The Urologic clinics of North America
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Urol. Clin. North Am. · Feb 2020
ReviewSalvage Therapy Using Bacillus Calmette-Guérin Derivatives or Single Agent Chemotherapy.
Despite therapy with intravesical Bacillus Calmette-Guérin, roughly 50% of patients with high-risk non-muscle-invasive bladder cancer will recur. Although cystectomy is the oncologic gold standard in BCG unresponsive disease, salvage intravesical therapies are valuable treatment options that aim to preserve quality of life while decreasing the risk of cancer recurrence and progression. Single-agent intravesical chemotherapy has been a mainstay salvage treatment and foundational to future trials of combination therapy. Treatment with Bacillus Calmette-Guérin derivative therapies has shown promise with response rates comparable with those of single agent chemotherapy and may warrant further investigation in the continued climate of Bacillus Calmette-Guérin shortages.
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Urol. Clin. North Am. · Feb 2020
ReviewBacillus Calmette-Guérin Salvage Therapy: Definitions and Context.
High-risk non-muscle invasive bladder cancer is marked by frequent disease recurrences and risk of stage progression, contributing to high surveillance, treatment-related costs, and patient anxiety. Although the mainstay of high-risk non-muscle invasive bladder cancer clinical management remains transurethral resection followed by intravesical bacillus Calmette-Guérin (BCG), patients who develop BCG-unresponsive disease have few salvage options outside of a radical cystectomy with pelvic lymphadenectomy. This article provides a historical context relevant to the development of the BCG-unresponsive definition, an overview of current clinical trial expectations, and an introduction to this issue of Urologic Clinics.
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Urol. Clin. North Am. · Feb 2020
ReviewSalvage Therapies for Non-muscle-invasive Bladder Cancer: Who Will Respond to Bacillus Calmette-Guérin? Predictors and Nomograms.
The best predictors of response to intravesical immunotherapy are tumor grade and stage, tumor recurrence pattern, nomograms, panels of urinary cytokines, and fluorescent in situ hybridization patterns of urine cytology examinations. Future investigations on predictors of Bacillus Calmette-Guérin efficacy are needed to better select those patients who will really benefit from a conservative treatment. Hardly any of the proposed nomograms were designed to precisely predict the outcome of Bacillus Calmette-Guérin immunotherapy. A new nomogram for NMIBC recurrence and progression based on all non-muscle-invasive bladder cancer subgroups would include factors already proven in cancer prognosis and prediction.
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Urol. Clin. North Am. · Feb 2020
ReviewIdentification of Candidates for Salvage Therapy: The Past, Present, and Future of Defining Bacillus Calmette-Guérin Failure.
Disease progression and recurrence are common among patients on Bacillus Calmette-Guérin (BCG) therapy, and options for bladder-preserving subsequent therapy remain limited. Ongoing efforts to develop better second-line bladder-sparing therapies rely on clinical trials of patients deemed to have failed management with BCG. This article describes historical definitions of BCG failure, as well as recent efforts to better delineate and refine the clinical criteria for identifying individual patients who will not benefit from further intravesical BCG therapy. It also reviews guidance from the most recent expert consensus panels and professional association guidelines regarding which patients should not receive additional BCG therapy.
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After Bacillus Calmette-Guerin (BCG) failure, there is likely a 6- to 24-month window whereby salvage intravesical therapy might allow for preservation of the bladder without disease worsening. Combination intravesical, salvage therapy for nonmuscle invasive bladder cancer represents a promising avenue for treatment in patients unfit or unwilling to undergo cystectomy. BCG with concomitant immune stimulating agents or immune checkpoint inhibitors, combination chemotherapy regimens, such as gemcitabine and docetaxol, and novel agents currently in clinical trials provide hope for a bladder-sparing alternative for patients after BCG failure.