What's the next step for an 82-year-old patient with stage one non-muscle invasive bladder cancer (NMIBC) and multiple small recurrences after 6 weeks of Mitomycin (mitomycin) treatment, status post Transurethral Resection of Bladder Tumor (TURBT) and re-TURBT, who is unwilling to undergo radical cystectomy?

Management of Recurrent Low-Grade Stage 1 NMIBC After Mitomycin Failure

This 82-year-old patient with multiple small low-grade T1 recurrences after mitomycin therapy should undergo repeat TURBT followed by induction BCG therapy (6 weekly instillations) with subsequent maintenance BCG for at least 1-3 years, as this represents the standard of care for recurrent disease after intravesical chemotherapy failure. 1

Immediate Next Step: Repeat TURBT

• Perform another TURBT to completely resect all visible recurrent lesions, as this is essential for accurate restaging and optimal treatment outcomes 1
• The presence of multiple recurrences after initial intravesical chemotherapy indicates treatment failure and necessitates both complete resection and a change in therapeutic approach 1
• Even though these are low-grade lesions, the T1 stage (subepithelial invasion) and multifocal nature place this patient in a higher-risk category requiring more aggressive intravesical therapy 1

Post-TURBT Treatment: Switch to BCG Therapy

The NCCN guidelines explicitly state that patients with recurrent/persistent tumors after initial intravesical treatment can be given a second induction course, but this should be with BCG rather than repeating mitomycin, given the superior efficacy of BCG for T1 disease. 1

BCG Induction Protocol:

• Administer BCG weekly for 6 weeks 1
• Allow a rest period of 4-6 weeks 1
• Perform full reevaluation at week 12 (3 months after starting therapy) with cystoscopy and cytology 1

BCG Maintenance Protocol (Critical for Success):

• If complete response is achieved at 3-month evaluation, maintenance BCG is strongly recommended (though technically optional per guidelines) 1
• Maintenance consists of 3 weekly instillations at 3,6, and 12 months after induction 1
• For high-risk features (multifocal T1 disease), continue maintenance for up to 3 years with instillations at 18,24,30, and 36 months 1
• Meta-analysis data shows BCG with maintenance is superior to mitomycin C for preventing recurrence in intermediate and high-risk NMIBC 1

Rationale for BCG Over Continued Mitomycin

• The guidelines specify no more than 2 consecutive induction courses of the same agent should be given 1
• BCG is the category 1 recommendation (preferred) for T1 disease, even when low-grade 1
• BCG with maintenance reduces recurrence risk by 32% compared to mitomycin C in trials with maintenance therapy 1
• The patient has already demonstrated mitomycin failure, making BCG the logical next step 1

Addressing Cystectomy Refusal in This Context

While the patient refuses radical cystectomy, this is actually reasonable for low-grade T1 disease at initial recurrence:

• Cystectomy is primarily recommended for high-grade T1 disease that recurs after BCG failure, not after mitomycin failure 1
• The patient deserves a trial of BCG therapy before cystectomy is considered mandatory 1
• At age 82, the morbidity of cystectomy must be weighed against potential benefits, making bladder-sparing approaches more appropriate if BCG can control disease 1

Surveillance Protocol

After BCG treatment:

• Cystoscopy every 3 months for the first 2 years 1
• If no recurrences, extend to every 6 months in years 3-4 2
• Annual surveillance thereafter 2
• Include urinary cytology at each visit 1, 2

Critical Pitfalls to Avoid

• Do not give immediate post-TURBT chemotherapy in this setting - the patient needs induction BCG, not a single instillation 1
• Do not repeat mitomycin induction - this represents treatment failure requiring a different agent 1
• Do not skip maintenance BCG - this is where much of the benefit comes from, particularly for preventing progression 1
• Do not delay treatment - multifocal T1 disease carries risk of progression even when low-grade 1

When to Reconsider Cystectomy

The patient should be counseled that cystectomy becomes the primary recommendation if:

• High-grade disease appears on subsequent biopsies 1
• Disease persists or recurs after adequate BCG therapy (BCG-unresponsive disease) 1
• Progression to muscle-invasive disease occurs 1

However, for now, BCG therapy represents appropriate standard-of-care bladder-sparing treatment with reasonable expectation of disease control 1.