Optimizing Treatment for Non–Muscle Invasive Bladder Cancer

Phoebe Starr

April 2017, Vol 8, No 2 - Genitourinary Cancers Symposium


Orlando, FL—The incidence of bladder cancer is on the rise, and bladder cancer is 4 to 5 times more expensive to treat than breast or prostate cancer. The cost of bladder cancer treatment can be reduced by adhering to the National Comprehensive Cancer Network or the American Urological Association treatment guidelines.

At the 2017 Genitourinary Cancers Symposium, Karim Chamie, MD, MSHS, Assistant Professor of Urology, Department of Urology, University of California, Los Angeles, urged urologists and oncologists to follow treatment guidelines and use adequate staging, offer the best available therapies to patients, comply with close surveillance, and provide prompt treatment at disease recurrence.

“Healthcare spending does not always lead to improved outcomes. More interventions are not necessarily better, they just lead to more procedures. A problem with urologists is that we practice too little, too late,” said Dr Chamie.

Adequate staging is important. In a chart review of 1865 patients with bladder cancer, muscle involvement was reported as present in 52% of patients, muscle involvement was not present in 30% of patients, and was not mentioned in 18% of patients.1

“Urologists get a false sense of security with no muscle mentioned in the report,” he said.

Undertreatment and Poor Surveillance

Available treatments for bladder cancer, such as mitomycin C and Bacillus Calmette-Guérin (BCG), have been shown to minimize bladder cancer recurrence and progression, but recent data suggest that patients with non–muscle invasive bladder cancer are often undertreated.

Dr Chamie and colleagues used SEER-Medicare linked data to identify patients who were diagnosed with high-grade, non–muscle invasive bladder cancer between 1992 and 2002. The data showed that perioperative intravesical mitomycin C was used in approximately 3% of patients and BCG was used in approximately 13% of patients.2

In addition, a study by Barocas and colleagues showed that only 35% of ideal candidates received intravesical therapy.3

Furthermore, a recent study showed that 60% of patients with high-grade non–muscle invasive bladder cancer did not receive BCG therapy upfront. After 6 disease recurrences, the percentage of patients who did not receive BCG declined to 28%.4

Urologists and oncologists often fail to provide close surveillance of patients with high-grade, non–muscle invasive bladder cancer.

“In a recent study, only 13% of patients got at least 4 cystoscopies and 4 cytologies over 2 years, which is the level that is associated with reduced likelihood of recurrence,” Dr Chamie emphasized.5

More concerning is that approximately only 25% of all patients undergo prompt definitive treatment after multiple disease recurrences.6

“Among healthy young patients with at least 4 recurrences, less than 50% got definitive treatment,” he stated.

Dr Chamie cited several reasons for the suboptimal adherence to treatment guidelines among urologists.

“There is a false sense of security with low-grade bladder cancer. Our treatment of bladder cancer is more reactive than proactive. Many doctors perceive the side effects associated with mitomycin C and BCG to be unacceptable. Drug shortages affect compliance, and there is fear of bladder perforation with cystoscopy,” he said.

“Practice patterns can be influenced by reimbursement. When reimbursement goes up, the number of endoscopies go up. Urologists tend to follow practice patterns based on reimbursement, and this can improve the quality of care,” added Dr Chamie.

Reducing Costs

Approaches to reducing the cost of care for non–muscle invasive bladder cancer include repeat resection at recurrence, with the goal of no residual disease. “Repeat TURBT [transurethral resection of a bladder tumor] picks up residual disease and leads to better response to therapy,” said Dr Chamie.

In addition, using one-third of the dose of BCG and/or 1 year of maintenance therapy has been shown to reduce disease recurrence without compromising survival. For maintenance therapy, the Tice strain of BCG is superior to the Connaught strain, he said. Continuous bladder irrigation for 24 hours is recommended but is not feasible at most institutions, and is equivalent to intravesical mitomycin C, said Dr Chamie.


References

  1. Chamie K, Ballon-Landa E, Bassett JC, et al. Quality of diagnostic staging in patients with bladder cancer: a process-outcomes link. Cancer. 2015;121:379-385.
  2. Chamie K, Saigal CS, Lai J, et al. Compliance with guidelines for patients with bladder cancer: variation in the delivery of care. Cancer. 2011;117:5392-5401.
  3. Barocas DA, Liu A, Burks FN, et al. Practice based collaboration to improve the use of immediate intravesical therapy after resection of nonmuscle invasive bladder cancer. J Urol. 2013;190:2011-2016.
  4. Lenis AT, Donin NM, Litwin MS, et al; for the Urologic Diseases in America Project. Association between number of endoscopic resections and utilization of Bacillus Calmette-Guérin therapy for patients with high-grade, non–muscle-invasive bladder cancer. Clin Genitourin Cancer. 2017;15:e25-e31.
  5. Chamie K, Saigal CS, Lai J, et al; for the Urologic Diseases in America Project. Quality of care in patients with bladder cancer: a case report? Cancer. 2012;118:1412-1421.
  6. Chamie K, Ballon-Landa E, Daskivich TJ, et al; for the Urologic Diseases in America Project. Treatment and survival in patients with recurrent high-risk non-muscle-invasive bladder cancer. Urol Oncol. 2015;33:20.e9-20.e17.