Progression of Disease after Bacillus Calmette-Guérin Therapy: Refining Patient Selection for Neoadjuvant Chemotherapy before Radical Cystectomy. Issue 5 (29th November 2021)

• Record Type: Journal Article
• Authors: Hensley, Patrick J.; Bree, Kelly K.; Campbell, Matthew T.; Alhalabi, Omar; Kokorovic, Andrea; Miest, Tanner; Nogueras-Gonzalez, Graciela M.; Gao, Jianjun; Siefker-Radtke, Arlene O.; Guo, Charles C.; Navai, Neema; Dinney, Colin P.; Kamat, Ashish M.
• Is Part Of: Journal of urology. Volume 206:Issue 5(2021)
• Page Start: 1258
• Page End: 1267
• Publication Date: 2021-11-29
• Subjects: urinary bladder neoplasms -- neoadjuvant therapy -- cystectomy -- mycobacterium bovis; Genitourinary organs -- Periodicals; Urology -- Periodicals; Urology -- Periodicals; Urologie -- Périodiques; Urologie; 616.6
• DOI: 10.1097/JU.0000000000001943
• Languages: English
• ISSNs: 0022-5347

Abstract

Abstract : Purpose: Data from the pre-neoadjuvant chemotherapy (NAC) era suggests patients who progress on bacillus Calmette-Guérin (BCG) to muscle-invasive bladder cancer (P-MIBC) exhibit worse outcomes compared to de novo MIBC (D-MIBC). Herein, we investigate whether P-MIBC is an independent poor risk factor in the setting of contemporary NAC use. Materials and Methods: A review of patients who underwent radical cystectomy (RC) for cT2-3 MIBC from 2005 to 2018 was performed. Patients were stratified into high risk (lymphovascular invasion, variant histology, hydronephrosis, cT3b) vs low risk (no risk factors) and P-MIBC (≤pT1 treated with at least induction BCG who progressed to ≥cT2) vs D-MIBC. Results: Among 801 patients who underwent RC 20.3% had P-MIBC and 79.7% had D-MIBC. In low-risk patients treated without NAC, P-MIBC was associated with pathological upstaging (64.9% vs 42.7%, p=0.004) and worse overall (OS, p=0.006) and cancer-specific survival (CSS, p=0.001) compared to D-MIBC. P-MIBC status conferred uniformly poor survival outcomes to patients who did not receive NAC compared to D-MIBC without NAC (median OS 51.5 months [95% CI 40.0–81.0] vs 85.1 months [95% CI 62.8–96.0], p=0.040; median CSS not reached, p=0.014). However, P-MIBC status did not remain a negative prognostic factor in the setting of NAC (median OS 90.5 months [95% CI 34.0–not estimable] vs 87.8 months [95% CI 68.7–not estimable], p=0.606; median CSS not reached, p=0.448). Conclusions: P-MIBC confers a poor prognosis when managed with RC alone. Treatment with NAC results in equivalent pathological response and survival outcomes compared to D-MIBC. P-MIBC should be included in risk-stratified approaches to NAC selection.