(UroToday.com) The 2025 Society of Urologic Oncology (SUO) Annual Meeting was host to a bladder cancer poster session. Dr. Mohamad Abou Chakra presented a study evaluating worldwide clinical practices in the management of BCG-unresponsive, non-muscle invasive bladder cancer (NMIBC).
The management of BCG-unresponsive NMIBC remains a significant global challenge, particularly amid the ongoing BCG shortage and the lack of clear guidance for recommended alternatives to radical cystectomy in patients who are unfit for or decline surgery. This study examined real-world clinical practices across the United States, Europe, Asia, and Arab countries to evaluate for variability in treatment approaches. Gaining insight into these real-world patterns and differences in global urology practices is essential for identifying current gaps in care and guiding the development of standardized research protocols and clinical trials that better reflect the ‘practical realities’ across diverse practice settings. Such efforts are critical for improving global outcomes for patients with BCG-unresponsive disease.
To examine global treatment practices for BCG-unresponsive NMIBC, the study investigators conducted a structured literature search using MeSH terms and keywords such as “BCG-unresponsive,” “BCG failure,” “treatment patterns,” and “survey.” The search was restricted to articles published in English and excluded abstracts without full-text availability.
Of the 55 articles identified, five met the inclusion criteria based on clinical relevance and a focus on provider-level treatment decisions by country. The data were organized based on the key survey questions administered, and the responses were compiled accordingly. While not all surveys addressed identical questions, supplementary data from other sections were used to ‘fill gaps’, allowing for a more comprehensive overview of real-world treatment approaches of BCG-unresponsive disease. Descriptive statistics were used to summarize participant responses, with categorical variables reported as frequencies and percentages.
Data were analyzed from multiple regions: Europe, the US, China, Japan, and Arab countries, as illustrated in the map below.
In the United States, 53% of providers reported using intravesical chemotherapy, followed by radical cystectomy at 27%, systemic therapy at 14%, and other approaches (6%), such as repeat BCG and re-resection.
In Arab countries, radical cystectomy was the most common choice (50%), followed by intravesical chemotherapy (30%), repeat BCG (12%), and re-resection (8%).
European practices varied widely – radical cystectomy (15–67%), intravesical chemotherapy (4–27%), systemic therapy (5–17%), re-resection (24–46%), and watchful waiting (up to 60%).
In China, 64% used intravesical chemotherapy, 23% systemic therapy, 39% watchful waiting, and only 7% radical cystectomy. In Japan, 49% opted for watchful waiting, 35% for re-resection, 11% for intravesical chemotherapy, and 13% for radical cystectomy.
Biopsy and fulguration were used by 10-25% of respondents in Europe, 16% of those in Japan, and 36% of those in China.
Dr. Abou Chakra concluded that worldwide management strategies for BCG-unresponsive NMIBC vary significantly. While intravesical chemotherapy is commonly utilized in the United States and parts of Asia, radical cystectomy remains the preferred approach in the Arab world and several European countries. Notably, recently FDA-approved agents for BCG-unresponsive disease have seen limited adoption in clinical practice, highlighting a clear disconnect between regulatory approvals and real-world implementation patterns. These significant disparities underscore the need to further investigate factors driving the variations in global treatment preferences for BCG-unresponsive NMIBC and the reasons for adoption of guideline-discordant care patterns, both from provider and patient perspectives.
Presented by: Mohamad Abou Chakra, MD, Urologic Oncology Fellow, Department of Urology, University of Iowa, Iowa City, IA
Written by: Rashid K. Sayyid, MD, MSc, Assistant Professor, Urologic Oncologist, Department of Urology at The University of Arizona and Banner University Medical Center – Tucson, AZ, @rksayyid on X during the 2025 Society of Urologic Oncology (SUO) annual meeting held in Phoenix, AZ, between the 2nd and 5th of December 2025.