Long-Term Intravesical Adjuvant Chemotherapy Further Reduces Recurrence Rate Compared With Short-Term Intravesical Chemotherapy And Short-Term Therapy

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology;  Clinical Trials / Drug Trials
Article Date: 11 Jun 2007 - 0:00 PDT

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UroToday.com- After transurethral resection of bladder tumors, adjuvant intravesical therapy is commonly used to affect the natural history and decrease the probability of recurrence and progression. For low-risk tumors, intravesical chemotherapy is advocated while for high-risk tumors, intravesical BCG (induction and maintenance) remain the treatments of choice.

Controversy remains however, on what constitutes the optimal treatment for intermediate-risk tumors. While meta-analysis suggests that intravesical BCG (with maintenance) is superior to chemotherapy, not all studies support this conclusion. In the March issue of European Urology, Friedrich and colleagues present their randomized, multicenter trial comparing short (6 week)- and long-term (6 weeks plus every month for 3 years) chemoprophylaxis with mitomycin C (MMC) with short-term ( 6 weeks) immunoprophylaxis with BCG for non-muscle-invasive bladder carcinoma.

The study recruited 495 patients, from 1995 to 2002, with recurrent and/or multifocal pTaG1, TaG2-3, and T1G1-3 tumors. The 3-yr recurrence-free rates were 65.5% for short-term BCG, and 68.6% for short-term MMC, compared to 86.1% with MMC long-term therapy (p=0.001), histology. Within the subgroup of patients with pTaG2 tumors (n= 253), the 3-yr recurrence-free rates were 74.0%, 70.0% and 89.6% in the BCG 6-wk, MMC 6-wk and MMC long-term arms respectively (p = 0.0087). Toxicity was lowest with short-term MMC, followed by long-term MMC and then the BCG group.

These data suggest that long-term MMC can be considered for patients with intermediate-risk (especially recurrent pTaG2) tumors, to decrease probability of recurrence. What is unclear however, is whether this would help patients who have already received peri-operative MMC, which is now considered 'standard' therapy. Also, the reader is cautioned against extrapolating this data to mean that MMC is 'superior' to BCG â€" not only did the authors use sub-optimal BCG (induction only) but also, patients with truly high-risk tumors â€" prior intravesical therapy, presence of CIS or large T1 tumors (> 2.5 cm) were excluded. For these patients, BCG induction and maintenance clearly remains the intravesical agent of choice.

Friedrich MG, Pichlmeier U, Schwaibold H, Conrad S, Huland H.

Eur. Urol. 2007, Mar 12.
doi: 10.1016/j.eururo.2007.02.063

Reported by UroToday.com Contributing Editor Ashish Kamat, MD.

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