Dr. Mark S. Soloway, University of Miami School of Medicine presented the argument for management of stage T1 bladder cancer with intravesical BCG therapy. First, he argued to eliminate the term "superficial" bladder cancer as it includes a heterogeneous group of tumors. However, many of these are not low risk and the term "superficial" implies no invasion and low risk for progression. Dr. Soloway pointed out that cystectomy for stage T1 disease is over-treatment in 25-40% of patients. However, he showed data on 319 of his patients who had cystectomy. Of those, 30% were not organ confined. The 5-year estimated overall survival was 65% and the 69% for disease-specific survival. This serves as evidence, he said that we are currently waiting too long to treat many patients. Better patient selection through re-TUR will help to identify patients at risk for progression or understaging. Dr. Soloway also cited the excellent response rates to BCG in stage T1 tumors and that a significant percentage of these patients would never need to go on to cystectomy. Dr. Soloway referred to the data on BCG maintenance therapy and its role in decreasing tumor progression. Lower doses of BCG can minimize side effects without compromising the anti-tumor effects.

Dr. Eila Skinner, USC Norris Cancer Center presented the case for management of stage T1 bladder cancer with cystectomy. She discussed the risks of understaging T1 disease and the fact that metastatic bladder cancer is not curable. Between 37-39% of patients with T1G3 disease and CIS will be up-staged. Dr. Skinner was concerned that BCG may delay recurrence but may not impact long-term cancer specific survival. She pointed out that even with cystectomy, some patients went on to fail due to micro-metastatic disease. The USC series for patients who had cystectomy shows that the survival curves for T1 and T2 are extremely similar. As such, she felt that T1 and T2 were similar and should be treated the same. Dr. Skinner pointed out that cystectomy is an operation with low morbidity and mortality. The outcomes with orthotopic urinary diversion are excellent and in combination with extended pelvic lymphadenectomy give the best chances for cure.

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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