aimed to assess both efficacy and safety outcomes of lowering the dose of BCG compared to intravesical chemotherapies in non-muscle-invasive bladder cancer (NMIBC) patients using a systematic review, meta-analysis, and network meta-analysis approach. A comprehensive literature search was performed through Pubmed®, Web of Science™, and Scopus® in December 2022 to identify randomized controlled trials comparing the oncologic and/or safety outcomes of reduced dose intravesical BCG and/or intravesical chemotherapies according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. The outcomes of interest were risk of recurrence, progression, treatment-related adverse events, and discontinuation. Overall, 24 studies were eligible for quantitative synthesis. Among 22 studies that adopted induction followed by maintenance intravesical therapy, with reference to the lower-dose BCG, epirubicin was associated with a significantly higher risk of recurrence (Odds ratio [OR]: 2.82, 95% CI: 1.54-5.15), but not other intravesical chemotherapies. There were no significant differences in risk of progression among the intravesical therapies. On the other hand, standard-dose BCG was associated with a higher risk of any AEs (OR: 1.91, 95% CI: 1.07-3.41) but other intravesical chemotherapies had a comparable risk of AEs compared to lower-dose BCG. The discontinuation rate did not significantly differ between lower-dose and standard-dose BCG (OR: 1.40, 95% CI: 0.81-2.43) as well as other intravesical. According to the surface under the cumulative ranking curve, gemcitabine, and standard-dose BCG were preferable to lower-dose BCG in terms of recurrence risk; gemcitabine was also preferable to lower-dose BCG in terms of risk of AEs. In patients with NMIBC, lowering the dose of BCG decreases the risks of AEs and discontinuation rate compared to standard-dose BCG, but there is no difference in these endpoints compared to other intravesical chemotherapies. Standard-dose of BCG is preferred for all intermediate and high-risk NMIBC patients based on oncologic efficacy; however, lower-dose BCG and intravesical chemotherapies, especially gemcitabine, could be considered a reasonable alternative to BCG in selected patients who suffer from significant AEs or in case standard-dose BCG is not available.
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Affiliation(s)
- Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcin Chlosta
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Jeremy Yuen-Chun Teoh
- Department of Surgery, S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Marko Babjuk
- Department of Urology, Second Faculty of Medicine of Charles University, University Hospital Motol, Prague, Czech Republic
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
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4
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Del Giudice F, Asero V, Bologna E, Scornajenghi CM, Carino D, Dolci V, Viscuso P, Salciccia S, Sciarra A, D'Andrea D, Pradere B, Moschini M, Mari A, Albisinni S, Krajewski W, Szydełko T, Małkiewicz B, Nowak Ł, Laukhtina E, Gallioli A, Mertens LS, Marcq G, Cimadamore A, Afferi L, Soria F, Mori K, Tully KH, Pichler R, Ferro M, Tataru OS, Autorino R, Crivellaro S, Crocetto F, Busetto GM, Basran S, Eisenberg ML, Chung BI, De Berardinis E. Efficacy of Different Bacillus of Calmette-Guérin (BCG) Strains on Recurrence Rates among Intermediate/High-Risk Non-Muscle Invasive Bladder Cancers (NMIBCs): Single-Arm Study Systematic Review, Cumulative and Network Meta-Analysis. Cancers (Basel) 2023; 15:cancers15071937. [PMID: 37046598 PMCID: PMC10093360 DOI: 10.3390/cancers15071937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND In an era of Bacillus of Calmette-Guérin (BCG) shortages, the comparative efficacy from different adjuvant intravesical BCG strains in non-muscle invasive bladder cancer (NMIBC) has not been clearly elucidated. We aim to compare, through a systematic review and meta-analysis, the cumulative BC recurrence rates and the best efficacy profile of worldwide available BCG strains over the last forty years. METHODS PubMed, Scopus, Web of Science, Embase, and Cochrane databases were searched from 1982 up to 2022. A meta-analysis of pooled BC recurrence rates was stratified for studies with ≤3-y vs. >3-y recurrence-free survival (RFS) endpoints and the strain of BCG. Sensitivity analysis, sub-group analysis, and meta-regression were implemented to investigate the contribution of moderators to heterogeneity. A random-effect network meta-analysis was performed to compare BCG strains on a multi-treatment level. RESULTS In total, n = 62 series with n = 15,412 patients in n = 100 study arms and n = 10 different BCG strains were reviewed. BCG Tokyo 172 exhibited the lowest pooled BC recurrence rate among studies with ≤3-y RFS (0.22 (95%CI 0.16-0.28). No clinically relevant difference was noted among strains at >3-y RFS outcomes. Sub-group and meta-regression analyses highlighted the influence of NMIBC risk-group classification and previous intravesical treated categories. Out of the n = 11 studies with n = 7 BCG strains included in the network, BCG RIVM, Tice, and Tokyo 172 presented with the best-predicted probability for efficacy, yet no single strain was significantly superior to another in preventing BC recurrence risk. CONCLUSION We did not identify a BCG stain providing a clinically significant lower BC recurrence rate. While these findings might discourage investment in future head-to-head randomized comparison, we were, however, able to highlight some potential enhanced benefits from the genetically different BCG RIVM, Tice, and Tokyo 172. This evidence would support the use of such strains for future BCG trials in NMIBCs.
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Affiliation(s)
- Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Vincenzo Asero
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Eugenio Bologna
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Carlo Maria Scornajenghi
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Dalila Carino
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Virginia Dolci
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Pietro Viscuso
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Stefano Salciccia
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Alessandro Sciarra
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Department of Urology, La Croix du Sud Hospital, 31130 Quint-Fonsegrives, France
| | - Marco Moschini
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, 50134 Florence, Italy
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Łukasz Nowak
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Andrea Gallioli
- Department of Urology, Fundacio Puigvert, 16444 Barcelona, Spain
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, 1066 Amsterdam, The Netherlands
| | - Gautier Marcq
- Urology Department, Claude Huriez Hospital, CHU Lille, 59000 Lille, France
- Cancer Heterogeneity Plasticity and Resistance to Therapies, UMR9020-U1277-CANTHER, Institut Pasteur de LilleCHU Lille, Inserm, CNRS University of Lille, 59000 Lille, France
| | - Alessia Cimadamore
- Department of Medical Area (DAME), Institute of Pathological Anatomy, University of Udine, 33100 Udine, Italy
| | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, 6004 Luzern, Switzerland
| | - Francesco Soria
- Urology Division, Department of Surgical Sciences, University of Studies of Torino, 10124 Turin, Italy
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Karl Heinrich Tully
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, 44780 Herne, Germany
| | - Renate Pichler
- Department of Urology, Comprehensive Cancer Center Innsbruck, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matteo Ferro
- Division of Urology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Octavian Sabin Tataru
- Department of Simulation Applied in Medicine, The Institution Organizing University Doctoral Studies (I.O.S.U.D.), George Emil Palade University of Medicine, Pharmacy, Sciences, and Technology, 540142 Târgu Mureș, Romania
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Simone Crivellaro
- Health Sciences System, Department of Urology, University of Illinois Hospital e Camp, Chicago, IL 60612, USA
| | - Felice Crocetto
- Reproductive Sciences and Odontostomatology, Urology Unit, Department of Neurosciences, University of Naples "Federico II", 80138 Naples, Italy
| | - Gian Maria Busetto
- Department of Urology and Organ Transplantation, University of Foggia, 71122 Foggia, Italy
| | - Satvir Basran
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Michael L Eisenberg
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Benjamin Inbeh Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Ettore De Berardinis
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
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5
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Jin YH, Zeng XT, Liu TZ, Bai ZM, Dou ZL, Ding DG, Fan ZL, Han P, Huang YR, Huang X, Li M, Li XD, Li YN, Li XH, Liang CZ, Liu JM, Ma HS, Qi J, Shi JQ, Wang J, Wang DL, Wang ZP, Wang YY, Wang YB, Wei Q, Xia HB, Xing JC, Yan SY, Zhang XP, Zheng GY, Xing NZ, He DL, Wang XH. Treatment and surveillance for non-muscle-invasive bladder cancer: a clinical practice guideline (2021 edition). Mil Med Res 2022; 9:44. [PMID: 35978389 PMCID: PMC9382792 DOI: 10.1186/s40779-022-00406-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) is a major type of bladder cancer with a high incidence worldwide, resulting in a great disease burden. Treatment and surveillance are the most important part of NIMBC management. In 2018, we issued "Treatment and surveillance for non-muscle-invasive bladder cancer in China: an evidence-based clinical practice guideline". Since then, various studies on the treatment and surveillance of NMIBC have been published. There is a need to incorporate these materials and also to take into account the relatively limited medical resources in primary medical institutions in China. Developing a version of guideline which takes these two issues into account to promote the management of NMIBC is therefore indicated. We formed a working group of clinical experts and methodologists. Through questionnaire investigation of clinicians including primary medical institutions, 24 clinically concerned issues, involving transurethral resection of bladder tumor (TURBT), intravesical chemotherapy and intravesical immunotherapy of NMIBC, and follow-up and surveillance of the NMIBC patients, were determined for this guideline. Researches and recommendations on the management of NMIBC in databases, guideline development professional societies and monographs were referred to, and the European Association of Urology was used to assess the certainty of generated recommendations. Finally, we issued 29 statements, among which 22 were strong recommendations, and 7 were weak recommendations. These recommendations cover the topics of TURBT, postoperative chemotherapy after TURBT, Bacillus Calmette-Guérin (BCG) immunotherapy after TURBT, combination treatment of BCG and chemotherapy after TURBT, treatment of carcinoma in situ, radical cystectomy, treatment of NMIBC recurrence, and follow-up and surveillance. We hope these recommendations can help promote the treatment and surveillance of NMIBC in China, especially for the primary medical institutions.
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Affiliation(s)
- Ying-Hui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Tong-Zu Liu
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Zhi-Ming Bai
- Department of Urology, Haikou People's Hospital, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Haikou, 570208, China
| | - Zhong-Ling Dou
- Department of Urology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, 450052, Henan, China
| | - De-Gang Ding
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, 450003, China
| | - Zhi-Lu Fan
- Department of Urology, the Second Hospital of Dalian Medical University, Dalian, 116023, Liaoning, China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi-Ran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200120, China
| | - Xing Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Ming Li
- Department of Urology, the People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830002, China
| | - Xiao-Dong Li
- Department of Urology, Huaihe Hospital of Henan University, Kaifeng, 475000, Henan, China.,Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000, Henan, China
| | - Yi-Ning Li
- Department of Urology, the Second Affiliated Hospital and Second Clinical Medical College of Fujian Medical University, Quanzhou, 362000, Fujian, China
| | - Xu-Hui Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Chao-Zhao Liang
- Department of Urology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Jiu-Min Liu
- Department of Urology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Hong-Shun Ma
- Department of Urology, Tianjin First Central Hospital, Tianjin, 300190, China
| | - Juan Qi
- Department of Urology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Jia-Qi Shi
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Jian Wang
- Department of Urology, Qinghai University Affiliated Hospital, Xining, 810012, China
| | - De-Lin Wang
- Department of Urology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042, China
| | - Zhi-Ping Wang
- Department of Urology, Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Lanzhou, 730030, China
| | - Yun-Yun Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yong-Bo Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hai-Bo Xia
- Department of Urology, Chifeng Cancer Hospital, the Second Affiliated Hospital of Chifeng University, Chifeng, 024000, Inner Mongolia Autonomous Region, China
| | - Jin-Chun Xing
- Key Laboratory of Urinary Tract Tumors and Calculi, Department of Urology, the First Affiliated Hospital of Xiamen University, Xiamen, 361003, China
| | - Si-Yu Yan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Xue-Pei Zhang
- Department of Urology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Guo-You Zheng
- Department of Urology, the Second Division of the First Hospital of Jilin University, Changchun, 130061, China
| | - Nian-Zeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Da-Lin He
- Department of Urology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Xing-Huan Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China. .,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Roumiguié M, Kamat AM, Bivalacqua TJ, Lerner SP, Kassouf W, Böhle A, Brausi M, Buckley R, Persad R, Colombel M, Lamm D, Palou-Redorta J, Soloway M, Brothers K, Steinberg G, Lotan Y, Sylvester R, Alfred Witjes J, Black PC. International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer. Eur Urol 2022; 82:34-46. [PMID: 34955291 DOI: 10.1016/j.eururo.2021.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design. OBJECTIVE To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease. EVIDENCE ACQUISITION We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC. EVIDENCE SYNTHESIS BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided. CONCLUSIONS The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state. PATIENT SUMMARY Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.
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Affiliation(s)
- Mathieu Roumiguié
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada; Department of Urology, Toulouse Cancer Institute and Toulouse University Hospital, Toulouse, France
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Trinity J Bivalacqua
- Perelman Center for Advanced Medicine, University of Pennsylvania, Division of Urology, Department of Surgery, Philadelphia, PA.
| | - Seth P Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Canada
| | - Andreas Böhle
- Departments of Urology, University of Lübeck, Lübeck, Germany; HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | | | - Roger Buckley
- North York General Hospital, Toronto, Ontario, Canada
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol Hospitals Trust, Bristol, UK
| | - Marc Colombel
- Claude Bernard University, Hôpital Edouard Herriot, Lyon, France
| | - Donald Lamm
- University of Arizona and BCG Oncology, Phoenix, AZ, USA
| | - Juan Palou-Redorta
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mark Soloway
- Division of Urology, Memorial Cancer Institute, Memorial Hospital, Hollywood, FL, USA
| | - Ken Brothers
- Patient Advocate, National Cancer Institute Bladder Cancer Task Force, Snowbasin, UT, USA
| | - Gary Steinberg
- Department of Urology, NYU Langone Health, New York, NY, USA
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter C Black
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada.
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Jiang S, Redelman-Sidi G. BCG in Bladder Cancer Immunotherapy. Cancers (Basel) 2022; 14:3073. [PMID: 35804844 PMCID: PMC9264881 DOI: 10.3390/cancers14133073] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 01/18/2023] Open
Abstract
BCG is a live attenuated strain of Mycobacterium bovis that is primarily used as a vaccine against tuberculosis. In the past four decades, BCG has also been used for the treatment of non-muscle invasive bladder cancer (NMIBC). In patients with NMIBC, BCG reduces the risk of tumor recurrence and decreases the likelihood of progression to more invasive disease. Despite the long-term clinical experience with BCG, its mechanism of action is still being elucidated. Data from animal models and from human studies suggests that BCG activates both the innate and adaptive arms of the immune system eventually leading to tumor destruction. Herein, we review the current data regarding the mechanism of BCG and summarize the evidence for its clinical efficacy and recommended indications and clinical practice.
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Affiliation(s)
- Song Jiang
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Gil Redelman-Sidi
- Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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8
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Adjuvant therapies for non-muscle-invasive bladder cancer: advances during BCG shortage. World J Urol 2022; 40:1111-1124. [PMID: 35083522 DOI: 10.1007/s00345-021-03908-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023] Open
Abstract
Non-muscle-invasive bladder cancer (NMIBC) represents a significant global therapeutic challenge, particularly in the era of Bacillus Calmette-Guérin (BCG) shortage. High-risk NMIBC can progress to muscle invasive or metastatic disease in 25% of patients. Optimal treatment selection, according to risk stratification, is imperative. International guidelines slightly differ in their categorisation of low, intermediate and high-risk NMIBC. Nonetheless, a single post-operative instillation of chemotherapy with Mitomycin C (MMC) or Gemcitabine improves relapse-free survival (RFS) in low-risk NMIBC. Induction and maintenance intravesical BCG remains the historical gold standard for patients with intermediate or high-risk NMIBC. However, clinicians may be forced to consider alternatives given the current BCG shortage. Both intravesical MMC and Gemcitabine have been associated with similar efficacy to BCG, albeit in smaller studies. MMC may also be manipulated using a variety of methods to potentiate its effects. BCG treatment delivery may also be modified without affecting efficacy through dose reduction and abbreviation or omission of maintenance therapy. Preliminary data also highlight that directly proceeding to radical cystectomy may not adversely affect long-term quality of life measures. Access to new systemic and intravesical therapies must be prioritised for patients with BCG recurrent or unresponsive disease. When used in conjunction with molecularly defined biomarkers, these agents herald the potential for improved survival outcomes and alleviation of the current BCG shortage.
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9
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Steinberg RL, Packiam VT, Thomas LJ, Brooks N, Vitale A, Mott SL, Crump T, Wang J, DeWolf WC, Lamm DL, Kates M, Hyndman ME, Kamat AM, Bivalacqua TJ, Nepple KG, O'Donnell MA. Intravesical sequential gemcitabine and docetaxel versus bacillus calmette-guerin (BCG) plus interferon in patients with recurrent non-muscle invasive bladder cancer following a single induction course of BCG. Urol Oncol 2022; 40:9.e1-9.e7. [PMID: 34092482 DOI: 10.1016/j.urolonc.2021.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Repeat BCG induction remains an option for select non-muscle invasive bladder cancer (NMIBC) patients who fail initial therapy. Alternative salvage intravesical regimens such as Gemcitabine and Docetaxel (Gem/Doce) have been investigated. We aimed to compare the efficacy BCG plus interferon a-2b (BCG/IFN) and Gem/Doce in patients with recurrent NMIBC after a single prior BCG course. METHODS The National Phase II BCG/IFN trial database and multi-institutional Gem/Doce database were queried for patients with recurrent NMIBC after one prior BCG induction course, excluding those with BCG unresponsive disease. Stabilized inverse probability treatment weighted survival curves were estimated using the Kaplan-Meier method and compared. Propensity scores were derived from a logistic regression model. The primary outcome was recurrence free survival (RFS); secondary outcomes were high-grade (HG) RFS and risk factors for treatment failure. RESULTS We identified 197 BCG/IFN and 93 Gem/Doce patients who met study criteria. Patients receiving Gem/Doce were older and more likely to have HG disease, CIS, and persistent disease following induction BCG (all P < 0.01). After propensity score-based weighting, the adjusted 1- and 2-year RFS was 61% and 53% after BCG/IFN versus 68% and 46% after Gem/Doce (P = 0.95). Adjusted 1- and 2-year HG-RFS was 60% and 51% after BCG/IFN versus 63% and 42% after Gem/Doce (P = 0.68). Multivariable Cox regression revealed that Gem/Doce treatment was not associated with an increased risk of failure (HR = 0.97, P = 0.89) as compared to BCG/IFN. CONCLUSION Patients with recurrent NMIBC after a single induction BCG failure and not deemed BCG unresponsive had similar oncologic outcomes with Gem/Doce and BCG/IFN in a post-hoc analysis. Additional prospective studies are needed.
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Affiliation(s)
| | | | - Lewis J Thomas
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Andrew Vitale
- Department of Urology, University of Iowa, Iowa City, IA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Trafford Crump
- Department of Urology, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Donald L Lamm
- University of Arizona School of Medicine, Phoenix, Az; BCG Oncology, Phoenix, Az
| | - Max Kates
- Department of Urology, Johns Hopkins University, Baltimore, MD
| | - M Eric Hyndman
- Department of Urology, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Kenneth G Nepple
- Department of Urology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Michael A O'Donnell
- Department of Urology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
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10
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Shi X, Feng D, Wei W. A Systematic Review and Meta-Analysis Protocol of Chemoablation vs. Transurethral Resection of Bladder Tumor in Patients With Non-Muscle-Invasive Bladder Cancer. Front Surg 2021; 8:753547. [PMID: 34869561 PMCID: PMC8634134 DOI: 10.3389/fsurg.2021.753547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/14/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Bladder cancer is the second-ranked tumor of the genitourinary system. Transurethral resection of bladder tumor (TURBT) is currently the most important diagnosis and treatment method for non-muscular invasive bladder cancer (NMIBC). However, due to its high recurrence and progression rate, as well as high cost and inapplicability to some patients, intravesical chemoablation as an alternative to TURBT may be promising for NMIBC patients. However, there are very little data comparing its effectiveness, safety, best effective drug type, dosage selection, and cost with TURBT at present, which deserves further evaluation. The present study was designed in order to discuss which treatment is superior to another between chemoablation and TURBT in patients with NMIBC. Methods and Analysis: Databases including PubMed, MEDLINE, EMBASE, and Cochrane Library databases, as well as Chinese databases including CNKI (China national knowledge infrastructure), Wan Fang database, and Chinese Clinical Trial Registry, from August 1994 to the time when the official submission of this review was published was included in this review and screened by two reviewers (XS and DCF) independently. There were no language limitations. The study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data was analyzed using RevMan and Stata software. The primary aims were the clinical effectiveness, including response rate, complete response OS, CSM, recurrence rate, time to recurrent, progression rate, and time to progression, among others. The secondary aims mainly included safety and tolerability, including costs, operation time, hospital stay, bleeding volume, and complications, among others. Study Registration: This study is registered as PROSPERO CRD42021271124.
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Affiliation(s)
- Xu Shi
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
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11
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Subiela JD, Faba ÓR, Aumatell J, Krajewski W, Calderón J, Parada R, Huguet J, Algaba F, Breda A, Palou J. Impact of clinical and pathological subtypes of carcinoma in situ (CIS) of the bladder: Lessons learned from long-term follow-up of a series of CIS patients treated with BCG. Urol Oncol 2021; 40:9.e9-9.e17. [PMID: 34140244 DOI: 10.1016/j.urolonc.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Some attempts have previously been made to stratify patients with CIS for the purpose of risk-adapted clinical management and clinical trial design. In particular, two classification systems have been proposed: clinical classification, comprising primary (P-CIS), concomitant (C-CIS), and secondary (S-CIS) disease, and pathological classification, comprising P-CIS, cTa-CIS, and cT1-CIS. The aim of the present study was to assess the impact of both classifications on BCG response, recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS). PATIENTS AND METHODS We performed a retrospective analysis of 386 patients with bladder CIS, with or without associated cTa/cT1 disease, treated with BCG instillations between 2008 and 2015. Patients were stratified according to the two classification systems. Cox multivariate regression models were used to assess the impact of these subtypes on BCG response, RFS, PFS, OS, and CSS. We also performed a cumulative meta-analysis according to PRISMA guidelines. RESULTS The median follow-up was 70.5 months. According to the clinical classification, 34 (8.8%) patients had P-CIS, 81 (21%) S-CIS, and 271 (70.2%) C-CIS. The pathological classification showed 34 (8.8%) patients to have P-CIS, 190 (49.2%) cTa-CIS, and 162 (42%) cT1-CIS. In the overall cohort, BCG response was reported in 296 (76.7%); 159 (41.2%) had recurrence, 55 (14.2%) had progression, and 67 (17.4%) underwent radical cystectomy. Death from any cause was recorded in 135 (35%) and death from urothelial carcinoma in 38 (9.9%). Cox multivariate regression analysis showed that neither clinical classification nor pathological classification is an independent predictive factor for BCG response, RFS, PFS, OS, or CSS after adjusting for confounders. In the pooled meta-analysis, two studies and the present series were included for evidence synthesis, recruiting a total of 941 patients. We found no statistically significant difference across the groups for both classifications with respect to BCG response, RFS, PFS, and CSS. CONCLUSIONS Currently, the supporting evidence for an impact of clinical classification and pathological classification on oncological outcomes of CIS of the bladder is insufficient to justify their use to guide clinical management or follow-up.
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Affiliation(s)
- José Daniel Subiela
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain.
| | - Óscar Rodríguez Faba
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Julia Aumatell
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Wojciech Krajewski
- Department of Pathology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Morphological Sciences, Barcelona, Spain
| | - Julio Calderón
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Rubén Parada
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Jorge Huguet
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Ferran Algaba
- Department of Urology and Oncological Urology, Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Alberto Breda
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Joan Palou
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
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12
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Morelli M, Baboudjian M, Vanacore D, Gondran-Tellier B, McManus R, Karsenty G, Lechavallier E, Montanari E, Boissier R. Early PDD Cystoscopy after BCG Induction for High-risk Non-Muscle Invasive Bladder Cancer Significantly Increased the Detection of BCG-refractory Tumors. J Endourol 2021; 35:1824-1828. [PMID: 34107773 DOI: 10.1089/end.2021.0313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To compare the detection rate of BCG refractory tumors between white light cystoscopy (WL-C) and Photodynamic Diagnosis cystoscopy (PDD-C). METHODS We performed a monocentric retrospective study that included all consecutive patients with high-risk non-muscle-invasive bladder cancer (NMIBC) diagnosed from January 2017 to January 2021. All patients had an initial Transurethral resection of bladder tumor (TURBT) with PDD ± restaging TURBT if needed, followed by full-dose BCG induction. Within 8 weeks following BCG induction all patients had both WL-C and PDD-C under general anesthesia ± TURBT in case of suspicious lesion. The primary endpoint was the detection of bladder cancer (BC) at post-BCG cystoscopy. RESULTS A total of 136 consecutive patients met inclusion criteria. Initial BC characteristics were: 35.6% of T1 tumor, 92.6% high-grade and 48.6% associated cis. BC was diagnosed in 33/136 cases (24%) at early PDD-C after BCG induction: 77% Ta, 23% T1, 56% associated cis, 68% high grade and 6% MIBC. Sensibility and Specificity of WL-C and PDD-C: 41 vs 91% (p<0.001) and 86 vs 75% (p=0.001). PDD-C detected 16 additional tumors: 81.3% Ta, 18.7% T1, 75% associated cis and 75% high grade. CONCLUSIONS Systematic use of PDD after BCG induction increased the detection of BCG-refractory tumors and lead to significant modification in the treatment of high-risk NMIBC. Future studies are needed to evaluate long-term oncological benefit of early PDD reevaluation and its cost-effectiveness.
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Affiliation(s)
- Michele Morelli
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
| | - Michael Baboudjian
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, 147 bd baille, Marseille, France, 13005.,Marseille, France;
| | - Davide Vanacore
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
| | - Bastien Gondran-Tellier
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, Marseille, France;
| | - Robin McManus
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, Conception Academic Hospital, Aix Marseille University, Marseille, Marseille, France, France;
| | - Gilles Karsenty
- Assistance Publique Hopitaux de Marseille, 36900, Urologie, Marseille, Provence-Alpes-Côte d'Azu, France;
| | - Eric Lechavallier
- hopital La Conception, Urologie, 147 bd Baille, Marseille, France, 13385;
| | - Emanuele Montanari
- IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Urology, via della Commenda 15, Milan, Italy, 20122;
| | - Romain Boissier
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
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13
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Veskimae E, Subbarayan S, Campi R, Carron D, Omar MI, Yuan C, Dimitropoulos K, Van Hemelrijck M, Bryan RT, N'Dow J, Babjuk M, Alfred Witjes J, Sylvester R, MacLennan S. A Systematic Review of Outcome Reporting, Definition and Measurement Heterogeneity in Non-Muscle Invasive Bladder Cancer Effectiveness Trials of Adjuvant, Prophylactic Treatment After Transurethral Resection. Bladder Cancer 2021; 7:221-241. [PMID: 38994538 PMCID: PMC11181687 DOI: 10.3233/blc-201510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/28/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Heterogenous outcome reporting in non-muscle-invasive bladder cancer (NMIBC) effectiveness trials of adjuvant treatment after transurethral resection (TURBT) has been noted in systematic reviews (SRs). This hinders comparing results across trials, combining them in meta-analyses, and evidence-based decision-making for patients and clinicians. OBJECTIVE We aimed to systematically review the extent of reporting and definition heterogeneity. METHODS We included randomized controlled trials (RCTs) identified from SRs comparing adjuvant treatments after TURBT or TURBT alone in patients with NMIBC (with or without carcinoma in situ) published between 2000-2020. Abstracts and full texts were screened independently by two reviewers. Data were extracted by one reviewer and checked by another. RESULTS We screened 807 abstracts; from 15 SRs, 57 RCTs were included. Verbatim outcome names were coded to standard outcome names and organised using the Williamson and Clarke taxonomy. Recurrence (98%), progression (74%), treatment response (in CIS studies) (40%), and adverse events (77%) were frequently reported across studies. However, overall (33%) and cancer-specific (33%) survival, treatment completion (17%) and treatment change (37%) were less often reported. Quality of Life (3%) and economic outcomes (2%) were rarely reported. Heterogeneity was evident throughout, particularly in the definitions of progression and recurrence, and how CIS patients were handled in the analysis of studies with predominantly papillary patients, highlighting further issues with the definition of recurrence and progression vs treatment response for CIS patients. Data reporting was also inconsistent, with some trials reporting event rates at various time-points and others reporting time-to-event with or without Hazard Ratios. Adverse events were inconsistently reported. QoL data was absent in most trials. CONCLUSIONS Heterogenous outcome reporting is evident in NMIBC effectiveness trials. This has profound implications for meta-analyses, SRs and evidence-based treatment decisions. A core outcome set is required to reduce heterogeneity. PATIENT SUMMARY This systematic review found inconsistencies in outcome definitions and reporting, pointing out the urgent need for a core outcome set to help improve evidence-based treatment decisions.
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Affiliation(s)
- Erik Veskimae
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | | | - Riccardo Campi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Cathy Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Konstantinos Dimitropoulos
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
- Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Mieke Van Hemelrijck
- King's College London, Faculty of Life Sciences and Medicine, Translational and Oncology Research (TOUR), London, UK
| | - Richard T Bryan
- Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
- Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Marek Babjuk
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
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14
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Calò B, Sanguedolce F, Falagario UG, Chirico M, Fortunato F, Carvalho-Diaz E, Busetto GM, Bettocchi C, Carrieri G, Cormio L. Assessing treatment response after intravesical bacillus Calmette-Guerin induction cycle: are routine bladder biopsies necessary? World J Urol 2021; 39:3815-3821. [PMID: 33830306 PMCID: PMC8519823 DOI: 10.1007/s00345-021-03690-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/27/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To determine the need for routine bladder biopsies (BBs) in assessing response to the induction cycle of intravesical bacillus Calmette-Guérin (BCG) for high-risk non-muscle-invasive bladder cancer (NMIBC). METHODS Our prospectively maintained NMIBC database was queried to identify patients with high-risk disease (carcinoma in situ, high-grade Ta/T1) who underwent BBs after BCG induction cycle. Urine cytology, cystoscopy, and BBs findings were evaluated. RESULTS A total of 219 patients met the inclusion criteria. Urine cytology was positive in 20 patients and negative in 199; cystoscopy was positive in 35 patients, suspicious in 32 and normal in 152 patients. BBs yielded bladder cancer (BCa) in 43 (19.6%) patients, with a BCa rate of 9.3% in patients with negative cytology and cystoscopy as opposed to 38.0% in patients whereby one or both exams were suspicious/positive. The diagnostic accuracy of urine cytology, cystoscopy, and combined tests was 0.56, 0.70, and 0.71, respectively. The negative predictive value of combined tests was 90.7%. Performing BBs only in patients with positive cytology and/or positive/suspicious cystoscopy would have spared 140 (64%) patients to undergo this procedure while missing BCa in 13 (9.3%) of them, representing 30% of all BCa cases. CONCLUSION Performing BBs only in patients with positive cytology and suspicious/positive cystoscopy would spare 64% of un-necessary BBs but miss a non-negligible number of BCas. While no data are available regarding the potential consequences of missing such BCas, such information should be taken into account in patient's counselling.
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Affiliation(s)
- Beppe Calò
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy ,Department of Urology, Bonomo Teaching Hospital, Andria (BAT), Italy
| | | | - Ugo G. Falagario
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy
| | - Marco Chirico
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy
| | | | - Emanuel Carvalho-Diaz
- Department of CUF Urology and Service of Urology, Hospital of Braga, Braga, Portugal
| | - Gian Maria Busetto
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy
| | - Carlo Bettocchi
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy
| | - Giuseppe Carrieri
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy
| | - Luigi Cormio
- Department of Urology and Renal Transplantation, University of Foggia—Ospedali Riuniti of Foggia, Foggia, Italy ,Department of Urology, Bonomo Teaching Hospital, Andria (BAT), Italy
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15
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Intravesical Salvage Therapy After BCG/Regular Chemo. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_12] [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]
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16
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Abstract
PURPOSE OF REVIEW The standard diagnosis of carcinoma in situ (CIS) of the bladder, based on white light cystoscopy and urine cytology, is limited because CIS can vary from normal-appearing mucosa to a lesion indistinguishable from an inflammatory process. Intravesical instillation of Bacillus Calmette-Guerin (BCG) remains first-line therapy; however, a significant proportion of cases persist or recur after BCG treatment. This review summarizes recent improvements in the detection and treatment of CIS. RECENT FINDINGS The new optical technologies improve CIS detection, with a potential positive impact on oncological outcomes. The usefulness of MRI-photodynamic diagnosis fusion transurethral resection in CIS detection is unclear and further studies are needed. BCG instillation remains the first-line therapy in CIS patients and seems to improve recurrence and progression rates, especially with the use of maintenance. Intravesical device-assisted therapies could be effective in both BCG-naïve and BCG-unresponsive CIS patients, but further studies are ongoing to clarify their clinical benefit. A phase II clinical trial with pembrolizumab has shown the potential effectiveness of immune checkpoint inhibitors in BCG-unresponsive CIS patients and further trials are ongoing. SUMMARY New optical techniques increase the CIS detection rate. BCG instillation remains the first-line treatment. Immune checkpoint inhibitors could be a future alternative in BCG-naïve and BCG-unresponsive CIS patients.
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17
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Koch GE, Smelser WW, Chang SS. Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to Manage Them. Urology 2020; 149:11-20. [PMID: 33181123 DOI: 10.1016/j.urology.2020.10.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
Intravesical therapy for nonmuscle invasive bladder cancer decreases recurrence and progression but carries a high risk of side effects, which limit patient adherence. Appropriate management of the toxicities from intravesical therapy requires consideration of the agent used, the side effects experienced, and the timing of those side effects. Management strategies for intravesical toxicities ideally improve patient tolerance without sacrificing oncologic outcomes. This review aims to provide a comprehensive overview of the available evidence regarding the side effects of intravesical therapies for nonmuscle invasive bladder cancer and to propose practical strategies for toxicity management.
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Affiliation(s)
- George E Koch
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Woodson W Smelser
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN.
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18
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Alcorn J, Burton R, Topping A. Withdrawing from treatment for Bladder cancer: Patient experiences of
BCG
installations. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2020. [DOI: 10.1111/ijun.12236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jason Alcorn
- Mid Yorkshire Hospitals NHS Trust Pinderfields Hospital Wakefield West Yorkshire UK
| | - Rob Burton
- School of Nursing and Midwifery Griffith University Mount Gravatt Queensland Australia
| | - Annie Topping
- School of Nursing University of Birmingham & University Birmingham Hospitals NHS Foundation Trust Birmingham UK
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19
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Piszczek R, Krajewski W, Małkiewicz B, Krajewski P, Tukiendorf A, Zdrojowy R, Kołodziej A. Clinical outcomes and survival differences between primary, secondary and concomitants carcinoma in situ of urinary bladder treated with BCG immunotherapy. Transl Androl Urol 2020; 9:1338-1344. [PMID: 32676418 PMCID: PMC7354324 DOI: 10.21037/tau.2020.03.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background The carcinoma in situ (CIS) of urinary bladder is a flat, high-grade and aggressive manifestation of urothelial cancer which carries a great risk for progression to muscle invasive disease and metastatic spread. The aim of the study was to analyse the clinical history and survival differences between primary, secondary and concomitants CIS of the bladder. Methods We analysed a database of 301 patients who were treated between 1998 and 2017 in university BCG outpatient department. Primary, secondary and concomitants CIS cases were included in the study with minimum follow-up of 12 months. Recurrence-free survival (RSF), progression-free survival (PFS) and cancer specific survival (CSS) were analysed by Kaplan–Meier curves and log-rank test. Additionally, Cox regression models were performed. Results Seventy-two patients with primary, 58 with secondary and 171 with CIS concomitants were analysed. The patients were followed from mean 61,9 months. RFS rates at 5-years follow-up were 54.9%, 55.3% and 60.4% for primary, concomitants and secondary CIS (P>0.05). PFS rates at 5-years follow-up were 65.8%, 72.1% and 77% for primary, concomitants and secondary CIS (P>0.05). CSS rates at 5-years follow-up were 83.1%, 81.9% and 90.1% for primary, concomitants and secondary CIS (P>0.05). There were no statistically significant differences between any CIS subtype in any of analysed endpoints in multivariate analysis. Female gender was associated with worse RFS and the instillation number was positively associated with all analysed survival rates. On contrary, age was not statistically related to RFS, PFS nor CSS. Conclusions In this study it was shown that when compared with secondary and concomitants CIS, primary CIS presented the worst RFS and PFS, however, the differences between subgroups were not statistically significant.
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Affiliation(s)
- Radosław Piszczek
- Department of Urology and Oncologic Urology, Lowersilesian Specialistic Hospital, Wroclaw, Poland
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Piotr Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Andrzej Tukiendorf
- Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Romuald Zdrojowy
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Anna Kołodziej
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
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20
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The Tumor Microenvironment of Bladder Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1296:275-290. [PMID: 34185299 DOI: 10.1007/978-3-030-59038-3_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bladder cancer has been well known as immunotherapy-responsive disease as intravesical therapy with BCG has been the standard of care for non-muscle invasive disease for several decades. In addition, immune checkpoint inhibitors have dramatically changed the treatment of metastatic bladder cancer. However, only a small fraction of patients with bladder cancer can benefit from these therapies. As immunotherapies act on the tumor microenvironment, understanding it is essential to expand the efficacy of modern treatments. The bladder cancer microenvironment consists of various components including tumor cells, immune cells, and other stromal cells, affecting each other via immune checkpoint molecules, cytokines, and chemokines. The development of an antitumor immune response depends on tumor antigen recognition by antigen presenting cells and priming and recruitment of effector T cells. Accumulated evidence shows that these processes are impacted by multiple types of immune cells in the tumor microenvironment including regulatory T cells, tumor-associated macrophages, and myeloid derived suppressor cells. In addition, recent advances in genomic profiling have shed light on the relationship between molecular subtypes and the tumor microenvironment. Finally, emerging evidence has shown that multiple factors can impact the tumor microenvironment in bladder cancer, including tumor-oncogenic signaling, patient genetics, and the commensal microbiome.
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21
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Hobbs C, Bass E, Crew J, Mostafid H. Intravesical BCG: where do we stand? Past, present and future. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818817120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High and intermediate risk non-muscle invasive bladder cancer poses a real challenge for treatment. Approximately 70% of bladder cancer presents as non-muscle invasive and 20–25% will progress to muscle invasive disease. Recurrences occur in up to 70% but treatment options are limited. Intravesical bacillus Calmette–Guérin is still considered the bladder sparing treatment of choice despite its well documented pitfalls. This review considers how bacillus Calmette–Guérin has become the recommended treatment, its benefits and risks and the alternative options for treatment. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Edward Bass
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
| | - Jeremy Crew
- Department of Urology, Churchill Hospital, UK
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
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22
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Alcorn J, Burton R, Topping A. Patterns of patient withdrawal from BCG treatment for bladder cancer: A retrospective time interval analysis. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2019. [DOI: 10.1111/ijun.12191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jason Alcorn
- Department of Urology, Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Wakefield West Yorkshire UK
| | - Rob Burton
- School of Nursing and MidwiferyGriffith University Brisbane Queensland Australia
| | - Annie Topping
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham & University Birmingham Hospitals NHS Foundation Trust Birmingham UK
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23
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Carcinoma In Situ of the Urinary Bladder: A Systematic Review of Current Knowledge Regarding Detection, Treatment, and Outcomes. Eur Urol Focus 2019; 6:674-682. [PMID: 30910393 DOI: 10.1016/j.euf.2019.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/04/2019] [Accepted: 03/12/2019] [Indexed: 11/20/2022]
Abstract
CONTEXT Carcinoma in situ (CIS) of the bladder is defined as a high-grade flat lesion confined to the mucosa. Intravesical treatment with bacillus Calmette-Guérin (BCG) is commonly used to reduce the risk of recurrence and progression; however, CIS of the bladder exhibits a heterogeneous clinical behavior and a significant proportion of patients do not show a primary response. OBJECTIVE To evaluate the available evidence concerning diagnosis, treatment strategies, follow-up, prognosis, and oncological outcomes in patients with CIS of the bladder. EVIDENCE ACQUISITION A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using the databases PubMed/MEDLINE and Embase. We included randomized controlled trials, systematic reviews, meta-analyses, and observational studies. Outcomes of interest were: (1) diagnostic strategies, (2) first- and second-line treatments, (3) follow-up strategies, and (4) prognosis and oncological outcomes. EVIDENCE SYNTHESIS Overall 62 articles met the inclusion criteria. Most articles concerned retrospective studies and presented mixed data with other non-muscle-invasive bladder cancer categories. The evidence shows that new optical imaging modalities significantly increase the detection rate of CIS. BCG immunotherapy remains the first-line therapy in patients with CIS of the bladder; however, after treatment, adequate follow-up is necessary. Clinicopathological factors remain the main indicators of response to BCG, recurrence, and progression. CONCLUSIONS New optical imaging modalities are superior to white light cystoscopy in the detection of CIS of the bladder. There are no robust data that justify consideration of other agents as an alternative to BCG immunotherapy. Despite efforts to identify relevant biomarkers, clinicopathological factors remain the most important prognostic factors. PATIENT SUMMARY New optical techniques have improved the detection of carcinoma in situ (CIS) of the bladder. Bladder preservation using bacillus Calmette-Guérin immunotherapy remains the cornerstone of the treatment of CIS of the bladder.
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24
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Moschini M, Zamboni S, Mattei A, Amparore D, Fiori C, De Dominicis C, Esperto F. Bacillus Calmette-Guérin unresponsiveness in non-muscle-invasive bladder cancer patients: what the urologists should know. MINERVA UROL NEFROL 2019; 71:17-30. [DOI: 10.23736/s0393-2249.18.03309-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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25
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Updates on the use of intravesical therapies for non-muscle invasive bladder cancer: how, when and what. World J Urol 2018; 37:2017-2029. [PMID: 30535583 DOI: 10.1007/s00345-018-2591-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Intravesical therapy has been an important aspect of the management of non-muscle invasive bladder cancer (NMIBC) for 40 years. Bacillus Calmette-Guerin (BCG) is considered standard of care for intermediate and high-grade non-invasive disease, yet understanding the nuances of subsequent intravesical therapy is important for any provider managing bladder cancer. Herein, we review the literature and describe optimal use of intravesical therapies for NMIBC. METHODS A comprehensive search of the medical literature was performed and highlighted in this review of intravesical therapy for NMIBC. RESULTS Post-resection intravesical Mitomycin C therapy for low-risk disease remains an important component of care, and gemcitabine now has level-one evidence demonstrating efficacy in this setting but is not yet a guideline recommendation. BCG intravesical therapy remains the most effective therapy preventing recurrence and progression of intermediate and high-risk NMIBC. Adequately characterizing BCG-failure is critical in determining the next step in management which includes radical cystectomy, additional intravesical immunotherapy, chemotherapy with intravesical gemcitabine ± docetaxel and clinical trials. CONCLUSIONS Intravesical therapy remains the mainstay of treatment for NMIBC and bladder preservation. Intravesical induction BCG followed by maintenance therapy remains standard of care for intermediate and high-risk patients. Detailing the timing and characteristics of recurrence after intravesical therapy is crucial in determining subsequent treatment recommendations. Current clinical trials focus on systemic immunotherapy and enhancing the intravesical immune response by augmenting the delivery mechanism.
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26
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Ye Z, Chen J, Hong Y, Xin W, Yang S, Rao Y. The efficacy and safety of intravesical gemcitabine vs Bacille Calmette-Guérin for adjuvant treatment of non-muscle invasive bladder cancer: a meta-analysis. Onco Targets Ther 2018; 11:4641-4649. [PMID: 30122955 PMCID: PMC6087023 DOI: 10.2147/ott.s170477] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Objective Several studies have compared the safety and efficacy of intravesical gemcitabine (Gem) with Bacille Calmette-Guérin (BCG) for non-muscle invasive bladder cancer. However, the results are not consistent. We carried out a meta-analysis to provide a more comprehensive analysis of the efficacy and safety of these 2 drugs. Methods We searched PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and reference lists. Randomized controlled trials and retrospective controlled trials comparing intravesical Gem and BCG in adjuvant therapy for non-muscle invasive bladder cancer published in Eng-lish were included in this study. The strength of association was weighed by pooled risk ratio (RR) with 95% CIs. Sensitivity analysis was performed to examine whether the findings of the meta-analysis were robust. Results We analyzed 386 subjects from 5 pooled trials. Compared with BCG, intravesical Gem had lower incidence of dysuria (overall RR =0.31, 95% CI: 0.16, 0.61, I2=0%, p=0.001) and hematuria (overall RR =0.27, 95% CI: 0.11, 0.71, I2=0%, p=0.008). There were no statistical differences in risk of recurrence, progression, incidence of fever, and any adverse events between intravesical Gem and BCG therapy (p>0.05). No publication bias was found. Conclusion This meta-analysis suggests that intravesical Gem may have similar efficacy and lower incidence of dysuria and hematuria compared with BCG. Nevertheless, we recommend additional high-quality randomized controlled trials to confirm these results.
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Affiliation(s)
- Ziqi Ye
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China,
| | - Jie Chen
- The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Yun Hong
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China,
| | - Wenxiu Xin
- Laboratory of Clinical Pharmacy, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Si Yang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China,
| | - Yuefeng Rao
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China,
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27
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Zhuo C, Li X, Zhuang H, Tian S, Cui H, Jiang R, Liu C, Tao R, Lin X. Evaluating the efficacy and safety of intravesical chemotherapies for non-muscle invasive bladder cancer: a network meta-analysis. Oncotarget 2018; 7:82567-82579. [PMID: 27788495 PMCID: PMC5347714 DOI: 10.18632/oncotarget.12856] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022] Open
Abstract
Various intravesical therapies have been introduced into clinical practices for controlling non-muscle invasive bladder cancer (NMIBC). However, evidence with respect to the efficacy and safety of those intravesical therapies is very limited. Hence, we present a network meta-analysis in order to address this limitation in the current literature. The primary outcomes were the risk of tumor recurrence (TR), tumor progression (TP) and disease-specific mortality (DM). Secondary outcomes included the risk of fever, cystitis and haematuria. Conventional pair-wise and network meta-analysis were both performed for each endpoint. The surface under the cumulative ranking curve (SUCRA) was incorporated in our analysis for ranking the corresponding intravesical instillation interventions. In total, 23 randomized clinical trials (RCTs) were finally included in our study after irrelevant papers were screened out. Results of network meta-analysis suggested that Epirubicin (EPI) was less preferable than Bacille Calmette Guerin (BCG), BCG+EPI, BCG+ Isoniazid (INH), BCG+ Mytomicin C (MMC), Gemcitabine (GEM) and MMC with respect to TR. As suggested by the corresponding ranking probabilities and SUCRA, incorporating EPI or MMC into BCG may enhance the efficacy of BCG monotherapy.
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Affiliation(s)
- Chuanjun Zhuo
- Department of Psychological Medicine, Wenzhou Seventh People's Hospital, Wenzhou, Zhejiang, 325005, China.,Department of Psychological Medicine, Jining Medical University, Jining, Shandong, 272067, China.,Department of Psychological Medicine, Tianjin Anding Hospital, Tianjin, 300222, China
| | - Xubin Li
- Department of Radiotherapy, Tianjin Cancer Institute & Hospital, Tianjin, 30000, China
| | - Hongqing Zhuang
- Department of Radiotherapy, Tianjin Cancer Institute & Hospital, Tianjin, 30000, China
| | - Shunli Tian
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, 300075, China
| | - Hailong Cui
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin, 300075, China
| | - Ronghuan Jiang
- Department of Psychological Medicine, Chinese PLA (People's Liberation Army) General Hospital; Chinese PLA (People's Liberation Army) Medical School, Beijing, 100853, China
| | - Chuanxin Liu
- Department of Psychological Medicine, Jining Medical University, Jining, Shandong, 272067, China
| | - Ran Tao
- Beijing Shijian Integrated Medicine Science Institute, Beijing, 100700, China
| | - Xiaodong Lin
- Department of Psychological Medicine, Wenzhou Seventh People's Hospital, Wenzhou, Zhejiang, 325005, China
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28
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Treatment for Carcinoma In Situ. Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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29
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Alhogbani MM, Picard JA, Fassi-Fehri MH, Badet JL, Colombel CM. Prognostic impact of Bacillus Calmette-Guérin interruption at the time of induction and consolidation. Urol Ann 2017; 9:315-320. [PMID: 29118530 PMCID: PMC5656953 DOI: 10.4103/ua.ua_115_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/14/2017] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Intravesical Bacillus Calmette-Guérin (BCG) is a cause of bladder and systemic toxicity that is difficult to prevent and is responsible for treatment drop out in bladder cancer patients. More recently, BCG shortage has become the main cause of incomplete treatment. AIMS The aim of this study was to examine the impact on long-term prognosis of bladder cancer patients following discontinuation of BCG instillations. SETTINGS AND DESIGN In this retrospective study, data were examined from 333 consecutive nonmuscle invasive bladder cancer patients treated from 2005 to 2015 by transurethral resection (TUR) and had undergone adjuvant BCG therapy after TUR. SUBJECTS AND METHODS Rate of complete cure, the reason for the interruption, toxicity, and the associations between discontinuance of BCG therapy, tumor characteristics, association with carcinoma in situ and tumor recurrence or progression were analyzed. STATISTICAL ANALYSIS USED Recurrence and progression-free survival rate curves were estimated using the Kaplan-Meier method and were compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Differences among groups were considered as statistically significant when P < 0.05. RESULTS Overall, 303 patients were eligible for analysis. Median follow up was 36 (confidence interval: 7-120) months. A total of 55 (18.1%) had <6 installations (Group I); 87 (28.7%) completed induction and 1-year maintenance (Group III); and 161 (53.1%) completed the induction course, but not the 1-year maintenance (Group II). Grade III-IV toxicity rates were significantly higher in Group I than Group II and III. Interruption for BCG shortage was the main cause of interrupting BCG in Group II. Multivariate analysis showed that discontinuation of BCG induction therapy was an independent predictor for tumor recurrence (P < 0.001) and 1-year BCG maintenance therapy for tumor progression (P = 0.005). CONCLUSIONS Discontinuation of BCG therapy has a significantly deleterious effect on tumor recurrence and progression rates. Although BCG toxicity is a major cause of drop out, BCG shortage became a major cause of discontinuation. All effort must be done today to restore normal production of BCG worldwide.
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Affiliation(s)
- M. Mofarej Alhogbani
- Department of Urology and Transplant Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - J. Aude Picard
- Department of Urology and Transplant Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - M. Hakim Fassi-Fehri
- Department of Urology and Transplant Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - J. Lionel Badet
- Department of Urology and Transplant Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - C. Marc Colombel
- Department of Urology and Transplant Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
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30
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Management of Hepatic Granulomatous Tuberculosis After BCG Therapy for Bladder Cancer. Urol Case Rep 2017; 13:158-159. [PMID: 28567336 PMCID: PMC5447372 DOI: 10.1016/j.eucr.2017.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/14/2017] [Accepted: 04/20/2017] [Indexed: 11/22/2022] Open
Abstract
BCG therapy is used as a treatment in bladder cancer. Intravesical administration of Bacillus Calmette-Guérin is used as a treatment method in superficial bladder cancer. While it is commonly effective, some serious side effects may occur. We hereby report a 65-year-old man who developed granulomatous hepatitis as a complication following BCG therapy. He was treated successfully with antitubercular therapy and prednisolone.
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31
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BCG-unresponsive non-muscle-invasive bladder cancer: recommendations from the IBCG. Nat Rev Urol 2017; 14:244-255. [DOI: 10.1038/nrurol.2017.16] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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32
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Colombel MC. Re: Intravesical Bacillus Calmette-Guérin Versus Combination of Epirubicin and Interferon-α2a in Reducing Recurrence of Non–Muscle-invasive Bladder Carcinoma: FinnBladder-6 Study. Eur Urol 2017; 71:139-140. [DOI: 10.1016/j.eururo.2016.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/08/2016] [Indexed: 11/26/2022]
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33
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Kaasinen E, Wijkström H, Rintala E, Mestad O, Jahnson S, Malmström PU. Seventeen-year follow-up of the prospective randomized Nordic CIS study: BCG monotherapy versus alternating therapy with mitomycin C and BCG in patients with carcinomain situof the urinary bladder. Scand J Urol 2016; 50:360-8. [DOI: 10.1080/21681805.2016.1210672] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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34
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Abstract
Intravesical immunotherapy with bacille-Calmette-Guerin (BCG) is indicated in the treatment of high-risk and intermediate-risk non-muscle invasive bladder cancer (NMIBC). Our goal is to describe the various disease states following induction and maintenance BCG and to describe contemporary treatment options and the current and projected clinical trial landscape for patients who recur following BCG therapy.
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Affiliation(s)
- Friedrich-Carl von Rundstedt
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
| | - Seth P Lerner
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
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35
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Kamat AM, Sylvester RJ, Böhle A, Palou J, Lamm DL, Brausi M, Soloway M, Persad R, Buckley R, Colombel M, Witjes JA. Definitions, End Points, and Clinical Trial Designs for Non-Muscle-Invasive Bladder Cancer: Recommendations From the International Bladder Cancer Group. J Clin Oncol 2016; 34:1935-44. [PMID: 26811532 DOI: 10.1200/jco.2015.64.4070] [Citation(s) in RCA: 261] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide recommendations on appropriate clinical trial designs in non-muscle-invasive bladder cancer (NMIBC) based on current literature and expert consensus of the International Bladder Cancer Group. METHODS We reviewed published trials, guidelines, meta-analyses, and reviews and provided recommendations on eligibility criteria, baseline evaluations, end points, study designs, comparators, clinically meaningful magnitude of effect, and sample size. RESULTS NMIBC trials must be designed to provide the most clinically relevant data for the specific risk category of interest (low, intermediate, or high). Specific eligibility criteria and baseline evaluations depend on the risk category being studied. For the population of patients for whom bacillus Calmette-Guérin (BCG) has failed, the type of failure (BCG unresponsive, refractory, relapsing, or intolerant) should be clearly defined to make comparisons across trials feasible. Single-arm designs may be relevant for the BCG-unresponsive population. Here, a clinically meaningful initial complete response rate (for carcinoma in situ) or recurrence-free rate (for papillary tumors) of at least 50% at 6 months, 30% at 12 months, and 25% at 18 months is recommended. For other risk levels, randomized superiority trial designs are recommended; noninferiority trials are to be used sparingly given the large sample size required. Placebo control is considered unethical for all intermediate- and high-risk strata; therefore, control arms should comprise the current guideline-recommended standard of care for the respective risk level. In general, trials should use time to recurrence or recurrence-free survival as the primary end point and time to progression, toxicity, disease-specific survival, and overall survival as potential secondary end points. Realistic efficacy thresholds should be set to ensure that novel therapies receive due review by regulatory bodies. CONCLUSION The International Bladder Cancer Group has developed formal recommendations regarding definitions, end points, and clinical trial designs for NMIBC to encourage uniformity among studies in this disease.
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Affiliation(s)
- Ashish M Kamat
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
| | - Richard J Sylvester
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Andreas Böhle
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Joan Palou
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Donald L Lamm
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Maurizio Brausi
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Mark Soloway
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Raj Persad
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Roger Buckley
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Marc Colombel
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - J Alfred Witjes
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Steinberg RL, Thomas LJ, Nepple KG. Intravesical and alternative bladder-preservation therapies in the management of non-muscle-invasive bladder cancer unresponsive to bacillus Calmette-Guérin. Urol Oncol 2016; 34:279-89. [PMID: 26777259 DOI: 10.1016/j.urolonc.2015.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/02/2015] [Accepted: 12/09/2015] [Indexed: 11/17/2022]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) remains the standard of care in the treatment of bladder carcinoma in situ and as adjuvant therapy after thorough transurethral resection of high-grade non-muscle-invasive bladder cancer. Despite BCG therapy, in up to 40% of patients it would recur and 60% to 70% of those would fail repeat BCG induction be deemed BCG unresponsive. For such patients, cystectomy remains the preferred treatment option per the American Urological Association and European Association of Urology, though some patients would be medically unfit or refuse radical surgery. Further intravesical therapy for bladder-preservation therapies may preserve quality of life in these patients and in some cases can be curative. There are numerous non-BCG intravesical salvage options available, including immunotherapy, single-agent chemotherapy, combination chemotherapy, and device-assisted chemotherapy. In addition, investigation of radiation-based treatment and other novel therapies including checkpoint inhibitors (programmed death-1/programmed death ligand-1), are currently underway. In this review, we examine the current status of alternatives to BCG in salvage therapy for bladder preservation.
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Affiliation(s)
| | - Lewis J Thomas
- Department of Urology, University of Iowa, Iowa City, IA
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37
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Gandhi NM, Bertrand LA, Lamm DL, O'Donnell MA. Intravesical immunotherapy. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Casey RG, Catto JW, Cheng L, Cookson MS, Herr H, Shariat S, Witjes JA, Black PC. Diagnosis and Management of Urothelial Carcinoma In Situ of the Lower Urinary Tract: A Systematic Review. Eur Urol 2015; 67:876-88. [DOI: 10.1016/j.eururo.2014.10.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/24/2014] [Indexed: 12/28/2022]
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Alcorn J, Burton R, Topping A. BCG treatment for bladder cancer, from past to present use. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2014. [DOI: 10.1111/ijun.12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jason Alcorn
- Mid Yorkshire Hospitals NHS Trust; Pinderfields Hospital; Aberford Road West Yorkshire WF1 4DG UK
| | - Rob Burton
- Head of International Business; School Of Human and Health Sciences, Ramsden R2/41; University Of Huddersfield; West Yorkshire HD1 3DH UK
| | - Annie Topping
- Assistant Executive Director of Nursing Hamad Medical Corporation; Department of Nursing Education; Qatar
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Alcorn J, Burton RL, Topping A. Non-muscle invasive bladder cancer and bacillus Calmette-Guerin treatment: a review of the literature. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2014. [DOI: 10.1111/ijun.12055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jason Alcorn
- Mid Yorkshire Hospitals NHS Trust; Pinderfields Hospital; Aberford Road Wakefield West Yorkshire, WF1 4DG UK
| | - Rob L Burton
- School Of Human and Health Sciences; University of Huddersfield; Ramsden R2/41 Huddersfield West Yorkshire, HD1 3DH UK
| | - Annie Topping
- Department of Nursing Education; Hamad Medical Corporation; Hamad Qatar
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41
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Pérez-Jacoiste Asín MA, Fernández-Ruiz M, López-Medrano F, Lumbreras C, Tejido Á, San Juan R, Arrebola-Pajares A, Lizasoain M, Prieto S, Aguado JM. Bacillus Calmette-Guérin (BCG) infection following intravesical BCG administration as adjunctive therapy for bladder cancer: incidence, risk factors, and outcome in a single-institution series and review of the literature. Medicine (Baltimore) 2014; 93:236-254. [PMID: 25398060 PMCID: PMC4602419 DOI: 10.1097/md.0000000000000119] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Bacillus Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur following instillation. Much of the current knowledge about this complication comes from single case reports, with heterogeneous diagnostic and therapeutic approaches and no investigation on risk factors for its occurrence. We retrospectively analyzed 256 patients treated with intravesical BCG in our institution during a 6-year period, with a minimum follow-up of 6 months after the last instillation. We also conducted a comprehensive review and pooled analysis of additional cases reported in the literature since 1975. Eleven patients (4.3%) developed systemic BCG infection in our institution, with miliary tuberculosis as the most common form (6 cases). A 3-drug antituberculosis regimen was initiated in all but 1 patient, with a favorable outcome in 9/10 cases. There were no significant differences in the mean number of transurethral resections prior to the first instillation, the time interval between both procedures, the overall mean number of instillations, or the presence of underlying immunosuppression between patients with or without BCG infection. We included 282 patients in the pooled analysis (271 from the literature and 11 from our institution). Disseminated (34.4%), genitourinary (23.4%), and osteomuscular (19.9%) infections were the most common presentations of disease. Specimens for microbiologic diagnosis were obtained in 87.2% of cases, and the diagnostic performances for acid-fast staining, conventional culture, and polymerase chain reaction (PCR)-based assays were 25.3%, 40.9%, and 41.8%, respectively. Most patients (82.5%) received antituberculosis therapy for a median of 6.0 (interquartile range: 4.0-9.0) months. Patients with disseminated infection more commonly received antituberculosis therapy and adjuvant corticosteroids, whereas those with reactive arthritis were frequently treated only with nonsteroidal antiinflammatory drugs (p < 0.001 for all comparisons). Attributable mortality was higher for patients aged ≥65 years (7.4% vs 2.1%; p = 0.091) and those with disseminated infection (9.9% vs 3.0%; p = 0.040) and vascular involvement (16.7% vs 4.6%; p = 0.064). The scheduled BCG regimen was resumed in only 2 of 36 patients with available data (5.6%), with an uneventful outcome. In the absence of an apparent predictor of the development of disseminated BCG infection after intravesical therapy, and considering the protean variety of clinical manifestations, it is essential to keep a high index of suspicion to initiate adequate therapy promptly and to evaluate carefully the risk-benefit balance of resuming intravesical BCG immunotherapy.
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Affiliation(s)
- María Asunción Pérez-Jacoiste Asín
- Unit of Infectious Diseases (MAPJA, MFR, FLM, CL, RSJ, ML, JMA), Department of Urology (AT, AAP), and Department of Internal Medicine (SP), Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (i+12), Madrid, Spain
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van Lingen AV, Arends TJH, Witjes JA. Expert review: an update in current and developing intravesical therapies for non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 13:1257-68. [PMID: 24168049 DOI: 10.1586/14737140.2013.852474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Non-muscle-invasive bladder cancer is a highly prevalent disease and recurrences, after initial therapy, are common. Consequently, the healthcare costs for non-muscle-invasive bladder cancer are high. Despite a primary adequate response to adjuvant intravesical treatment, many patients suffer from recurrences, and some even from progression. To date, cystectomy remains the only option for those non-responding patients with high risk of recurrence and progression. Mainly because outcome after progression, in this group, is poor. Therefore, new intravesical therapies are needed. Moreover, new accurate and individual parameters, to distinguish responder from non-responders, will provide additional benefit in clinical decision-making. In this review, current diagnostics and therapies will be discussed. In addition, we will elucidate developing therapies in non-muscle-invasive bladder cancer.
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Affiliation(s)
- Anna V van Lingen
- Department of Urology, Radboud University Medical Center, Geert Grooteplein zuid 10, 6525GA Nijmegen, The Netherlands
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Kausch I, Doehn C, Jocham D. Recent improvements in the detection and treatment of nonmuscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 6:1301-11. [PMID: 17020462 DOI: 10.1586/14737140.6.9.1301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In total, 70-80% of newly diagnosed bladder cancers are confined to the mucosa and staged as Ta, T1 or carcinoma in situ according to the 2002 tumor, lymph nodes and metastasis classification. The standard treatment for these nonmuscle-invasive bladder cancers is transurethral tumor resection with or without adjuvant intravesical chemotherapy or intravesical immunotherapy and subsequent follow-up. Diagnosis and follow-up of nonmuscle-invasive bladder cancer offers two main problems. First, approximately 10-20% of all tumors are not seen in standard cystoscopy. Additionally, frequently repeated follow-up cystoscopies are bothersome for the patient. As an adjunct to standard cystoscopy, fluorescence-guided cystoscopy has demonstrated significantly higher tumor detection rates and optimized patient treatment in recent Phase III studies. Second, routinely performed urine cytology is characterized by high specificity but low sensitivity. Today, several urine tests are available that may increase diagnostic accuracy and potentially prolong intervals of follow-up cystocopy. Owing to rather high recurrence rates after transurethral tumor resection in most tumors and high progression rates in poorly differentiated tumors, adjuvant intravesical chemotherapy or intravesical immunotherapy has gained widespread use in patients with nonmuscle-invasive bladder cancer. Only a few further immunomodulatory drugs, such as recombinant cytokines, have shown significant clinical effectiveness. Additional approaches, such as photodynamic therapy with different photosensitizers and thermotherapy in combination with intravesical chemotherapy, have been evaluated in Phase III studies.
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Affiliation(s)
- Ingo Kausch
- Department of Urology, University of Lubeck Medical School, Ratzeburger Allee 160, 23538 Lubeck, Germany.
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van Lingen AV, Witjes JA. Current intravesical therapy for non-muscle invasive bladder cancer. Expert Opin Biol Ther 2013; 13:1371-85. [DOI: 10.1517/14712598.2013.824421] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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Gontero P, Fiorito C, Oderda M, Pappagallo G, Brausi M. Phase II study of biweekly gemcitabine as first line therapy in CIS of the bladder: What does an aborted trial tell us? Urol Oncol 2013; 31:671-5. [DOI: 10.1016/j.urolonc.2011.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 03/28/2011] [Accepted: 03/28/2011] [Indexed: 12/26/2022]
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Ali-El-Dein B, Barakat TS, Nabeeh A, Ibrahiem EHI. Weekly intravesical bacillus Calmette-Guerin (BCG) alternating with epirubicin in Ta and T1 urothelial bladder cancer: An approach to decrease BCG toxicity. Urol Ann 2013; 5:103-8. [PMID: 23798868 PMCID: PMC3685738 DOI: 10.4103/0974-7796.110008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 04/07/2012] [Indexed: 11/04/2022] Open
Abstract
Context: Bacillus Calmette-Guerin (BCG) therapy is the standard treatment for nonmuscle-invasive bladder cancer (NMIBC). However, its toxicity is a major concern. Aim: If we reduce the number of BCG doses by half and replace the second half with epirubicin, we may have a lower toxicity while maintaining the same efficacy of BCG. To test this hypothesis, we conducted this study as an update of our previous report. Setting and Design: The study included 607 patients with Ta and T1 NMIBC between January 1994 and December 2008. Materials and Methods: After transurethral resection of bladder tumor (TURBT), the patients received weekly doses of 120 mg BCG alternating with 50 mg epirubicin for six weeks (three weekly doses of each). Maintenance was given. Recurrence, progression rates, and toxicity were assessed. End points were progression, recurrence, and cancer-specific survival. Results: A total of 532 patients were eligible for evaluation (mean age: 58 years; median follow-up: 45 months). Of these, 291 (55%) were free, 157 (29.5%) showed recurrence, and 84 (15.8%) showed muscle-invasive progression. Toxicity developed in 221 patients. These were mild in the majority (167), whereas 10 developed hematuria, 30 severe cystitis, and five systemic complications. The rate of permanent therapy discontinuation was 3.8%. Statistical Analysis Used: SPSS package version 16 and Kaplan-Meier curves were used to evaluate survival. Conclusions: Reducing the frequency of BCG instillations by half and replacing the second half with epirubicin results in a similar efficacy and a lower toxicity compared with historical cases receiving BCG alone. However, further trials are required to support these results.
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Affiliation(s)
- Bedeir Ali-El-Dein
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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The Value of Transurethral Bladder Biopsy after Intravesical Bacillus Calmette-Guérin Instillation Therapy for Nonmuscle Invasive Bladder Cancer: A Retrospective, Single Center Study and Cumulative Analysis of the Literature. J Urol 2012; 188:748-53. [DOI: 10.1016/j.juro.2012.05.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Indexed: 11/24/2022]
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48
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Järvinen R, Kaasinen E, Rintala E, Group TF. Long-term results of maintenance treatment of mitomycin C or alternating mitomycin C and bacillus Calmette–Guérin instillation therapy of patients with carcinoma in situ of the bladder: A subgroup analysis of the prospective FinnBladder 2 study with a 17-year follow-up. ACTA ACUST UNITED AC 2012; 46:411-7. [DOI: 10.3109/00365599.2012.694906] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Riikka Järvinen
- Department of Urology, Helsinki University Hospital,
Helsinki, Finland
| | - Eero Kaasinen
- Department of Surgery, Hyvinkää Hospital,
Hyvinkää, Finland
| | - Erkki Rintala
- Department of Urology, Helsinki University Hospital,
Helsinki, Finland
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Biot C, Rentsch CA, Gsponer JR, Birkhauser FD, Jusforgues-Saklani H, Lemaitre F, Auriau C, Bachmann A, Bousso P, Demangel C, Peduto L, Thalmann GN, Albert ML. Preexisting BCG-Specific T Cells Improve Intravesical Immunotherapy for Bladder Cancer. Sci Transl Med 2012; 4:137ra72. [DOI: 10.1126/scitranslmed.3003586] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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50
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The EORTC Genito-Urinary Cancers Group: 35 years of achievements and future strategy. EJC Suppl 2012. [DOI: 10.1016/s1359-6349(12)70012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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