Age >70 years is considered an adverse prognostic factor in the current EAU NMIBC risk stratification. Whether poorer outcomes in older adults reflect differences in tumor biology or reduced access to guideline-concordant Bacillus Calmette-Guérin (BCG) therapy remains unclear. We evaluated the relationship between age, BCG adherence, and oncological outcomes in a contemporary multicenter cohort.
We retrospectively analyzed 1,741 patients with intermediate-, high-, or very high-risk non-muscle-invasive bladder cancer (NMIBC) treated with Bacillus Calmette-Guérin (BCG) at European tertiary referral centers between 2005 and 2024. Adequate BCG was defined according to International Bladder Cancer Group (IBCG) criteria. Multivariable linear, logistic, Cox, and Fine-Gray competing-risk regression models assessed the association between age and (1) BCG delivery and (2) recurrence, high-grade recurrence, progression, and cancer-specific mortality (CSM) among adequately treated patients, adjusting for standard clinicopathologic variables.
Among 1,317 (77%) patients with ≥1 year of follow-up and no early high-grade recurrence, increasing age was associated with lower BCG delivery (per 10 years: β -0.83 for number of instillations; OR 0.76 for adequate treatment; OR 0.87 for 1-year completion; all P < 0.05). Findings were similar when dichotomizing age at 70 years. No significant interaction was observed between age and BCG adequacy for oncological endpoints. Median follow-up was 40 months (IQR: 21-70). Among adequately treated patients (n = 1,296, 74%), 5-year risks for ≤70 vs. >70 years were comparable for any recurrence (28% vs. 30%; aHR: 1.12, 95% CI: 0.91-1.37), high-grade recurrence (22% vs. 25%; aHR: 1.27, 95% CI: 0.93-1.52), progression (11% vs. 13%; aHR: 1.04, 95% CI: 0.67-1.63), and CSM (5% vs. 8%; aHR: 1.90, 95% CI: 0.95-3.79).
Older age was associated with reduced adherence to BCG schedules, but not with worse oncological outcomes when adequate BCG was delivered. These findings indicate that age itself does not appear to diminish BCG effectiveness. Efforts to optimize treatment adherence, rather than age-based de-escalation, should be prioritized in the management of older NMIBC patients.
Urologic oncology. 2026 Apr 11 [Epub ahead of print]
Pietro Scilipoti, Paolo Zaurito, Mattia Longoni, Angelo Occhi, Mario de Angelis, Natasha Disabato, Giovanni Tremolada, Silvio Barracco, Aleksander Ślusarczyk, Francesco Soria, Wojciech Krajewski, David D'Andrea, Andrea Mari, Francesco Del Giudice, Renate Pichler, José Daniel Subiela, Gautier Marcq, Andrea Gallioli, Luca Afferi, Riccardo Mastroianni, Giuseppe Simone, Simone Albisinni, Laura S Mertens, Ekaterina Laukhtina, Katharina Oberneder, José Luis Rodríguez Elena, Javier Aranda, Alfonso Lafuente Puentedura, Jorge Caño Velasco, Roberto Contieri, Rodolfo Hurle, Keiichiro Mori, Piotr Radziszewski, Shahrokh F Shariat, Paolo Gontero, Morgan Rouprêt, Benjamin Pradere, Francesco Montorsi, Alberto Briganti, Marco Moschini, European Association of Urology - Young Academic Urologists (EAU-YAU), Urothelial carcinoma working group
Department of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy., Department of General, Oncological and Functional Urology, Medical University of Warsaw, Warsaw, Poland., Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy., Department of Urology and Oncologic Urology, Wrocław Medical University, Wroclaw, Poland., Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria., Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy., Department of Maternal Infant and Urologic Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome Italy., Department of Urology, Medical University of Innsbruck, Innsbruck, Austria., Department of Urology, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain., Department of Urology, Claude Huriez Hospital, CHU Lille, Lille, France., Fundació Puigvert, Department of Urology, Barcelona, Spain; Institut de Recerca Sant Pau (IR SANT PAU), Sant Quintí 77-79, Barcelona, 08041, Spain., Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland., IRCCS "Regina Elena" National Cancer Institute, Rome, Italy., Urology Unit, Department of Surgical Sciences, University of Tor Vergata, Rome, Italy., Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands., Department of Urology, Hospital Universitario de Cáceres, Cáceres, Spain., Department of Urology, Gregorio Marañón University Hospital, Madrid, Spain., Clinica Universidad De Navarra, Pamplona, Spain., Department of Urology, Istituto Nazionale Tumori IRCCS, "Fondazione G. Pascale", Naples, Italy., Department of Urology, Humanitas Clinical and Research Institute IRCCS Rozzano, Milan, Italy., Department of Urology, The Jikei University School of Medicine, Tokyo, Japan., Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Texas Southwestern, Dallas, TX; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic., GRC 5 Predictive Onco-Uro, AP-HP, Urology, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France., Department of Urology UROSUD, La Croix Du Sud Hospital, Quint-Fonsegrives, France., Department of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address: .