Evolving approaches to intermediate-risk non–muscle-invasive bladder cancer

Intermediate-risk bladder cancer is often more challenging to manage than high-risk or low-risk bladder cancer, so how do clinicians determine the best treatment method for this type of patient?

Kristen Scarpato, MD

At the 2021 Society of Urologic Oncology Annual Meeting, Kristen Scarpato, MD, MPH, and a team of urologists participated in a case-based discussion on intermediate-risk non-muscle invasive bladder cancer to examine the factors in managing patients with this category of disease. In this interview, conducted on December 2, 2021, Scarpato provided an overview of the discussion and discussed how her own practice has evolved regarding intermediate-risk non–muscle-invasive bladder cancer. Scarpato is an associate professor, residency program director, and vice chair of education in the department of urology at the Vanderbilt University Medical Center in Nashville, Tennessee.

Could you summarize the ideas of this discussion?

I am looking forward to participating in this roundtable. Angie Smith [,MD, MS], is going to be leading this session with Trinity Bivalacqua [MD, PhD], Andrea Kokorovic [,MD], and myself. And we're going to be focusing on patients with intermediate-risk non-muscle invasive bladder cancer. We'll start by going through some definitions, based on the 2016 AUA and SUO guideline of non–muscle-invasive bladder cancer, and then we'll go through some of the guidelines. I think many urologists feel really comfortable with management of low-risk patients and high-risk patients, and this intermediate-risk group is really heterogeneous and can be a little bit more challenging to manage. There's some more practice variability in this intermediate-risk group. And so, I am anticipating that we will talk about specific patient scenarios and how each of us might manage them, how we might counsel our patients, and maybe talk about some new and emerging data about the diagnosis and management of patients in this group.

What points will you be making in this discussion?

I'm not quite sure what Dr. Smith is going to ask me yet, but I will, again, try and make a point about the importance of this topic, given the heterogeneity, and focus on some of the known issues associated with management of bladder cancer in general. So, things like complication rates, the financial toxicity associated with patients who have non–muscle-invasive bladder cancer, and the impact of frequent cystoscopy and [transurethral resection of the bladder tumor (TURBT)] on patients who are often older and sicker with lower urinary tract symptoms already. So, focusing on why this is such an important topic, and how we might better counsel our patients. I hope to talk about some of the ways that I have incorporated enhanced endoscopy into my own practice, because I think that's evolved over time as well.

How has your approach to intermediate-risk non–muscle-invasive bladder cancer evolved since you began your clinical practice?

It has certainly changed over the past several years. Overall, I think I have become a little bit more aggressive in both the work-up and the management of these patients. Two specific examples: I used to reserve enhanced cystoscopy for surveillance and follow up of patients with a known diagnosis of high-risk disease, and really, I've come to see the benefit of using enhanced cystoscopy for all patients. Specifically, in my practice that's blue light cystoscopy. I've seen that it leads to a more effective TURBT, so I'm better at detecting cancer in general and it leads to a more complete resection, which improves patient outcomes. And then, I'm more aggressive with my intravesical therapy in these patients. I think, historically, we were using a lot of mitomycin C, and patients had significant symptoms associated with that and often significant scarring [that] can be very dramatic. So, I shied away from using that as induction or maintenance therapy in these intermediate-risk patients. [I'm] now more readily using BCG or, of course with the BCG shortage, utilizing gemcitabine induction and maintenance in these patients. Not only has it been shown to have good results, but patients tolerate gemcitabine quite well oftentimes.

What new and forthcoming advances in bladder cancer diagnosis and treatment, if any, do you think may alter your approach to intermediate-risk disease?

I know that there are a couple of clinical trials in the works right now that are very exciting. There is one trial in particular[, the OPTIMA II trial,]¹ looking at a reverse thermal agent in the bladder for these intermediate-risk patients. This is chemoablation, and I think that the preliminary results are really encouraging in terms of efficacy, and [also] in terms of the patient side effects and patient-reported outcomes related to this management. I'm really excited about that. In non–muscle-invasive bladder cancer, we need more biomarkers, which can hopefully reduce the frequency of invasive procedures for these patients. I'm hopeful and optimistic that over the next couple of years, we have some really reliable biomarkers to utilize in these patients who we know have frequent recurrences.

Reference

1. National Institutes of Health US National Library of Medicine ClinicalTrials.gov. A phase 2b study of UGN-102 for low grade intermediate risk non-muscle-invasive bladder cancer (OPTIMA II). Updated September 13, 2021. Accessed December 9, 2021. https://clinicaltrials.gov/ct2/show/NCT03558503