Bladder cancer in situ calls for aggressive management

NEW YORK (Reuters Health) - A large proportion of patients with primary carcinoma in situ (CIS) of the bladder will show rapid disease progression, researchers report in the July issue of the Journal of Urology.

Dr. Guido Dalbagni told Reuters Health by email that "primary CIS of the bladder is a potentially lethal disease that requires aggressive management. Moreover, further studies are necessary to devise the optimal evidence-based approaches and to describe the different biological and clinical behavior of other distinct entities of CIS."

Dr. Dalbagni of Memorial Sloan-Kettering Cancer Center, New York, and colleagues retrospectively reviewed data on 155 patients treated at his institution between 1990 and 2008. All underwent transurethral resection and within 6 months, received intravesical bacillus Calmette-Guerin (BCG) therapy.

After adjusting for the competing risk of radical cystectomy, the 5-year cumulative incidence of progression to invasive disease (cT1 or higher) was 45%. Incidence of progression to muscle invasive disease (cT2 or higher) was 17%.

Of the 130 patients evaluated for BCG response, 81 (62%) were considered responders, with no recurrence or progression within 6 months.

Such response was significantly associated with a lower rate of progression to cT1 or higher and to radical cystectomy (hazard ratio, 0.59). This was also true of progression to cT2 or higher and radical cystectomy (hazard ratio, 0.53).

There was a similar 3-year cumulative incidence of progression to muscle invasive disease between responders (9.2%) and nonresponders (11.8%). "Nonetheless," say the investigators, "these findings appear to be driven by the higher rate of radical cystectomy in BCG nonresponders after progression to invasive disease."

They add that the "natural history of primary CIS is unclear and its management remains a challenge."

Commenting on the study in an accompanying editorial, Dr. Seth P. Lerner of Baylor College of Medicine, Houston, observes that "these results strongly support a meticulous treatment and follow-up approach. This is particularly important in the first 6 months when the disease course often declares itself and early intervention with cystectomy can provide long-term survival."

http://www.jurology.com/article/S0022-5347(10)03007-7/ppt

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