Prognostic Implications of Treatment Delays for Patients with Non-muscle-invasive Bladder Cancer

Contemporary outcomes in non-muscle-invasive bladder cancer: a large European multicentre study

OBJECTIVE

To report real-world rates of non-muscle-invasive bladder cancer (NMIBC) recurrence and progression within a European multicentre cohort with detailed information on intravesical instillation courses, as contemporary data on oncological outcomes in NMIBC are limited.

PATIENTS AND METHODS

A total of 1918 patients with NMIBC treated with transurethral resection of bladder tumour (TURBT) were retrospectively identified from six tertiary-referral European centres (2015-2022). Patients were stratified according to European Association of Urology 2021 criteria into low- (LR), intermediate- (IR), high- (HR) and very high-risk (VHR) categories. Cumulative incidence plots and multivariable competing risks regression models addressing 5-year rates of high-grade (HG) recurrence and progression were fitted. Sensitivity analyses focused on patients receiving intravesical instillations and tested for the effect of adequate course (Bacillus Calmette-Guérin: five or more induction + two or more maintenance instillations; mitomycin C: complete induction + ≥11 maintenance instillations).

RESULTS

Of all NMIBC patients identified, 467 (24.3%) were LR vs 582 (30.3%) IR vs 739 (38.5%) HR vs 130 (6.8%) VHR. The median (interquartile range) follow-up after TURBT was 26 (12-46) months. The 5-year HG recurrence rates were 7.2% in LR vs 17.3% in IR vs 26.7% in HR vs 30.9% in VHR patients, resulting in a three-, five- and seven-fold higher risk of IR, HR and VHR, respectively, relative to LR (all P < 0.001). The 5-year progression rates were 3.9% in LR vs 5.2% in IR vs 13.6% in HR vs 31.6% in VHR patients, resulting in a six- and nine-fold higher risk for HR and VHR, respectively, relative to LR (all P < 0.001). In all, 1001 (52.2%) patients underwent intravesical instillations. Those receiving adequate instillation course (244/1001 [24.3%]) had lower HG-recurrence (hazard ratio 0.3, P < 0.001) and progression (hazard ratio 0.2, P = 0.001) risk.

CONCLUSIONS

Patients with HR/VHR NMIBC face significantly higher HG recurrence and progression risks. While tailored treatment strategies are needed, adherence to adequate instillation course remains crucial for optimising oncological outcomes.

Organizational impact of systematic urine culture before Bacillus Calmette Guerin (BCG) induction instillations

PURPOSE

There are conflicting recommendations concerning the performance of a systematic urine culture (UC) prior to Bacillus Calmette Guerin (BCG) bladder instillations for non-muscle-invasive bladder tumor. The objective was to study the organizational impact of the UC performed before bladder instillations, defined as the number and proportion of BCG instillations postponed due to a positive urine culture result.

METHODS

Induction BCG records in a single academic center between 2015 and 2020 were retrospectively reviewed. All patients had a UC prior to each instillation, treated if positive. Risk factors associated with the occurrence of a positive UC, an adverse event or postponement of instillation were studied.

RESULTS

A total of 156 patients were included, among which 68.9% of patients had at least one risk factor of UTI and 33% of patients presented at least one positive UC at induction. During BCG induction, 76/909 (8.4%) urine cultures performed were positive and 33% of patients had at least one postponement of BCG instillation. There were 64 instillations postponed, caused by untreated positive urine culture for 40 (62.5%) and absence of urine culture performed for 6 (9.4%) In multivariate analysis, only the presence of lower urinary tract symptoms was significantly associated with a risk of positive UC.

CONCLUSION

Positive UC during BCG instillations is a frequent event and a source of disorganization in BCG induction, with possible oncological consequences. A strategy of performing UC only in selected patients, could facilitate proper BCG administration and avoid unreasonable use of antibiotics.

Intravesical chemotherapy in BCG waiting period may prolong time to recurrence for high-risk NMIBC patients

PURPOSE

This study aimed to determine whether administering intravesical chemotherapy (IVC) during the Bacillus Calmette - Guérin (BCG) waiting period after the second TURBT improves the recurrence-free survival (RFS) of patients with non - muscle - invasive bladder cancer (NMIBC).

METHODS

A retrospective analysis was performed on patients who had undergone a second TURBT and subsequent intravesical BCG immunotherapy (IBI) at the Affiliated Hospital of Xuzhou Medical University between January 2012 and December 2023. The patients were divided into two groups (A and B) based on whether they continued IVC during the BCG waiting period, and RFS was compared between the two groups.

RESULTS

A total of 164 patients were included in this study. The log-rank test results indicated that IVC administered during the BCG waiting period was associated with a more favorable RFS for patients with NMIBC, particularly those at high risk. Multivariate analysis revealed that pathological T-stage (HR 2.084, 95% CI [1.132, 3.834], p = 0.018) and IVC received during the BCG waiting period (HR 0.261, 95% CI [0.140, 0.488], p < 0.001) were significantly correlated with patient RFS.

CONCLUSIONS

Administering IVC during the BCG waiting period is recommended to prolong the time to recurrence in patients with high-risk NMIBC. Conversely, this additional treatment is unnecessary for patients at intermediate risk.

Identifying optimal candidates for active surveillance in low-grade intermediate-risk non-muscle invasive bladder cancer

OBJECTIVE

The intermediate-risk non-muscle invasive bladder cancer (IR-NMIBC) prognostic group is heterogeneous. Growing evidence supports the role of active surveillance (AS) for patients with low-risk NMIBC, however, no clear data exists considering IR-NMIBC. The aim of the study was to assess the risk of recurrence of patients eligible for AS based on the International Bladder Cancer Group (IBCG) stratification.

METHODS

We retrospectively evaluated 174 LG IR-NMIBC patients who underwent transurethral resection of bladder tumor (index TURBT) from 2012 to 2023 at a tertiary referral center and fulfilled the inclusion criteria for enrollment in AS protocols at the index TURBT (≤ 5 suspicious lesions, no macrohematuria, negative urine cytology, lesions ≤ 1 cm). Patients were then stratified according to the International Bladder Cancer Group (IBCG) risk factors: frequent recurrence, early recurrence, previous instillation, and multifocality. Kaplan Meier plots and multivariable Cox regression analysis (MVA) were used to assess the risk of any and high-grade (HG) recurrence according to the number of risk factors.

RESULTS

Overall, 168 (97%) patients had a Ta low grade bladder tumor. After a median follow-up of 36 months [Interquartile range (IQR) 20-54], 75 (43%) and 32 (18%) patients experienced any- and HG recurrence, respectively. The 3-year recurrence free-survival (RFS) was 86% [95% Confidence Interval (CI) 76-98%] for patients with 0, 76% (95% CI 68-84%) for those with 1-2, and 54% (95% CI 34-84%) for those with ≥ 3 risk factors. The 3-year HG-RFS was > 90% for patients with 0 and 1-2 risk factors, compared to 76% (95% CI 58-99%) for those with ≥ 3 risk factors. At MVA, the presence of ≥ 3 risk factors was associated with a higher risk of recurrence [hazard ratio: 4.74, 95% CI 1.75-12.8, p = 0.002].

CONCLUSION

Among patients with LG IR-NMIBC eligible for AS, those with more than 2 IBCG risk factors may not be suitable candidates due to a higher risk of developing HG recurrence. Randomized controlled trials with standardized AS protocols are necessary to validate these findings and optimize patient selection for AS in LG IR-NMIBC.

Effect of prior radiation on stage, differentiation, and survival in bladder cancer

PURPOSE

Clinically significant differences in radiation-related bladder tumors are not well-characterized, and survival analyses are needed. In this study, we aimed to utilize a national cancer database to evaluate the effect of prior radiation on tumor characteristics and survival in bladder cancer patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) 9 database was queried to identify patients diagnosed with bladder cancer as a second malignancy. Patients having undergone radiation prior to developing bladder cancer were selected for comparative analysis. Logistic regression was used to generate odds ratios to evaluate differences in differentiation, stage, grade, and tumor size. Kaplan-Meier analysis and Cox non-proportional hazards regression models were used to assess the association between previous radiation and bladder cancer survival.

RESULTS

A total of 25,408 patients were identified, of which 14,570 patients had sufficient data for analysis. Of these, 5968 (41.0%) received radiation for their primary malignancy. Prior radiation conferred a lower risk of developing moderately- or poorly-differentiated bladder tumors and muscle invasive or node-positive disease. An increased risk of squamous cell carcinoma was noted (OR 1.43, CI 1.06-1.93). Prior radiation led to an increased risk of bladder cancer-specific (HR 1.13, CI 1.03-1.24) mortality at 5 years. The greatest effect of prior radiation was an increased risk of bladder cancer-specific mortality for carcinoma in situ at 5 years (OR 2.37, CI 1.45-3.86).

CONCLUSION

Prior radiation is associated with lower grade and stage of bladder tumors in addition to worse cancer-specific survival.