Treating high-risk bladder cancer: It's about time

Mariani and colleagues used a standardized hematuria evaluation and urologic follow-up in a Kaiser-Permanente HMO in Hawaii from 1976 to 1985 (see article, page 9). Applying current AUA standards, 1,000 successive hematuria investigations yielded 62 cases of bladder cancer, representing 69% of all 90 cases discovered in the Kaiser population.

Importantly, when compared with a parallel cohort in the Hawaii SEER database, the researchers observed a notable 2-fold reduction in the bladder cancer death rate (10% vs. 22% at 5 years, respectively, and 13% vs. 28% at 10 years). Interestingly, this reduction in death risk is quite similar to that reported by Messing et al (Urology 1995; 45:387-97) using a home hematuria screening program in men over age 50 years. Certain clues suggest that the success of the Mariani series may be attributed to both earlier detection and to adherence to a regimented urologic investigation.

In a second study, Lerner and colleagues surprised us with findings showing timing of recurrences after BCG therapy do not influence prognosis. Using the SWOG 8507 BCG maintenance study database, this group observed that any disease recurrence, whether early (<12 months) or late (>12 months) after randomization to therapy was associated with nearly a 30% progression rate and a 2.5-fold relative risk of death.

How can one explain this? Perhaps the answer can be found in the rather long delays before proceeding with cystectomy. Less than half of the patients with documented progression even received an indicated cystectomy. It is little wonder then that 5-year survival results were lower than expected.

Michael A. O’Donnell, MD