Possible factors affecting response to intravesical bacillus Calmette-Guérin (Tokyo 172 strain) therapy for carcinoma in situ of the bladder: a multivariate analysis

Efficacy of Different Bacillus of Calmette-Guérin (BCG) Strains on Recurrence Rates among Intermediate/High-Risk Non-Muscle Invasive Bladder Cancers (NMIBCs): Single-Arm Study Systematic Review, Cumulative and Network Meta-Analysis

BACKGROUND

In an era of Bacillus of Calmette-Guérin (BCG) shortages, the comparative efficacy from different adjuvant intravesical BCG strains in non-muscle invasive bladder cancer (NMIBC) has not been clearly elucidated. We aim to compare, through a systematic review and meta-analysis, the cumulative BC recurrence rates and the best efficacy profile of worldwide available BCG strains over the last forty years.

METHODS

PubMed, Scopus, Web of Science, Embase, and Cochrane databases were searched from 1982 up to 2022. A meta-analysis of pooled BC recurrence rates was stratified for studies with ≤3-y vs. >3-y recurrence-free survival (RFS) endpoints and the strain of BCG. Sensitivity analysis, sub-group analysis, and meta-regression were implemented to investigate the contribution of moderators to heterogeneity. A random-effect network meta-analysis was performed to compare BCG strains on a multi-treatment level.

RESULTS

In total, n = 62 series with n = 15,412 patients in n = 100 study arms and n = 10 different BCG strains were reviewed. BCG Tokyo 172 exhibited the lowest pooled BC recurrence rate among studies with ≤3-y RFS (0.22 (95%CI 0.16-0.28). No clinically relevant difference was noted among strains at >3-y RFS outcomes. Sub-group and meta-regression analyses highlighted the influence of NMIBC risk-group classification and previous intravesical treated categories. Out of the n = 11 studies with n = 7 BCG strains included in the network, BCG RIVM, Tice, and Tokyo 172 presented with the best-predicted probability for efficacy, yet no single strain was significantly superior to another in preventing BC recurrence risk.

CONCLUSION

We did not identify a BCG stain providing a clinically significant lower BC recurrence rate. While these findings might discourage investment in future head-to-head randomized comparison, we were, however, able to highlight some potential enhanced benefits from the genetically different BCG RIVM, Tice, and Tokyo 172. This evidence would support the use of such strains for future BCG trials in NMIBCs.

Oncologic outcomes of Bacillus Calmette-Guérin therapy in elderly patients with non-muscle-invasive bladder cancer: A meta-analysis

Introduction

There is a challenge on the medical efficacy of intravesical Bacillus Calmette-Guérin (BCG) therapy and the power of the immune system boosting, which can be influenced by the age of the non-muscle-invasive bladder cancer (NMIBC) patients. This meta-analysis evaluates the efficacy of BCG therapy among aged (>70) and younger patients with non-muscle-invasive bladder cancer (NMIBC).

Methods

The central database of PubMed, Scopus, and Web of Science were queried until August 4, 2021, by using "BCG," "Bladder Cancer," "AGE," and "efficacy" keywords. After excluding duplicated results, titles and abstracts were evaluated by two independent reviewers. The exclusion criteria included non-English studies, conference abstracts, reviews, editorials, letters, and comments. Three main outcomes, disease-free survival (DFS), progression-free survival (PFS), and cancer-specific survival (CSS), were considered. The statistical analysis was performed using STATA (version 14; Stata Corp, College Station, Texas, USA).

Results

From 1115 found documents, the 24 research articles were recruited in the systematic review, and 10 were the candidate for meta-analysis. The overall estimate of H.R. revealed that BCG therapy in those over age 70 is significantly associated with an improved risk of progression and cancer-specific death in studied patients. However, this association was not statistically significant for DFS (1.04 (95% CI: 0.85,1.26)).

Conclusion

The BCG maintenance therapy improved CSS and PFS oncological outcomes in elderly patients with NMIBC. BCG therapy did not significantly change the DSF.

Clinical usefulness of random biopsies in diagnosis and treatment of non-muscle invasive bladder cancer: Systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

This systematic review of the literature has been focused on determining the clinical usefulness of random bladder biopsies (RB) in the diagnosis of carcinoma in situ. A meta-analysis was performed to establish the clinic and pathological factors associated to positive biopsies.

EVIDENCE ACQUISITION

A systematic review was performed using Pubmed/Medline database according to the PRISMA guidelines. Thirty-seven articles were included, recruiting a total of 12,657 patients, 10,975 were submitted to RB.

EVIDENCE SYNTHESIS

The overall incidence of positive RB was 21.91%. Significant differences were found in the incidence of positive RB when patients were stratified according to urine cytology result, tumor multiplicity, tumor appearance, stage and grade. The results of the meta-analysis revealed that the presence of positive cytology, tumor multiplicity, non-papillary appearance tumors, stage T1 and histological grades G2 and G3 represent the risk factors to predict abnormalities in RB.

CONCLUSIONS

The incidence of positive RB in patients with non-muscle invasive bladder cancer was 21.91%. The maximum usefulness of RB was observed when these are performed in a standardized way. The results of the meta-analysis showed that besides positive cytology and non-papillary appearance tumors, tumor multiplicity and histological grades G2 and G3 represent risk factors associated to positive RB, suggesting that the use of RB might be extensive to the intermediate risk group of the European Organization for Research and Treatment of Cancer (EORTC).

High-grade Ta urothelial carcinoma and carcinoma in situ of the bladder

We sought to review the definition, diagnosis, prognosis, and treatment of high-grade Ta urothelioma carcinoma and carcinomas in situ (CIS) in order to provide evidence-based guidelines for their diagnosis and treatment. The English-language literature on high-grade Ta urothelial carcinoma and CIS was identified and critically reviewed by a panel of 9 international experts. The panel then met at a consensus conference to present their conclusions. Levels of evidence and grades of recommendation were assessed. Findings from approximately 100 publications appearing prior to February 2005 were reviewed and summarized. High-grade Ta urothelial carcinoma and CIS are relatively rare tumors; thus results are often based on small nonrandomized studies. Their assessment is made more difficult owing to inaccuracies in staging and grading. Although there were similar numbers of level 1, level 2, and level 3 evidence citations, guidelines have been developed based only on levels of evidence supporting grade A and grade B recommendations. These evidence-based guidelines have been developed to aid clinicians in the diagnosis and treatment of patients with high-grade Ta urothelial carcinoma and CIS.

Long-term Outcome of a Low-dose Intravesical Bacillus Calmette–Guerin Therapy for Carcinoma In Situ of the Bladder: Results After Six Successive Instillations of 40 mg BCG

BACKGROUND

In Japan, bacillus Calmette-Guerin (BCG: Tokyo 172 strain) instillation is generally performed at a dose of 80 mg once weekly for eight consecutive weeks; however, many adverse effects including severe ones have been reported. We employed a dose of 40 mg once a week for six consecutive weeks in principle for carcinoma in situ (CIS) of the bladder, and retrospectively evaluated its effectiveness and safety.

METHODS

A total of 43 patients with CIS of the bladder were treated by this method and followed-up for a subsequent 12-79 months (median, 54 months). The patients consisted of 35 males and eight females aged 45-87 years (mean, 67.5 years). Intravesical BCG instillation at a dose of 40 mg was conducted once a week for six consecutive weeks.

RESULTS

A complete response (CR) was achieved in 84% of the patients, in whom the recurrence-free rate was 72.4% after 3 years and 61.9% after 5 years. The median CR duration was 37.5 months. Two patients underwent total cystectomy, but none died of bladder cancer. As adverse effects, bladder irritation symptoms were observed in 48.8%, pyuria in 46.5%, macroscopic hematuria in 18.6% and fever (>37.5 degrees C) in 9.3%. There were no severe adverse effects requiring discontinuation of drug administration.

CONCLUSION

Our present study corroborated both the effectiveness and safety of low-dose BCG therapy for CIS of the bladder. This therapy warrants further study by prospective randomized trials in the future.

Evaluation of multiple recurrence events in superficial bladder cancer patients treated with intravesical bacillus Calmette-Guérin therapy using the Andersen-Gill's model

To evaluate factors affecting recurrence after intravesical bacillus Calmette-Guérin (BCG) therapy (Tokyo 172 strain), we reviewed data for 101 patients with superficial bladder cancer (pTa [n = 80] and pT1 [n = 21]) treated between 1985 and 1999. The median follow-up period was 58.9 months. Factors affecting the first tumour recurrence were evaluated using Cox's proportional hazards model and those affecting multiple recurrence with Andersen-Gill's model. The 5-year recurrence-free rate was 63% for all 101 patients. The recurrence frequency, defined as times per 100 patient-months of follow-up, greatly decreased from 7.3 +/- 9.6 (SD) before the instillation to 2.6 +/- 5.6 after the therapy (p < 0.0001). Patients with pT1 tumours tended to have earlier recurrence than those with pTa tumours (p = 0.06). Multivariate analysis using Cox's proportional hazards model revealed that a history of bladder cancer and pathological stage were independent factors affecting the first tumour recurrence after the BCG therapy. When multiple endpoints of recurrence were evaluated using the Andersen-Gill's model, number of tumours as well as a history of bladder cancer and pathological stage demonstrated significant links to tumour recurrence after the BCG therapy. The 5-year progression-free and 5-year survival rates were 89.3% and 85.3% for all the 101 patients, respectively. Because intravesical recurrence may involve multiple events during the clinical course of patients with bladder cancer, the Andersen-Gill's model appears useful for evaluation of risk factors.

Multivariate evaluation of factors affecting recurrence, progression, and survival in patients with superficial bladder cancer treated with intravesical bacillus Calmette-Guérin (Tokyo 172 strain) therapy: significance of concomitant carcinoma in situ

To evaluate the relative importance of clinicopathological factors affecting recurrence, progression, and survival in patients with superficial bladder cancer (pTa and pT1) undergoing bacillus Calmette-Guerin (BCG) therapy (Tokyo 172 strain), we reviewed data for 146 patients treated between 1985 and 1998. The median follow-up period was 64.7 months. Tumour recurrence, progression, and death were evaluated as endpoints using Cox's proportional hazards model. The 5-year recurrence-free rate was 56% for all 146 patients. Those with a past history of bladder cancer (n = 73) had significantly earlier recurrence than those without (n = 73, p = 0.017) and this tended to be the case for concomitant CIS (n = 34) although this did not reach statistical significance. The 5-year progression rate was 15% for all 146 patients and univariate analysis revealed that the presence of concomitant CIS was significantly associated with disease progression (p = 0.002). Multivariate analysis using the proportional hazards model confirmed the finding that only one factor, concomitant CIS, was significantly associated with progression. The 5-year survival rate was 84% for all 146 patients. Furthermore, univariate and multivariate analyses revealed that patient age, history of bladder cancer, and concomitant CIS were variables significantly related to patient survival. The present findings suggest that careful follow-up is mandatory after BCG instillation therapy for patients with superficial bladder cancer and concomitant CIS because of their relatively poor prognosis.