Chemo instillation reduces bladder Ca recurrence

For suspected low-grade, newly diagnosed, or occasionally recurrent bladder cancer, a single post-transurethral resection of bladder tumor instillation of gemcitabine (Gemzar) reduces bladder cancer recurrence by 47%, according to a recent study.

For suspected low-grade, newly diagnosed, or occasionally recurrent bladder cancer, a single post-transurethral resection of bladder tumor (TURBT) instillation of gemcitabine (Gemzar) reduces bladder cancer recurrence by 47%.

The simple step is not only potentially life-saving; it’s safe, well-tolerated, readily available, and much cheaper than mitomycin, according to Edward M. Messing, MD, of the University of Rochester School of Medicine and Dentistry, Rochester, NY.

Dr. Messing, an investigator with SWOG, the international clinical trials network funded by the National Cancer Institute, presented findings from a phase III blinded clinical trial during the AUA annual meeting in Boston.

The post-TURBT standard of care has been to use mitomycin C, but few patients received it-in part because of shortages of this medication, symptomatic side effects with its use, and, currently, its expense, according to Dr. Messing.

“Urologists in Europe and Canada have been doing this procedure for more than 20 years with other chemotherapy drugs, with the research to prove it. Even the AUA recommends immediate post-TURBT intravesical instillation of chemotherapy. Now that we’ve got results from an American study, using a readily available drug that is very well tolerated, maybe American urologists will start using gemcitabine this way. I certainly hope this finally changes our standard of care,” he said.

Dr. Messing and colleagues enrolled 406 patients with non-muscle invasive bladder cancer and followed them for 4 years. In one group, post-TURBT subjects received a single 3.5-ounce instillation of gemcitabine, administered right after surgery and allowed to sit in the bladder for 1 hour. The other group received an infusion of saline only, post TURBT.

Next: 34% reduction in risk of recurrence in all patients in study

The results support gemcitabine’s use, according to Dr. Messing. There was a significant 34% reduction in risk of recurrence in all patients in the study. And, if one only looks at low-grade tumors, there was a 47% reduction in risk of recurrence for patients receiving the gemcitabine infusion, he said.

Those in the treatment arm experienced no additional side effects, such as bleeding or irritable voiding, compared with the controls.

There are cases in which instilling this readily-available chemotherapy drug immediately post TURBT isn’t indicated. Dr. Messing said that urologists and other providers should not give gemcitabine immediately after TURBT if they suspect a bladder perforation or a very thin bladder, or if there is too much hematuria to clamp the catheter post operatively. It’s also not indicated in patients with suspected muscle-invasive bladder cancer.

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Dr. Messing said best results with gemcitabine occur when providers use 2-gm gemcitabine in 100 mL saline instilled immediately after TURBT and held in place for 1 hour.

“The big deal here is that cancer recurrence is common for people diagnosed with this less aggressive form of bladder cancer. I know some patients who undergo four TURBT procedures a year. If we can cut down on these recurrences, we will save a lot of people a lot of pain, money, and time lost to recovery,” Dr. Messing said.