- BCG refractory: patients who do not reach a disease-free state at 6 months after starting BCG (at least induction + maintenance) for high risk NMIBC (Ta/T1/CIS)
- BCG relapsing: patients who reach a disease-free state at 6 months, and continue on BCG, but later recur within 6 months of the last dose of BCG
Enhanced recovery pathways after surgery (ERAS) help, but it doesn’t change the comorbidity level of these patients. ERAS has decreased length of stay, but hasn’t changed complication rates (15%) or readmissions/mortality (15-30%). So, is there a “window of safety” with which to continue with bladder sparing therapy without missing oncologic cure? Dr. Porten thinks that there is, with a combination of treatment/therapies: (i) blue light/narrow band imaging, (ii) adequate prostatic urethra and upper tract evaluation to identify possible sanctuary sites for tumors, (iii) improved cross sectional imaging, and (iv) new biomarkers/genomics.
There are several single-agent salvage intravesical chemotherapy options that are available now that Dr. Porten highlighted1:
- Valrubicin: 6 weekly instillations. Has reported 1 year complete response rates of 14% and 8% complete response rates at 30 months.
- Gemcitabine: 6 weekly instillations and monthly x 12 months. Reported 28% 1-year complete response rates.
- Docetaxel: 6 weekly instillations and monthly x 9 months. Reported 40% 1-year complete response rates.
- Nab-paclitaxel: 6 weekly instillations and monthly x 6 months. Reported 36% 1-year complete response rates.
- Li R, Spiess PE, Kamat AM. Treatment options for patients with recurrence tumors after BCG therapy: Are we ignoring the obvious? Eur Urol 2018 [Epub ahead of print].
- Shore ND, Boorjian SA, Canter DJ, et al. Intravesical rAd-IFNalpha/Syn3 for patients with high-grade, Bacillus Calmette-Guerin-Refractory or relapsed non-muscle-invasive bladder cancer: A phase II randomized study. J Clin Oncol 2017;35(30):3410-3416.
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
Read the Rebuttal Presentation: High Risk BCG Recurrent/Refractory Disease: Immediate Cystectomy