AUA 2021: Intravesical Therapy in Patients with Intermediate-Risk Non-Muscle-Invasive Bladder Cancer: A Systematic Review and Network Meta-Analysis of Oncologic Outcomes

( Most patients newly diagnosed with bladder cancer have non-muscle invasive disease (NMIBC). For patients with intermediate or high-risk NMIBC and those with carcinoma in situ (CIS), adjuvant treatment is guideline-recommended on the basis of proven benefits in disease recurrence. While bacillus calmette-guérin (BCG) is preferred in those with high-risk disease, both intravesical chemotherapy and BCG are options in intermediate-risk disease.

In a podium presentation at the American Urologic Association Annual Meeting, Dr. Ekaterina Laukhtina and colleagues presented results of their systematic review and network meta-analysis (NMA) aimed at summarizing the available evidence on the oncologic outcomes of intravesical therapy among these patients.

To do so, the authors searched MEDLINE, EMBASE, and ‘’ databases in October 2020. They included studies that reported on oncologic outcomes in intermediate-risk NMIBC patients treated with TURBT with and without intravesical chemotherapy or BCG immunotherapy. For the assessment of 5-year recurrence risk, arm-based analyses were performed to estimate the odds ratio (OR) of the 5-year recurrence risk and 95% credible interval (CI) from the available data presented in the included manuscripts. The relative ranking of the different treatments for each outcome was estimated using the p-score, which can be considered a frequentist analog to the surface under the cumulative ranking curves.


The authors identified 12 studies that were included in a qualitative synthesis, among which three were deemed eligible for quantitative synthesis. A NMA of five different regimens was conducted for the association of treatment with the 5-year recurrence risk: 1) chemotherapy as standard regimen; 2) chemotherapy as delayed regimen; 3) chemotherapy as extended regimen; 4) immunotherapy in full dose; 5) immunotherapy in reduced dose. Chemotherapy with maintenance was associated with a lower likelihood of 5-year recurrence than chemotherapy without maintenance (OR:0.51, 95%CI:0.26–1.03). In contrast, a delayed chemotherapy regimen was not associated with a significantly lower likelihood of the 5-year recurrence risk compared to standard chemotherapy (OR:0.92, 95%CI:0.58–1.48). Immunotherapy, regardless of full or reduced dose regimen, was not associated with a significantly lower likelihood of the 5-year recurrence risk as compared with chemotherapy without maintenance (OR:0.90, 95%CI:0.39–2.11, and OR:0.93, 95%CI:0.40–2.19, respectively). The analysis of the treatment ranking found that chemotherapy with maintenance had the lowest 5-year recurrence risk (P score: 0.9666).


Thus, the authors concluded that, among patients with intermediate-risk NMIBC, intravesical chemotherapy with maintenance confers a superior oncologic benefit in terms of the 5-year recurrence risk compared to chemotherapy without maintenance. Regardless of dose regimen, immunotherapy with BCG does not appear to be superior to chemotherapy in patients with intermediate-risk NMIBC in terms of disease recurrence.

Presented by: Ekaterina Laukhtina, Institute for Urology and Reproductive Health, @SechenovUni

Written by: Christopher J.D. Wallis, University of Toronto Twitter: @WallisCJD during the 2021 American Urological Association, (AUA) Annual Meeting, Fri, Sep 10, 2021 – Mon, Sep 13, 2021.

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