BERKELEY, CA (UroToday Inc.) - Significant numbers of complete response rates occur after BCG therapy of pT1 or CIS bladder cancers. How do urologists apply this observation? Dr. F. N. Joudi, with his associates at the University of Iowa, Iowa City, report their study of degree of clinical application of intravesical immunotherapy chemotherapy in the USA in the December 2003 edition of Urology.

Their study differs from others in that it covered the entire nation and surveyed 226 urologists who practiced in large and small groups or in academic centers. They also requested information about year of graduation from urology training (either before or after 1985) and status of AUA Section membership.

Although they requested information on treatment plans regarding chemotherapy or immunotherapy for 17 different disease categories of bladder cancer (BCa), they ultimately compressed these into four broad categories: 1. Newly diagnosed lesions, 2. Lesions that failed initial intravesical chemotherapy, 3. Those that failed intravesical BCG once, and 4. Those that failed intravesical BCG twice.

Another outcome analyzed whether patients received additional intravesical therapy or underwent cystectomy after failing intravesical treatment, especially a second time.

They determined that membership in AUA Sections was relatively balanced, as was graduation before or after 1985. Ninety-two percent of urologists treated Ta disease by TURBT, and 98% used intravesical immunotherapy after diagnosis of CIS. Most urologists also administered a second course of intravesical immunotherapy after an initial failure.

Interestingly, however, only 19% of urologists recommended "aggressive treatment" (radical cystectomy) after a second failure of BCG.

Further analysis led to separation of those recommending cystectomy versus those not doing so. Urologists graduating after 1985 offered cystectomy 3 times more often that those graduating before. Also, urologists in practices with 4 or more participants were more likely to offer cystectomy after 2 BCG failures.

Academic urologists used intravesical chemotherapy after initial TUR for low-grade tumors 4 times as often as non-academics. Finally, practices in which BCG came prepared from outside sources (pharmacy, etc.) more often offered immunotherapy.

The authors conclude that overall "management of superficial bladder cancer...adhered to the AUA Bladder Cancer Guidelines Panel recommendations". They express some surprise that 81% of those surveyed did not recommend radical cystectomy for patients with high-grade disease who had failed BCG therapy twice.

Urology 2003;62:1083-1088