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UPJ INSIGHT US Practice Patterns in Treatment of Bacillus Calmette-Guérin–Unresponsive Nonmuscle-Invasive Bladder Cancer

By: Mohamad Abou Chakra, MD, University of Iowa Hospitals and Clinics, Iowa City; Neal D. Shore, MD, Carolina Urologic Research Center, Myrtle Beach, South Carolina; Rachelle Dillon, PhD, Winnipeg, Manitoba, Canada; Michael A. O’Donnell, MD, University of Iowa Hospitals and Clinics, Iowa City | Posted on: 19 Jan 2024

Chakra MA, Shore ND, Dillon R, O’Donnell MA. US clinical practice patterns of intravesical chemotherapy for bacillus Calmette-Guérin—unresponsive and bacillus Calmette-Guérin exposed—nonmuscle-invasive bladder cancer. Urol Pract. 2024;11(1):96-108.

Study Need and Importance

There is a lack of data on the patterns of treatment of patients with bacillus Calmette-Guérin (BCG)–unresponsive and BCG-exposed nonmuscle-invasive bladder cancer (NMIBC) in the US urologic community. The goal of this survey was to evaluate the treatment and practice patterns of patients with high-grade papillary Ta, T1 NMIBC, and carcinoma in situ (CIS) in BCG unresponsive (with adequate BCG exposure = adequate BCG) and those with less than adequate BCG exposure (BCG-exposed).

What We Found

The survey was completed by 159 urologists who treat patients with CIS tumors and 100 urologists who treat patients with papillary tumors in 2022. The majority (78%) were community-based urologists. Over the previous 6 months, study participants managed an average of 33 (range: 6-158) CIS patients and 44 (range: 10-200) high-grade papillary disease patients (without CIS). For BCG-unresponsive and BCG-exposed groups, over 70% of physicians chose gemcitabine (40%) or mitomycin C (30%) as the most commonly utilized intravesical chemotherapies. The majority of physicians reported using a specific regimen for induction (once a week × 6 weeks) and maintenance (once a month × 12 months) that included either gemcitabine 2 g or mitomycin C 40 mg. Responses appeared comparable in all BCG therapy groups (adequate vs BCG-exposed). For the adequate BCG patient, doctors were marginally more likely to use a maintenance regimen (Figure).

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Figure. Most commonly used intravesical chemotherapy treatment for patients with papillary tumor or carcinoma in situ (CIS) who are bacillus Calmette-Guérin (BCG) unresponsive or BCG exposed. VALSTAR indicates valrubicin.

Limitations

This survey canvassed a relatively small number of participants, thus it may not represent national practice. In addition, the target population included only urologists.

Interpretation for Patient Care

The most common treatments received by patients with BCG-unresponsive NMIBC were intravesical chemotherapy (single-agent gemcitabine or mitomycin C). The patterns of use were similar in high-grade papillary and in CIS patients. This is problematic as there is no strong evidence supporting either agent for BCG-unresponsive CIS.

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