NMIBC 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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