Experts offer guidance for intravesical therapy adverse effect management

Authors of a recently published article on adverse effects of intravesical therapy are hopeful that their overview can serve as a single source of information on strategies that can help patients with bladder cancer undergoing local therapy.¹

Written by urologists from Vanderbilt University in Nashville, Tennessee, and based on a comprehensive review of the literature, the paper provides an overview of the most common and significant adverse effects that can occur with intravesical BCG and with commonly utilized chemotherapies, timing of the events, and practical approaches for their management.

“Utilization of intravesical therapy is increasing, both as a strategy for bladder preservation and due to the need to use alternative regimens because of the ongoing nationwide shortage of BCG,” said study author Woodson W. Smelser, MD, clinical instructor and Society of Urologic Oncology fellow at Vanderbilt University. “As more patients receive intravesical therapy, the clinical burden of managing adverse effects will persist. We hoped to provide a concise reference containing information that could be used both for educating patients and managing [adverse] effects.”

George E. Koch, MD, a third-year urology resident at Vanderbilt University and lead author of the article, told Urology Times®, “Our hope is that our paper serves to highlight user-friendly and widely available treatment options for common but frustrating [adverse] effects of intravesical therapy.”

Koch noted that the idea for the article occurred after Meredith Donahue, APRN-BC, a nurse practitioner in Vanderbilt’s BCG clinic, asked about resources for managing adverse effects.

“We could not find a centralized resource that she could access and thought a review, including easy-to-use tables and algorithms, would be helpful for a wide group of urologists and advanced practice providers who have similar clinics,” Koch explained.

The authors gleaned information for the article from published English language articles identified through a keyword-driven literature search. Intravesical therapies reviewed aside from BCG include gemcitabine, mitomycin C, and anthracyclines (doxorubicin, epirubicin, and valrubicin). The paper also contains some information on emerging intravesical immunotherapies and chemotherapies.

In addition, the article includes a table that summarizes study data on the incidence of systemic and local toxicities associated with the various agents. Two additional tables, one for BCG and the other for chemotherapies, summarize information on the timing of the toxicities, the interventions, and additional relevant considerations.

“Delineating the time course for toxicities as they present can make a big difference in choosing a successful management strategy,” Koch said. “Tracking [adverse] effects experienced by individual patients and what management strategies work for them may help providers preempt subsequent toxicities for these patients who often undergo multiple instillations.”

In the paper, the authors also emphasize that patient education is a key component in managing adverse effects of intravesical therapy for bladder cancer.

“Counseling patients prior to intravesical therapy and providing anticipatory guidance regarding possible adverse events will improve the overall experience for patients and help with earlier recognition of adverse events,” Smelser said.

Koch added: “In some cases, anticipatory guidance may be the difference between keeping a patient on therapy or discontinuing it because of toxicity.”

According to senior author Sam S. Chang, MD, MBA, Patricia and Rodes Hart Professor of Urologic Surgery and chief surgical officer at Vanderbilt Ingram Cancer Center, “If patients understand what adverse events may occur after intravesical therapy, patient worry, phone calls, and [emergency department] visits may be avoided.”

Based on their literature search and review, the authors conclude that consistent adverse effect reporting and studies of interventions for intravesical therapy toxicity have been lacking.

“There is a need for research devoted to patient-reported outcomes and [adverse] effects to determine better intervention strategies and improve outcomes,” Chang said.

Reference

1. Koch GE, Smelser WW, Chang SS. Side effects of intravesical BCG and chemotherapy for bladder cancer: what they are and how to manage them. Urology. Published online November 9, 2020. doi:10.1016/j.urology.2020.10.039