When is immediate cystectomy necessary in TCC?

Scottsdale, AZ-While immediate cystectomy offers excellent long-term outcomes for patients with high-grade T1 transitional cell carcinoma, genetic biomarkers one day could help urologists select the most appropriate candidates for this surgery. Meanwhile, recent data suggest that optimal bacillus Calmette-Guerin therapy can delay the need for cystectomy without increasing mortality. These insights came from a presentation regarding immediate cystectomy for high-grade bladder cancer at the Perspectives in Urology: Point-Counterpoint meeting held here.

"That finding is true, but the difficulty is that researchers were only looking at the failures," he said. "One can't say that everybody should have up-front cystectomy because those who don't have it fare badly without knowing the denominator: How many do well with bladder-sparing treatments?"

However, he said, such studies are biased against immediate cystectomy because physicians naturally select out the highest-risk cases for this treatment.

"Another problem is that many of the people who say one should do immediate cystectomy are not using the optimal BCG treatment schedule," which includes maintenance BCG, Dr. Lamm added.

Perhaps the strongest argument for maintenance BCG therapy comes from a follow-up of the Southwest Oncology Group 3-week maintenance BCG study that attempted to demonstrate that intravesical therapy and delayed cystectomy worsened survival (J Urol 2007; 177:1727-31).

"In contrast, there was a highly significant-both clinically and statistically-reduction in mortality in patients who actually failed BCG and came to cystectomy," he said. "Those patients did better if they had received 3-week maintenance."