Venugopal P
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10 Mar 2023 08:34:24 AMNMIBC High Risk Management - No One Size Fits All
Dear All,
Radical cystectomy compared to
intravesical BCG immunotherapy for high-risk non muscle invasive bladder cancer
– is there a long-term survival
difference? A
Swedish nationwide analysis
Eugen Y-H wang* et al, 2020, Scandinavian Journal of Urology,
Published Online Dec 11th
https://www.tandfonline.com/doi/pdf/10.1080/21681805.2020.1851763?needAccess=true
This is a thought provoking article and challenges conventional thinking
in this area as has been mentioned in EAU Guidelines on NMIBC 2019 Wherein they
mention that RC will be required for NMIBC in ~20% as they are upstaged to MIBC
on Pathological Review. Many other studies also mention that Immediate RC could
be the preferred option for High Risk NMIBC. Clinical experience suggests that
patients being offered (and accepting) primary RC tends to have particularly
aggressive disease (multifocal disease, large volume disease, coexisting carcinoma
in situ and variant histology). But
there are studies dating from late 1990’s indicating that BCG could provide
adequate outcomes except in those exhibiting Variant Histology at initial
pathology. Data from studies have shown that BCG should be favoured in such
cases as RC has a mortality rate of 4.9% while this is extremely rare with BCG
Therapy. This data indicate superior outcomes among BCG treated patients. RE Hautmann
et al (2013 ICUD) showed a 93% CSS survival rate at 5 years for NMIBC patients.
So what can we conclude from this study? Firstly, based on these
data, urologists in Sweden (their database is probably among the top in the
world) appear to be very good at selecting
which patients with HR NMIBC have a relatively good prognosis
(and are therefore suitable for BCG) from those with a poorer prognosis (a
proportion of whom will not be ‘saved’ by RC alone). Secondly, given these results and the known 20%
understaging rate, RC alone appears inadequate for patients with HR NMIBC with
the very worst prognosis. Perhaps these patients should be considered for neoadjuvant
chemotherapy as they would be in if their disease was muscle-invasive from the
outset. Nevertheless the authors are to be congratulated for challenging the
dogma that patients with HR NMIBC invariably
have better outcomes with cystectomy than BCG.
Should our existing concepts change is a question facing us as
regards initial management of High Risk NMIBC? Should we not adopt BCG regime
in most cases of HG NMIBC except those with primary histological variants.
With the advent of Immune Checkpoint inhibitors for NMIBC, it
appears logical that a preliminary treatment with ICIs could be the way forward
prior to RC. But we are not yet sure on the efficacy of ICIs in this scenario
except that treatments with ICIs involve considerable financial toxicity.
With warm Regards,
Venu
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