Effect of Levofloxacin on the Efficacy and Adverse Events in Intravesical Bacillus Calmette-Guerin Treatment for Bladder Cancer: Results of a Randomized, Prospective, Multicenter Study

A Systematic Review and Meta-analysis of the Clinical Impact of Prophylactic Quinolones with Adjuvant Bacillus Calmette-Guérin Instillation for Non-muscle-invasive Bladder Cancer

BACKGROUND AND OBJECTIVE

Bacillus Calmette-Guérin (BCG) reduces disease recurrence and progression in intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC). BCG-associated adverse events during instillations are common, leading to treatment cessation. Prophylactic use of quinolones in conjunction with BCG instillations is one approach for reducing BCG-associated adverse events. Our aim was to delineate the clinical impact of quinolone prophylaxis (QP) in patients receiving adjuvant BCG instillations for NMIBC.

METHODS

In October 2024, a systematic search of MEDLINE, Embase, and the Cochrane Central Register of controlled trials was performed. Prospective and retrospective studies reporting comparative outcomes for patients with and without QP during BCG instillations were included. Outcomes were reported in a binary fashion. Random-effects meta-analysis using the weighted mean difference was conducted. Primary outcomes for pooled analyses included BCG-associated toxicities, the completion rate for BCG induction, the likelihood of antituberculosis treatment, and disease recurrence and progression at 12 mo.

KEY FINDINGS AND LIMITATIONS

The systematic review included five studies. Four randomised controlled trials were included in the meta-analysis, and one nonrandomised study was also included in the narrative review. The studies involved 445 patients, of whom 194 received QP + BCG and 251 received BCG alone. QP use was associated with lower incidence of class ≥2 (40.8% vs 54.7%; relative risk [RR] 0.79, 95% confidence interval [CI] 0.67-0.94; p = 0.006), and class ≥3 BCG-associated toxicities (25.3% vs 36.4%; RR 0.70, 95% CI 0.50-0.98; p = 0.04) and a higher completion rate for BCG induction (83.0% vs 70.6%; RR 1.16, 95% CI 1.01-1.34; p = 0.04). The 12-mo recurrence rates (14.7% vs 19.4%; RR 0.76, 95% CI 0.46-1.27; p = 0.3) and progression rates (4.5% vs 6.4%; RR 0.86, 95% CI 0.09-8.25; p = 0.9) did not significantly differ for QP + BCG versus BCG alone.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The use of QP with adjuvant BCG for NMIBC mitigated debilitating BCG-associated toxicities and improved the completion rate for BCG induction therapy.

BCG therapy in bladder cancer and its tumor microenvironment interactions

SUMMARYBacillus Calmette-Guérin (BCG) has been the standard treatment for non-muscle-invasive bladder cancer for over 30 years. Despite its proven efficacy, challenges persist, including unclear mechanisms of action, resistance in 30%-50% of patients, and significant side effects. This review presents an updated and balanced discussion of the antitumor mechanisms of BCG, focusing on its direct effects on bladder cancer and its interactions with various cell types within the bladder tumor microenvironment. Notably, recent research on the interactions between BCG and the bladder microbiome is also incorporated. We further summarize and analyze the latest preclinical and clinical studies regarding both intrinsic and adaptive resistance to BCG in bladder cancer. Based on the current understanding of BCG's therapeutic principles and resistance mechanisms, we systematically explore strategies to improve BCG-based tumor immunotherapy. These include the development of recombinant BCG, combination therapy with different drugs, optimization of therapeutic regimens and management, and the exploration of new approaches by targeting changes in the bladder microbiota and its metabolites. These measures aim to effectively address the BCG resistance in bladder cancer, reduce its toxicity, and ultimately enhance the clinical anti-tumor efficacy. Bacterial therapy, represented by genetically engineered oncolytic bacteria, has gradually emerged in the field of cancer treatment in recent years. As the only bacterial drug successfully approved for oncology use, BCG has provided decades of clinical experience. By consolidating lessons from BCG's successes and limitations, we hope to provide valuable insights for the development and application of bacterial therapies in cancer treatment.

Comparison of treatments for preventing lower urinary tract symptoms after BCG immunotherapy of bladder tumors : a systematic review and network meta-analysis

BACKGROUND

Bacillus Calmette-Guerin (BCG) immunotherapy is the standard adjuvant treatment for high-risk, non-muscle invasive bladder cancer (NMIBC). However, BCG immunotherapy is commonly accompanied by significant lower urinary tract symptoms (LUTS) including symptoms such as urinary urgency, frequency, dysuria and pelvic pain. These symptoms can undermine treatment adherence and clinical outcomes. In this study, the treatments for preventing LUTS after BCG instillations were compared through a systemic review and network meta-analysis (NMA).

METHODS

Eligible studies were obtained from the PubMed, Web of Science, Embase and Cochrane Library databases. We also searched the references of the included studies. Our protocol followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. We performed NMA using Review Manager 5.3 and STATA MP 18.0.

RESULT

The analysis included 6 studies with 556 participants. The results of the NMA revealed that celecoxib and prulifloxacin effectivelty reduce the incidence of LUTS including frequency, urgency and dysuria. Phenazopyridine showed the best performance in improving pelvic pain.

CONCLUSION

The NMA indicated that medications such as celecoxib, prulifloxacin and phenazopyridine are effective in reducing the incidence of LUTS after BCG immunotherapy of bladder tumors.

Management of Lower Urinary Tract Symptoms during the Treatment for Non-Muscle Invasive Bladder Cancer

PURPOSE OF REVIEW

This narrative review aims to report upon the existing treatment evidence and strategies for managing lower urinary tract symptoms (LUTS) during treatment, including transurethral resection and intravesical therapy. This review also attempts to examine novel approaches to mitigate treatment-related lower urinary tract symptoms and improve treatment adherence.

RECENT FINDINGS

There is sparse but promising evidence in improving LUTS secondary to intravesical therapy. Oral agents including phenazopyridine and hyaluronic acid, Bacillus Calmette-Guerin dose reduction, and emerging therapies including beta-3 agonists as well as Onabotulinumtoxin A injections all have demonstrated encouraging improvement in LUTS in limited research. Although recent literature explores new medications and potential strategies for managing intravesical therapy-related LUTS, further research is required to establish efficacy and new consensus on treatment strategies. Further research is also required to establish effective LUTS mitigation strategies with other emerging intravesical therapy regimens.

European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ)-A Summary of the 2024 Guidelines Update

BACKGROUND AND OBJECTIVE

This publication represents a summary of the updated 2024 European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ. The information presented herein is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation.

METHODS

For the 2024 guidelines on NMIBC, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

Key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with NMIBC. The guidelines stress the importance of defining patients' risk stratification and treating them appropriately.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2024 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, prognostic factors, treatment, and follow-up of NMIBC. These guidelines are designed for effective integration into clinical practice.

Differential Urinary Microbiome and Its Metabolic Footprint in Bladder Cancer Patients Following BCG Treatment

Recent studies have identified a urinary microbiome, dispelling the myth of urine sterility. Intravesical bacillus Calmette-Guérin (BCG) therapy is the preferred treatment for intermediate to high-risk non-muscle-invasive bladder cancer (BCa), although resistance occurs in 30-50% of cases. Progression to muscle-invasive cancer necessitates radical cystectomy. Our research uses 16S rRNA gene sequencing to investigate how the urinary microbiome influences BCa and its response to BCG therapy. Urine samples were collected via urethral catheterization from patients with benign conditions and non-muscle-invasive BCa, all of whom underwent BCG therapy. We utilized 16S rRNA gene sequencing to analyze the bacterial profiles and metabolic pathways in these samples. These pathways were validated using a real metabolite dataset, and we developed predictive models for malignancy and BCG response. In this study, 87 patients participated, including 29 with benign diseases and 58 with BCa. We noted distinct bacterial compositions between benign and malignant samples, indicating the potential role of the toluene degradation pathway in mitigating BCa development. Responders to BCG had differing microbial compositions and higher quinolone synthesis than non-responders, with two Bifidobacterium species being prevalent among responders, associated with prolonged recurrence-free survival. Additionally, we developed highly accurate predictive models for malignancy and BCG response. Our study delved into the mechanisms behind malignancy and BCG responses by focusing on the urinary microbiome and metabolic pathways. We pinpointed specific beneficial microbes and developed clinical models to predict malignancy and BCG therapy outcomes. These models can track recurrence and facilitate early predictions of treatment responses.

Quinolone Prophylaxis in Conjunction with Bacillus Calmette-Guérin Instillations for Bladder Cancer: Time To Reconsider the Evidence and Open the Quinolone Box?

Adjuvant bacillus Calmette-Guérin (BCG) instillations represent a cornerstone in the treatment of non-muscle-invasive bladder cancer. Instillation schedule and dose modifications have been evaluated in efforts to reduce the incidence of adverse events (AEs), but none so far has the same treatment efficacy as the full-dose recommended schedule. It has been shown that prophylactic quinolone use in conjunction with BCG instillations reduces AE incidence and improves timely completion of instillation regimens and patient survival. However, the European Medicines Agency imposed restrictions on the use of quinolones in 2019 because of side effects. Nevertheless, rational use of quinolone prophylaxis could be considered for selected individuals treated with BCG without risk factors for quinolone-associated side effects in conjunction with patient information about side-effect symptoms. PATIENT SUMMARY: Bladder instillations of BCG (bacillus Calmette-Guérin) are used in the treatment of non-muscle-invasive bladder cancer. Antibiotics from the quinolone class can reduce the adverse effects of BCG and help patients in completing the treatment course; however, these antibiotics have their own side effects. Our mini review suggests that the antibiotics could be used in selective cases if patients are given adequate information on these side effects and their symptoms.

Chest wall tumor following intravesical BCG instillation for non-muscle invasive bladder cancer

Mycobacterium bovis bacille Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for non-muscle invasive bladder cancer (NMIBC), administered after its transurethral resection. Although its instillation is generally well tolerated, BCG-related infectious complications may occur in up to 5% of patients. Clinical manifestations may arise in conjunction with initial BCG instillation or develop months or years after the last BCG instillation. The range of presentations and potential severity pose an imminent challenge for clinicians. We present a case of an isolated subcutaneous chest wall abscess in an immunocompetent 52-year-old patient nearly two years after intravesical BCG instillation for NMIBC, an absolute rarity. As the enlarging chest wall tumor may be misinterpreted as malignancy, its expedient diagnosis and prompt treatment are of critical importance.

Antibiotic therapy impact on intravesical BCG therapy efficacy for high-risk localized bladder cancer treatment

Intravesical Bacillus Calmettes-Guerin (BCG) instillations is the gold standard adjuvant treatment for high and very high-risk non-muscle-invasive bladder cancer (NMIBC). Antibiotics may be required to treat asymptomatic bacteriuria before instillations or to prevent side effects. By modifying the bladder microbiota and through its bactericidal action, it could modify the efficacy of BCG. This study evaluates the impact of antibiotics received during BCG-induction treatment on the oncological outcomes for high and very high risk NMIBC. We retrospectively included all patients who received a full induction regimen of BCG therapy between January 2017 and June 2022. Clinical and tumor characteristics as well as tolerability were collected. Recurrence-free survival (RFS) and progression-free survival (PFS) were compared according to the prescription of antibiotics, its type and duration. A total of 126 patients were included, 86.5% of the tumors were high risk and 13.5% very high risk. The median follow-up was 31 months (7-60). 36% of the patients received antibiotics during BCG-induction treatment (among which 44% received fluoroquinolones). 21.4% of patients had tumor recurrence. There was no difference in RFS (p=0.902) or PFS (p=0.88) according to the duration or the type of antibiotics received. The use of a prolonged antibiotic treatment (> 7 days) significantly increased the duration of the BCG-induction treatment from 35 to 41,5 days (p=0,049) and the median number of delayed treatments by 1,5 [0-4]. Neither the use of antibiotics nor their duration modified the risk of recurrence or the intensity of side effects in multivariate analysis. Antibiotics received during BCG-induction immunotherapy did not influence oncological short-term outcomes or intensity of side effects.