What is the recommended treatment approach for an elderly man with non-muscle-invasive bladder cancer (NMIBC)?

Treatment of Non-Muscle-Invasive Bladder Cancer in Elderly Men

The cornerstone of NMIBC treatment in elderly men is complete transurethral resection of bladder tumor (TURBT) followed by risk-stratified intravesical therapy, with treatment decisions based on tumor characteristics rather than age alone. 1

Initial Surgical Management

Primary TURBT Requirements

• Perform complete TURBT with resection deep into the detrusor muscle for all visible tumors 1
• For tumors <1 cm, resect en bloc with underlying bladder wall 1
• For larger tumors, perform fractional resection until normal muscle is exposed 1
• The pathology specimen MUST include detrusor muscle tissue for accurate staging 1, 2

When TURBT is Contraindicated in Elderly Patients

TURBT should NOT be performed if the patient has: 1

• Severe urethral stricture preventing instrumentation
• Inability to achieve lithotomy position due to skeletal/muscle disease (common in elderly)
• Conditions requiring immediate radical cystectomy

Repeat TURBT Indications

Perform repeat TURBT within 2-6 weeks for: 1

• Incomplete initial resection
• Absence of muscle tissue in initial specimen (except for Ta low-grade tumors)
• ALL T1 tumors
• ALL high-grade tumors (except primary CIS)

This is critical because residual tumor is found in 17-67% of Ta tumors and 20-71% of T1 tumors at repeat resection, and repeat TURBT reduces recurrence rates from 58% to 16% in Ta disease. 1

Risk-Stratified Adjuvant Therapy

Immediate Post-Operative Chemotherapy

Administer single-dose intravesical chemotherapy (mitomycin C) within 24 hours of TURBT for ALL patients unless contraindicated 1

• This reduces 5-year recurrence from 59% to 45% 1
• Contraindications include bladder perforation or extensive resection

Low-Risk Disease

(Single, primary, Ta low-grade tumor <3 cm)

• Single immediate intravesical chemotherapy instillation is sufficient 1
• Proceed to surveillance cystoscopy

Intermediate-Risk Disease

(Multiple/recurrent low-grade Ta tumors)

Choose ONE of the following: 1

1. Intravesical chemotherapy for up to 1 year, OR
2. BCG therapy: 6-week induction + maintenance at 3,6, and 12 months (preferred for higher-risk intermediate cases)

BCG reduces recurrence by 32% compared to chemotherapy alone in this population. 1

High-Risk Disease

(T1, high-grade Ta, or CIS)

Full-dose BCG for 1-3 years is the standard of care: 1

• Induction: 6 weekly instillations
• Maintenance: 3 weekly instillations at 3,6,12,18,24,30, and 36 months
• Minimum duration is 1 year; 3-year maintenance reduces recurrence more effectively (HR 1.61 for 1-year vs 3-year, p=0.01) 1

Very High-Risk Disease

(T1 high-grade with concurrent CIS, multiple/large T1 tumors, lymphovascular invasion, variant histology)

Early radical cystectomy should be strongly considered and discussed with all very high-risk patients 1, 3

• This is particularly important in elderly patients with aggressive features, as delaying cystectomy until progression may worsen survival 3
• If BCG is chosen, use the 3-year maintenance protocol 1

Special Considerations for Elderly Patients

Fitness Assessment

• Evaluate comorbidities that may affect surgical candidacy or tolerance of intravesical therapy 1
• Consider performance status and life expectancy when deciding between aggressive treatment vs. surveillance
• BCG toxicity may be higher in elderly patients; dose reduction to 1/3 is suboptimal and should be avoided 3

Treatment Modifications

• For elderly patients unable to tolerate lithotomy position, TURBT is not feasible 1
• For those with multiple comorbidities and low-risk recurrences, office fulguration may be considered as an alternative to repeat TURBT 1

Management of BCG Failure

BCG failure is defined as: 1

• BCG-refractory: Persistent high-grade disease at 6 months despite adequate BCG
• BCG-relapsing: Recurrence after initial complete response
• BCG-intolerant: Unable to complete therapy due to toxicity

For BCG-unresponsive disease in elderly patients:

• Radical cystectomy remains the gold standard if fit for surgery 1, 3
• For those unfit for cystectomy: consider device-assisted chemotherapy (EMDA) or enrollment in clinical trials with novel intravesical agents 3, 4, 5
• Postponing cystectomy until muscle-invasive progression worsens survival outcomes 3

Critical Pitfalls to Avoid

• Never accept a pathology specimen without detrusor muscle - this results in Tx staging and inadequate risk stratification 1, 2
• Do not use reduced-dose BCG (1/3 dose) in high-risk patients - this is suboptimal treatment 3
• Do not skip repeat TURBT for T1 or high-grade tumors - residual disease rates are unacceptably high 1
• Do not delay radical cystectomy in very high-risk patients who are surgical candidates - progression to muscle-invasive disease worsens prognosis 1, 3
• Avoid confusing DMSO (used for interstitial cystitis) with intravesical chemotherapy for bladder cancer 6