AUA 2018: High Risk BCG Recurrent/Refractory Disease: Immediate Cystectomy

San Francisco, CA ( Nick Liu, MD from SUNY Upstate provided the rebuttal to Dr. Sima Porten’s presentation on secondary therapy for high risk BCG recurrent/refractory disease. His opinion is that immediate cystectomy saves lives in BCG failure bladder cancer patients. Although there are broad/many definitions for BCG failure, Liu defines BCG failure as any recurrent disease after initiation of BCG therapy.

According to Liu there are several truths about BCG:
  • Nearly 40% of patients fail within the first year
  • In high risk patients, BCG can prevent recurrence but may not prevent progression or improve cancer specific survival
  • After BCG failure, each additional course of BCG carries a 7% increased risk of progression
His argument is that patients with non-invasive bladder cancer who failed BCG should undergo immediate cystectomy, purely because it is their best chance at survival. The pathology at recurrence is important – for patients with a high grade T1 recurrence after BCG failure, survival in a contemporary cohort is 69%, whereas historically it is as low as 52%. These patients undergoing immediate cystectomy have a disease specific death rate of 31% compared to patients that for cystectomy until disease progression (48%). Furthermore, patients who fail BCG and then undergo cystectomy have a pT2 or greater upstaging rate of 27%. 

In Liu’s opinion, understaging is a real problem among patients with BCG failure NMIBC – “muscle invasive bladder cancer after BCG failure is a different beast altogether.” In an older study from 2004 comparing progressive MIBC (n=74) vs primary MIBC (n=89), the 3 and 5-year survival rates for primary MIBC was 67% and 55%, respectively vs 37% and 28%, respectively, for progressive MIBC [1]. Subsequent meta-analyses support the notion that progressive MIBC is worse than primary MIBC with a cancer-specific survival of 35%, again highlighting that these patients are at risk of much worse outcomes and should undergo immediate cystectomy. Indeed, the prognosis is excellent with cystectomy in NMIBC with 5-year cancer specific survival rates of >80%, which Dr. Liu points out is far better than any of the salvage agents we currently have. 

Liu’s final point is that high-grade T1 bladder cancer has a 10% risk of lymph node involvement, which is equivalent to Gleason 9 prostate cancer. He poses the question: Would you offer conservative treatment? OR would you offer aggressive multimodal treatment?

1. Schrier BP, Hollander MP, van Rhijn BW, et al. Prognosis of muscle-invasive bladder cancer: Difference between primary and progressive tumours and implications for therapy. Eur Urol 2014;45(3):292-296.

Presented by: Nick Liu, SUNY Upstate, Syracuse, NY

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

Read the Original Presentation: High Risk BCG Recurrent/Refractory Disease: Secondary Intravesical Therapy