BackTable / Urology / Podcast / Episode #64
Management of BCG-refractory NMIBC
with Dr. Timothy Clinton and Dr. Eugene Pietzak
In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with two fellow urologic oncologists, Dr. Timothy Clinton (Brigham and Women’s Hospital) and Dr. Eugene Pietzak (Memorial Sloan Kettering), about the management of BCG-refractory non muscle-invasive bladder cancer.
BackTable, LLC (Producer). (2022, November 9). Ep. 64 – Management of BCG-refractory NMIBC [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Timothy Clinton
Dr. Timothy Clinton is a urologic oncologist with Brigham and Women’s Hospital in Boston, Massachussetts.
Dr. Eugene Pietzak
Dr. Eugene Pietzak is a urologic oncologist with Memoral Sloan Kettering in New York City.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
First, the doctors define BCG-refractory cancer from the clinical and FDA viewpoint. They emphasize the importance of determining the difference between BCG-resistant cancer and residual tumor from the primary resection. Blue light cystoscopy can help in confirming that the original tumor was totally resected. The doctors warn that although the initial response to BCG may be promising, there is still a chance of cancer recurrence. The success rate of BCG depends on the patient and tumor characteristics.
Next, they discuss BCG-intolerant patients. BCG has many side effects such as frequency and urgency symptoms and bladder spasms. Some patients will have a systemic immune response resulting in flu-like symptoms. However, most of these side effects are self-limiting and should resolve after the induction course. They also discuss how to deal with the current BCG shortage. They first prioritize starting an induction course and view the maintenance course as a secondary priority.
An erythematous and inflamed bladder can either be a result of BCG cystitis or a carcinoma in situ (CIS). The doctors agree that if the bladder is inflamed and the patient has a positive cytology, they would obtain a bladder biopsy to look for recurrent high-grade cancer. If the biopsy is positive, they would start a second induction course of BCG and introduce another form of therapy, like intravesical gemcitabine or an immune checkpoint modulator. If the bladder is inflamed and the patient has a negative cytology or a negative biopsy, they would continue with a BCG maintenance course and follow up.
Cystectomy is a curative option for BCG-refractory bladder cancer. Patients with tumors with high risk features such as lymphovascular invasion and varying histology are good candidates for cystectomy. Patient comorbidities, age, and willingness are also important factors in the decision. Dr. Bagrodia also recommends getting a CT scan to check for nodal metastases. Both Dr. Clinton and Dr. Pietzak agree that it is beneficial to introduce the idea of cystectomy early and explain that the procedure does not prevent patients from living a fulfilling life.
Finally, the doctors discuss recent BCG and gemcitabine clinical trials as well as new research about non-BCG therapies.
[Dr. Eugene Pietzak]
Cystosing erythematous lesions concerning for possible CIS versus BCG cystitis and the cytology is positive. I personally will take that patient to the operating room and under sedation at least do biopsies and fulgurate. I am a bit of a believer that I think there is a therapeutic benefit from trying to at least fulgurate some of the CIS and I do especially areas where it looks like there could be some early papillary changes. I will formally resect those areas safely at least.
Then once in a while, you'll see that there is some lamina propria involvement. Usually, it's focal and it's a small amount, but I think that's important to know because that is a concerning feature. If the cytology comes back negative, unless I'm very worried about the patient, I don't often take biopsies. I would probably just proceed with roundup maintenance BCG and then reassess it six months. The concerning aspect of that is we know that many patients based off the SWOG maintenance clinical trial data will convert to a complete response, but not everyone will.
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