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Azuri W, Jaunarena JH, Camean JJ, Chemi J, Villaronga A, Daneshmand S, Villoldo GM. The Impact of Dose Reduction of Bacillus Calmette-Guerin on Oncological Outcomes and Toxicity in Non-Muscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Bladder Cancer 2023; 9:227-236. [PMID: 38993181 PMCID: PMC11181759 DOI: 10.3233/blc-230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/03/2023] [Indexed: 07/13/2024]
Abstract
BACKGROUND Bacillus Calmette-Guerin (BCG) is the standard adjuvant treatment for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) following transurethral resection of the bladder (TURB). However, the optimal dose, strain, and schedule of BCG remain unclear. OBJECTIVE To evaluate the impact of BCG dose reduction on oncological outcomes and toxicity in patients with non-muscle invasive bladder cancer. METHODS We performed a systematic review of the literature in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases. Selected studies were analyzed for Meta Analysis using PRISMA criteria. The study focused on disease recurrence, progression, and toxicity. We also compared the oncological outcomes of the different BCG strains. RESULTS A total of 2963 patients in 13 randomized controlled trials were included. In recurrence analysis, we found a non-significant difference between the full dose and any dose reduction of BCG (RR = 1.17, [1.06-1.28], I2 = 0%, p = 0.7). In terms of progression, the difference was also non-statistically significant (RR: 1.12 [0.89 - 1.41], I2 = 0%, p = 0.93). In the toxicity analysis, there were more local (RR: 0.81 [0.67-0.99] I2 = 76%; p < 0.01) and systemic (RR: 0.53 [0.34-0.82] I2 = 83%; p < 0.01) side effects in the full dose group than in the dose reduction group. There were no statistically significant differences in oncological outcomes between the analyzed BCG strains. CONCLUSIONS Dose reduction did not affect the oncological outcomes of patients with NMIBC who received adjuvant therapy with BCG. On the other hand, dose reduction showed a significant trend towards fewer systemic and local side effects. Further studies comparing oncological and toxicity outcomes using different strains are needed.
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Affiliation(s)
- Wadi Azuri
- Instituto Alexander Fleming, Buenos Aires, Argentina
- Sanatorio Argentino, San Juan, Argentina
| | - Jorge Horacio Jaunarena
- Instituto Alexander Fleming, Buenos Aires, Argentina
- Centro de Urología CDU, Buenos Aires, Argentina
| | | | - Joaquín Chemi
- Instituto Alexander Fleming, Buenos Aires, Argentina
- Hospital Marie Curie, Buenos Aires, Argentina
| | | | - Siamak Daneshmand
- Keck Medicine, University of Southern California, Los Angeles, CA, USA
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Flaig TW, Spiess PE, Abern M, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, Chan K, Chang S, Friedlander T, Greenberg RE, Guru KA, Herr HW, Hoffman-Censits J, Kishan A, Kundu S, Lele SM, Mamtani R, Margulis V, Mian OY, Michalski J, Montgomery JS, Nandagopal L, Pagliaro LC, Parikh M, Patterson A, Plimack ER, Pohar KS, Preston MA, Richards K, Sexton WJ, Siefker-Radtke AO, Tollefson M, Tward J, Wright JL, Dwyer MA, Cassara CJ, Gurski LA. NCCN Guidelines® Insights: Bladder Cancer, Version 2.2022. J Natl Compr Canc Netw 2022; 20:866-878. [PMID: 35948037 DOI: 10.6004/jnccn.2022.0041] [Citation(s) in RCA: 118] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The NCCN Guidelines for Bladder Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with bladder cancer and other urinary tract cancers (upper tract tumors, urothelial carcinoma of the prostate, primary carcinoma of the urethra). These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines regarding the treatment of non-muscle-invasive bladder cancer, including how to treat in the event of a bacillus Calmette-Guérin (BCG) shortage; new roles for immune checkpoint inhibitors in non-muscle invasive, muscle-invasive, and metastatic bladder cancer; and the addition of antibody-drug conjugates for metastatic bladder cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Shilajit Kundu
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Ronac Mamtani
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Omar Y Mian
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Jeff Michalski
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Anthony Patterson
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Kamal S Pohar
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | - Jonathan L Wright
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; and
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Leon P, Saint F, Audenet F, Roumiguié M, Allory Y, Loriot Y, Masson-Lecomte A, Pradère B, Seisen T, Traxer O, Xylinas E, Roupret M, Neuzillet Y. Recommandations du Comité de cancérologie de l’Association Française d’Urologie (CC-AFU) pour la bonne pratique des instillations intravésicales de mitomycine C, d’épirubicine et de BCG pour le traitement des tumeurs de la vessie n’infiltrant pas le muscle (TVNIM). Prog Urol 2022; 32:299-311. [DOI: 10.1016/j.purol.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
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Audenet F, Sotto A, Roumiguié M, Allory Y, Andrejak C, Leon P, Loriot Y, Masson-Lecomte A, Pradère B, Seisen T, Traxer O, Xylinas E, Bruyère F, Roupret M, Saint F, Neuzillet Y. Recommandations des Comités de cancérologie (CC-AFU) et d’infectiologie (CI-AFU) de l’Association française d’urologie pour la prise en charge effets indésirables et complications du BCG. Prog Urol 2022; 32:165-176. [DOI: 10.1016/j.purol.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
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Surlemont L, Nouhaud FX, Dupuis H, Delcourt C, Defortescu G, Cornu JN, Pfister C. [BCG strain shortage from 2012 to 2014: Evaluation of its impact on the management of patients with high-risk NMIBC]. Prog Urol 2021; 31:324-331. [PMID: 33516609 DOI: 10.1016/j.purol.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION BCG instillations are the gold-standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC) with a decreased risk of tumor recurrence and muscle infiltration. From 2012 to 2014, a stock shortage of the Connaught strain has led to the cessation of supply for immucyst in France. The objective of this study was to evaluate the potential impact of BCG shortage on the management of patients with NMIBC. PATIENTS AND METHODS We conducted a retrospective single-center study including patients followed from May 2005 to May 2015 with a high-risk NMIBC (primo-diagnosis). Patients were separated into two groups: not impacted by the shortage (NISG: 56 patients) and impacted by the shortage (ISG: 53 patients). Data on tumour recurrence (RFS), muscle progression (PFS) and overall and specific survival (OS and SS) were also analysed. RESULTS The BCG induction schedule could not be carried out in 20.8% of cases in the ISG compared to only 5.3% of cases in NISG (P=0.02). Similarly, the maintenance treatment was incomplete for 56.6% of cases versus 37.5% in NISG (P=0.047). Nevertheless, it should be underlined that very high-risk NMIBC received a complete induction BCG schedule. The ISG seems to have benefited with the evolution of the guidelines with the use of diagnosis bladder fluorescence but without significant difference on the rate of second look bladder trans-uretral resection. The cystectomy rate was higher in ISG. No significant difference in RFS, PFS, OS, and SS between the two groups. CONCLUSION In our experience, RFS, PFS, OS or SS were not impacted by the BCG shortage. These data may be explained by a better selection of very high-risk patients including the recommended BCG schedule and more frequently the use of diagnosis bladder fluorescence. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- L Surlemont
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - F-X Nouhaud
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - H Dupuis
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - C Delcourt
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - G Defortescu
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - J-N Cornu
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France
| | - C Pfister
- Service urologie, CHU de Rouen, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France.
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Rossi SM, Murray T, McDonough L, Kelly H. Loco-regional drug delivery in oncology: current clinical applications and future translational opportunities. Expert Opin Drug Deliv 2020; 18:607-623. [PMID: 33253052 DOI: 10.1080/17425247.2021.1856074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Drug-based treatment regimens for cancer are often associated with off-target toxic side effects and low penetration of the drug at the tumor site leading to patient morbidity and limited efficacy. Loco-regional drug delivery has the potential to increase efficacy while concomitantly reducing toxicity.Areas covered: Clinical applications using loco-regional delivery include intra-arterial drug delivery in retinoblastoma, direct intra-tumoral (IT) injection of ethanol for ablation in hepatocellular carcinoma (HCC) and the use of HIPEC in peritoneal carcinomas. In recent years, there has been a significant increase in both approved products and clinical trials, with a particular emphasis on drug delivery platforms such as drug-eluting beads for HCC and hydrogel platforms for intravesical delivery in bladder cancer.Expert opinion: Development of loco-regional drug-delivery systems has been slow, limited by weak clinical data for early applications and challenges relating to dosing, delivery and retention of drugs at the site of action. However, there is increasing focus on the potential of loco-regional drug delivery when combined with bespoke drug-delivery platforms. With the growth in immunotherapies, the use of IT delivery to drive priming of the anti-tumor response has opened up a new field of opportunity for loco-regional drug delivery.
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Affiliation(s)
- Seona M Rossi
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Timothy Murray
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Liam McDonough
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Helena Kelly
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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Mohamed MB, Ali MH, Shamaa MA, Shaaban SM. Single course of intravesical Bacillus Calmette-Guerin versus single course with maintenance therapy in the management of nonmuscle invasive bladder cancer: A prospective randomized study. Urol Ann 2020; 12:360-365. [PMID: 33776333 PMCID: PMC7992517 DOI: 10.4103/ua.ua_137_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/26/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: The objective of the study was to compare maintenance versus single course of intravesical Bacillus Calmette–Guerin (BCG) in the management of high-risk nonmuscle invasive bladder cancer (NMIBC) regarding recurrence, progression, survival, and complications. Patients and Methods: After transurethral resection of bladder tumor (TURBT), Group I patients (33) received weekly doses of 90 mg of live attenuated Pasteur strain of BCG. The course was started 14 days after the second TURBT for 6 consecutive weeks. In Group II: 35 patients, the induction schedule was followed by 3 weekly instillations at months 3, 6, and 12 as a maintenance course. Recurrence, progression rates, survival, and toxicity were assessed in both the groups. Results: Patients with induction therapy alone had significantly higher recurrence rate than those received maintenance therapy (55.6% vs. 19.2%, P = 0.01). The 5-year recurrence-free survival rate was 41% and 78% in both the groups, respectively. There was no significant difference regarding the progression rate for both the groups. The mean 5-year progression-free time was comparable between the two groups. The 5-year progression-free survival was 69.8% for patients who underwent induction therapy alone compared to 70.7% for maintenance therapy. Overall local adverse events were significantly higher in patients who underwent maintenance treatment protocol. Statistical Analysis Used: SPSS package version 20 and Kaplan–Meier curves were used to evaluate the survival rate. Conclusions: Maintenance doses of BCG significantly decrease and delay the recurrence of high-risk NMIBC. However, there is no significant favor as regards tumor progression. Maintenance doses of BCG are significantly associated with a higher incidence of local adverse effects than induction doses alone.
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Affiliation(s)
- Mohamed Bakr Mohamed
- Department of Urology, Faculty of Medicine, Port Said University, Port Said, Egypt
| | - Mohamed Hassan Ali
- Department of Urology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mostafa A Shamaa
- Department of Urology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Sami M Shaaban
- Department of Urology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Lee S, Lim B, You D, Hong B, Hong JH, Kim CS, Ahn H, Jeong IG. Association of Bacillus Calmette-Guerin shortages with bladder cancer recurrence: A single-center retrospective study. Urol Oncol 2020; 38:851.e11-851.e17. [PMID: 32800440 DOI: 10.1016/j.urolonc.2020.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/29/2020] [Accepted: 07/12/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the association between Bacillus Calmette-Guerin (BCG) shortage and bladder cancer recurrence in high-risk non-muscle-invasive bladder cancer (NMIBC) patients. MATERIALS AND METHODS This retrospective study included 333 BCG-naive patients who underwent transurethral resection of bladder tumor for high-risk NMIBC between January 2014 and December 2017. The primary outcome was disease recurrence after operation. The secondary outcomes were trends in BCG shortages and differences in post-transurethral resection of bladder tumor intravesical treatments according to shortage. Multivariable Cox regression modeling was used to assess outcomes. RESULTS Among 333 patients (median age, 67 years; men, 270 [81.1%]), 94 (28.2%) experienced BCG shortage (BCG shortage group). Eleven episodes of BCG shortage occurred during the study period (median 10 days, range 2-97 days). Although we observed no statistically significant differences in clinical and pathological characteristics, there were significant differences in post-transurethral resection of bladder tumor intravesical treatments between the shortage and control groups (BCG: 28.7% vs. 68.1%, mitomycin/epirubicin: 27.7% vs. 1.7%, P < 0.001). The 3-year recurrence-free survival rate was significantly lower in the shortage group than that in the control group (38.0% vs. 60.2%, log-rank test, P = 0.010). In multivariable analysis, shortage (hazard ratio [HR] = 1.55, 95% confidence interval [CI] 1.09-2.21, P = 0.016) and tumor multiplicity (HR = 1.55, 95% CI 1.05-2.29, P = 0.028) were independent factors associated with the recurrence of bladder cancer. CONCLUSIONS High-risk NMIBC patients who experienced BCG shortage had a high risk of bladder cancer recurrence. Clinical trials of alternative treatment strategies and efforts to increase BCG supply are required.
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Affiliation(s)
- Sangmin Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bumjin Lim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dalsan You
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - In Gab Jeong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Leow JJ, Catto JWF, Efstathiou JA, Gore JL, Hussein AA, Shariat SF, Smith AB, Weizer AZ, Wirth M, Witjes JA, Trinh QD. Quality Indicators for Bladder Cancer Services: A Collaborative Review. Eur Urol 2020; 78:43-59. [PMID: 31563501 DOI: 10.1016/j.eururo.2019.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022]
Abstract
CONTEXT There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer. OBJECTIVE To evaluate the optimal management of bladder cancer and propose quality indicators (QIs). EVIDENCE ACQUISITION A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs. EVIDENCE SYNTHESIS For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care. CONCLUSIONS We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer. PATIENT SUMMARY After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.
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Affiliation(s)
- Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James W F Catto
- Academic Urology Unit, The University of Sheffield, Sheffield, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Ahmed A Hussein
- Department of Urology, Cairo University, Cairo, Egypt; Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Departments of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Angela B Smith
- Department of Urology, Lineberger Comprehensive Cancer Center, UNC-Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - J Alfred Witjes
- Department of Urology, Radboud University, Nijmegen, The Netherlands
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Sood R, Sharma H, Sharma B, Parekh S, Pujari P, Shewale S. A prospective comparative study to assess the efficacy and tolerability of 2 different doses of intravesical bacillus Calmette-Guerin (BCG) in patients with non-muscle-invasive bladder cancer. Urol Oncol 2020; 38:433-439. [PMID: 32037199 DOI: 10.1016/j.urolonc.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/06/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bacillus Calmette-Guerin (BCG) is widely used as an immunotherapeutic agent and recommended in management of non-muscle-invasive bladder cancer (NMIBC). There is no consensus on the optimal dose of the BCG. However, dose reduction has been assessed to decrease the side effects following instillation of BCG. This study compared the efficacy and safety of 80 and 120 mg doses of Sii Onco BCG (Moscow I, Russian strain) in patients with NMIBC. METHODS Patients with histologically confirmed, completely resected solitary or multiple Ta or T1 (with or without carcinoma in situ), grade 1 to 3 urothelial carcinoma of the bladder were included. After transurethral resection of the tumor, repeated intravesical instillations with Sii Onco BCG (80 or 120 mg) were administered, following the induction and 3 weekly maintenance schedule (at 3, 6, 9, 15, 21, 27, and 33 months). Recurrence and progression of the tumor were monitored at scheduled time intervals using cystoscopy. RESULTS A total of 104 eligible patients were enrolled to receive 80 mg (n = 51) dose or 120 mg dose (n = 53) of Sii Onco BCG. On completion of 3 years follow-up, recurrence-free survival rate of 84.31% and 86.79% and progression-free survival rate of 84.31% and 94.34% were observed for 80 and 120 mg groups, respectively; difference being statistically nonsignificant. CONCLUSION Both, 80 and 120 mg doses of Sii Onco BCG are effective and safe for prophylaxis and management of NMIBC.
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Affiliation(s)
- Rajeev Sood
- Department of Urology, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Hitt Sharma
- Serum Institute of India Pvt. Ltd., Pune, India.
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Wang Z, Xiao H, Wei G, Zhang N, Wei M, Chen Z, Peng Z, Peng S, Qiu S, Li H, Long J. Low-dose Bacillus Calmette-Guerin versus full-dose for intermediate and high-risk of non-muscle invasive bladder cancer: a Markov model. BMC Cancer 2018; 18:1108. [PMID: 30419836 PMCID: PMC6233591 DOI: 10.1186/s12885-018-4988-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the efficacy of low dose (27 mg) Bacillus Calmette-Guérin (BCG) and a full dose (81 mg) BCG immunotherapy for patients with intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) after a typical transurethral bladder resection. METHODS We constructed a Markov model for a 20-year simulation of the disease to compare the overall survival of patients with intermediate and high-risk of NMIBC between the full-dose therapy (FD group) and the low-dose therapy (LD group). Base case analysis, one-way and two-way sensitivity analysis and a second-order Monte Carlo analysis were performed based on data from 15 published articles. RESULTS The expected overall survivals were 9.56 (9.55-9.57) years for FD group and 9.63 (9.61-9.64) years for LD group(P < 0.001). The estimated mortality in the FD group at 5, 10, and 20 years were 34.23%, 57.51% and 83.14%, respectively. The corresponding values in the LD group were 34.11%, 57.17%, 82.16%, respectively. Age-specific mortality and metastatic rate after undergoing radical cystectomy (RC) were the most two sensitive parameters in both groups. The rate of disease recurrence with disease worsening is the determining factor when choosing the optimal dose of BCG treatment. CONCLUSIONS A low-dose BCG treatment may act slightly better than a full-dose BCG treatment for patients with intermediate and high-risk of NMIBC. This finding will require further high-quality studies to validate.
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Affiliation(s)
- Zongren Wang
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Han Xiao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Guangyan Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ning Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Mengchao Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zebin Chen
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenwei Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Sui Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shaopeng Qiu
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Heping Li
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jianting Long
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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[Urothelial tumors in 2016: Are we at the dawn of a new diagnostic and therapeutic era?]. Ann Pathol 2016; 36:369-370. [PMID: 27912839 DOI: 10.1016/j.annpat.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Low Dose BCG Infection as a Model for Macrophage Activation Maintaining Cell Viability. J Immunol Res 2016; 2016:4048235. [PMID: 27833923 PMCID: PMC5090099 DOI: 10.1155/2016/4048235] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/26/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
Mycobacterium bovis BCG, the current vaccine against tuberculosis, is ingested by macrophages promoting the development of effector functions including cell death and microbicidal mechanisms. Despite accumulating reports on M. tuberculosis, mechanisms of BCG/macrophage interaction remain relatively undefined. In vivo, few bacilli are sufficient to establish a mycobacterial infection; however, in vitro studies systematically use high mycobacterium doses. In this study, we analyze macrophage/BCG interactions and microenvironment upon infection with low BCG doses and propose an in vitro model to study cell activation without affecting viability. We show that RAW macrophages infected with BCG at MOI 1 activated higher and sustained levels of proinflammatory cytokines and transcription factors while MOI 0.1 was more efficient for early stimulation of IL-1β, MCP-1, and KC. Both BCG infection doses induced iNOS and NO in a dose-dependent manner and maintained nuclear and mitochondrial structures. Microenvironment generated by MOI 1 induced macrophage proliferation but not MOI 0.1 infection. In conclusion, BCG infection at low dose is an efficient in vitro model to study macrophage/BCG interactions that maintains macrophage viability and mitochondrial structures. This represents a novel model that can be applied to BCG research fields including mycobacterial infections, cancer immunotherapy, and prevention of autoimmunity and allergies.
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Zeng S, Yu X, Ma C, Zhang Z, Song R, Chen X, Sun Y, Xu C. Low-Dose Versus Standard Dose of Bacillus Calmette-Guerin in the Treatment of Nonmuscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e2176. [PMID: 26656345 PMCID: PMC5008490 DOI: 10.1097/md.0000000000002176] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Whether low-dose Bacillus Calmette-Guerin (BCG) treatment can reduce the side effects while maintaining efficacy for patients with nonmuscle invasive bladder cancer (NMIBC) is controversial.To investigate whether low-dose BCG treatment can reduce the side effects while maintaining efficacy for patients with NMIBC when compared with standard-dose BCG treatment.A comprehensive literature search of PubMed, EMBASE, CINAHL, LILACS, and CENTRAL databases was conducted to identify relevant randomized controlled trials (RCT) or quasi-randomized controlled trials (qRCT) that have assessed the efficacy of low- and standard-dose BCG therapy for patients with NMIBC. Systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis Criteria.Six RCTs and 2 qRCTs were eligible for meta-analysis. Low-dose BCG instillation was not inferior to reduce the risk of bladder tumor recurrence (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.00-1.31; P = 0.05), meanwhile no difference was found regarding tumor progression (HR = 1.08; 95%CI, 0.83-1.42; P = 0.57). However, low-dose BCG provided a significantly lower incidence of overall side effects (RR = 0.75; 95%CI, 0.60-0.94; P = 0.01), systemic side effects (RR = 0.57; 95%CI, 0.34-0.97; P = 0.04), severe side effects (RR = 0.52; 95%CI, 0.36-0.74; P = 0.0003), and withdrawal due to BCG toxicity (RR = 0.49; 95%CI, 0.26-0.91; P = 0.02). In contrast, local side effects were comparable between low- and standard-dose arms (RR = 0.89; 95%CI, 0.73-1.08; P = 0.24).Low-dose BCG instillation significantly reduces the incidence of overall side effects, especially severe and systemic symptoms in patients with NMIBC, while the oncological control efficacy of low-dose BCG is not inferior to standard-dose BCG. Further studies with stratification using different risk factors at randomization are required to assess whether the efficacy of low-dose BCG is comparable to standard dose BCG for different risk of patients.PROSPERO registration No CRD42014014871 (http://www.crd.york.ac.uk/prospero/).
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Affiliation(s)
- Shuxiong Zeng
- From the Department of Urology(SZ, CM, ZZ, RS, XC, YS, CX); and Department of Geriatrics(XY), Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
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Abstract
It is nearly 40 years since Bacillus Calmette-Guérin (BCG) was first used as an immunotherapy to treat superficial bladder cancer. Despite its limitations, to date it has not been surpassed by any other treatment. As a better understanding of its mechanism of action and the clinical response to it have evolved, some of the questions around optimal dosing and treatment protocols have been answered. However, its potential for toxicity and failure to produce the desired clinical effect in a significant cohort of patients presents an ongoing challenge to clinicians and researchers alike. This review summarizes the evidence behind the established mechanism of action of BCG in bladder cancer, highlighting the extensive array of immune molecules that have been implicated in its action. The clinical aspects of BCG are discussed, including its role in reducing recurrence and progression, the optimal treatment regime, toxicity and, in light of new evidence, whether or not there is a superior BCG strain. The problems of toxicity and non-responders to BCG have led to development of new techniques aimed at addressing these pitfalls. The progress made in the laboratory has led to the identification of novel targets for the development of new immunotherapies. This includes the potential augmentation of BCG with various immune factors through to techniques avoiding the use of BCG altogether; for example, using interferon-activated mononuclear cells, BCG cell wall, or BCG cell wall skeleton. The potential role of gene, virus, or photodynamic therapy as an alternative to BCG is also reviewed. Recent interest in the immune check point system has led to the development of monoclonal antibodies against proteins involved in this pathway. Early findings suggest benefit in metastatic disease, although the role in superficial bladder cancer remains unclear.
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Affiliation(s)
- Oliver Fuge
- Department of Urology, Lister Hospital, Stevenage, UK
| | - Nikhil Vasdev
- Department of Urology, Lister Hospital, Stevenage, UK
| | - Paula Allchorne
- Department of Urology, Bartshealth NHS Trust, Whipps Cross Rd, London, UK
| | - James Sa Green
- Department of Urology, Bartshealth NHS Trust, Whipps Cross Rd, London, UK
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Robinson R. Editorial Comment to Efficacy and tolerance of one-third full dose bacillus Calmette-Guérin maintenance therapy every 3 months or 6 months: two-year results of URO-BCG-4 multicenter study. Int J Urol 2014; 22:61. [PMID: 25345728 DOI: 10.1111/iju.12655] [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]
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