From the Guidelines
The next step for this 60-year-old man with bladder CIS who has completed induction BCG and shows no residual tumor but mild atypia on cytology is to proceed with maintenance BCG therapy. The standard maintenance regimen consists of three weekly instillations of BCG at 3,6,12,18,24, and 36 months after induction therapy. Each instillation typically involves intravesical administration of BCG (usually TICE strain at a dose of 50 mg or equivalent) with a dwell time of 1-2 hours. The presence of mild atypia on cytology without visible tumor is not uncommon after BCG and does not necessarily indicate treatment failure, but warrants close monitoring. During maintenance therapy, the patient should undergo regular cystoscopy and urine cytology every 3 months for the first 2 years, then every 6 months for years 3-4, and annually thereafter. If symptoms of BCG toxicity develop (severe bladder irritation, fever, or systemic symptoms), dose reduction to one-third or one-half of the standard dose may be considered. Maintenance BCG is recommended because it significantly reduces recurrence rates and may delay progression to muscle-invasive disease in high-risk non-muscle invasive bladder cancer, including CIS, as supported by recent guidelines 1. The mild atypia should resolve with continued BCG therapy, but persistent or worsening atypia would warrant repeat biopsy to rule out recurrence. Key considerations in the management of this patient include the risk of recurrence and progression, as well as the potential side effects of BCG therapy, which can be managed with appropriate monitoring and dose adjustments, as indicated by studies such as 1.
Some key points to consider in the management of this patient include:
- The importance of maintenance BCG therapy in reducing recurrence rates and delaying progression to muscle-invasive disease
- The need for regular monitoring with cystoscopy and urine cytology to detect any signs of recurrence or progression
- The potential side effects of BCG therapy and the need for dose adjustments as necessary
- The consideration of alternative treatments, such as intravesical chemotherapy or radical cystectomy, in cases of BCG failure or intolerance, as discussed in guidelines such as 1.
Overall, the management of this patient should be guided by the principles of reducing recurrence rates and delaying progression to muscle-invasive disease, while also minimizing the risk of side effects and ensuring the best possible quality of life, as supported by the latest evidence 1.
From the Research
Next Steps for a 60-year-old Man with CIS Bladder
- The patient has received an induction course of Bacillus Calmette-Guérin (BCG) and has no residual tumor but mild atypia on cytology.
- The next step in management should be based on the standard treatment protocols for non-muscle-invasive bladder cancer (NMIBC).
Treatment Options
- According to the study 2, maintenance BCG treatment is recommended for patients with NMIBC, but the optimal duration of treatment is unknown.
- The study 3 suggests that intravesical BCG therapy remains the most effective therapy for preventing recurrence and progression of intermediate and high-risk NMIBC.
- The study 4 compares the Southwest Oncology Group (SWOG) maintenance protocol with a monthly maintenance protocol comprising 12 monthly doses of intravesical BCG and finds that monthly maintenance BCG for 1 year is comparable in terms of outcome with SWOG protocol maintenance BCG.
Recommended Course of Action
- Based on the studies 2, 3, and 4, the recommended course of action would be to continue with maintenance BCG treatment.
- The patient should receive monthly BCG for one year, as this has been shown to be comparable to the SWOG maintenance protocol in terms of outcome 4.
- Alternatively, the patient could receive three weeks of BCG at three and six months, then every six months for two years, as this is also a common maintenance schedule 2.
Other Options
- Intravesical mitomycin C could be considered as an alternative to BCG, especially if the patient is experiencing side effects or if BCG is not available 5.
- However, the study 5 suggests that optimal mitomycin C treatment is as effective as optimal BCG treatment in intermediate-risk NMIBC patients, but this may not be the case for all patients.