Patients who progress on bacillus Calmette-Guérin (BCG) therapy to muscle-invasive bladder cancer (MIBC) have worse outcomes than patients with de novo MIBC and warrant neoadjuvant chemotherapy (NAC), according to investigators.
In a review of 801 patients who underwent radical cystectomy (RC) for cT2-3 N0M0 disease, 20.3% had progressive MIBC and 79.7% had de novo MIBC. Among patients with low-risk disease who did not receive NAC, progressive MIBC was significantly associated with greater pathologic upstaging (64.9% vs 42.7%) and worse overall survival (median 51.5 vs 95.1 months), cancer-specific survival (median not reached), and recurrence/metastasis-free survival (median 49.3 vs 87.9 months), compared with de novo MIBC.
NAC treatment significantly decreased the odds of pathologic upstaging by 81% and 74% in the progressive and de novo MIBC groups, respectively, Ashish M. Kamat, MD, of The University of Texas, MD Anderson Cancer Center in Houston, and colleagues reported in The Journal of Urology. Further, NAC treatment increased the odds of complete pathologic response 4.5- and 4.3-fold, respectively. The NAC regimen varied.
According to the investigators, the data suggest a comparable “window of cure” exists for patients with progressive MIBC and justify their inclusion in risk-stratified approaches to NAC patient selection.
“Our data suggest that, until underlying molecular rationale — and validated molecular markers — allow for personalized therapy (as is being studied in various prospective trials), NAC should be offered to patients who have progressed to MIBC after BCG therapy.”
In an accompanying editorial, LaMont J. Barlow, MD, and Gary D. Steinberg, MD, of NYU Langone Health in New York, New York, commented: “It is clear that localized MIBC represents a diverse patient population, and a ‘one size fits all’ treatment approach is inadequate. Efforts to further stratify patients based on genomic and clinical characteristics and their associated outcomes will help to facilitate patient-specific therapeutic strategies and improve bladder cancer management.”
Hensley PJ, Bree KK, Campbell MT, et al. Progression of disease after Bacillus Calmette-Guérin therapy: refining patient selection for neoadjuvant chemotherapy before radical cystectomy. J Urol. 2021 Nov;206(5):1258-1267. doi:10.1097/JU.0000000000001943
Barlow LJ, Steinberg GD. Editorial. J Urol. 2021 Nov;206(5):1258-1267. doi:10.1097/JU.0000000000001943.01