For patients with primary, solitary T1 bladder cancer, the guidelines are relatively straightforward. Perioperative intravesical chemotherapy is of little utility in this population. Recommendations support induction BCG with maintenance for up to 3 years. Surveillance cystoscopy should be performed quarterly for 2 years.
Professor Witjes then discussed some nuances in treated patients with BCG. Absolute contraindications include loss of mucosal integrity and allergy or serious sensitivity reaction. Relative contraindications to its use are immunocompromised state (not fully proven) or history of prior tuberculosis. BCG local toxicity is a real phenomenon. Some success in mitigating these symptoms has been achieved with pre-instillation ofloxacin or by reducing dwell time, number of instillations per course, treatment time, or dose. BCG strain is important in an era with increasing shortages of BCG. In both mice and humans, the Connaught strain has been shown to have fewer recurrences and produce a stronger immune response relative to the Tice strain.
For patients with recurrent T1 disease and low risk of recurrence, options include BCG or intravesical chemotherapy. He also introduced device-assisted therapy such as thermotherapy in this setting. Patients who are unresponsive to any of these approaches should be recommended to move forward with cystectomy.
For patients with primary multifocal T1 with or without concomitant carcinoma in situ, cystectomy is the preferred option for treatment. An alternative would be intravesical therapy or device-assisted therapy, though these approaches are oncologically inferior.
There are many exciting new investigations ongoing in the treatment of BCG-refractory non-muscle invasive bladder cancer. They include thermochemotherapy, thermosensitive hydrogel, GEMRIS (releases gemcitabine over the course of 1 week), thermosensitive liposomes (release chemotherapy from liposomes at certain temperature levels), and checkpoint inhibitors. Trials involving these approaches are ongoing and promise to change the management landscape over the next 5-10 years.
In conclusion, Professor Witjes noted that BCG is the treatment of choice in high-risk non-muscle invasive bladder cancer. For highest risk patients, “early” cystectomy should be offered.
Speaker: J.A. Witjes, Nijmegen, NL
Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA.
at the #EAU17 -March 24-28, 2017- London, England