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

San Francisco, CA (UroToday.com) 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?

References:
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

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