Outcomes in BCG failure: Outcome from a single centre UK experience

Area of Science:

• Urology
• Oncology
• Cancer Research

Background:

• Bacillus Calmette-Guérin (BCG) is a standard treatment for non-muscle-invasive bladder cancer.
• BCG failure necessitates alternative treatment strategies, including bladder-sparing treatments (BSTs) and radical cystectomy (RC).
• Real-world data on BSTs versus RC after BCG failure is limited.

Purpose of the Study:

• To compare real-world outcomes of patients with BCG failure undergoing BSTs versus RC.
• To evaluate event-free survival (EFS), complete response (CR), duration of response (DoR), cancer-specific survival (CSS), and overall survival (OS).

Main Methods:

• A single-institution audit of 112 patients with BCG failure treated between January 2017 and September 2022.
• Patients were categorized into BCG unresponsive, exposed, intolerant, or muscle-invasive bladder cancer (MIBC) groups.
• Treatments included BSTs (surveillance, hyperthermic mitomycin, further BCG) and RC.

Main Results:

• In BCG unresponsive/exposed groups, BSTs had significantly poorer EFS than RC (p < 0.001).
• A substantial proportion of patients on BSTs required second or third-line treatments.
• No significant difference in CSS or OS was observed between BST and RC in these groups.
• BCG intolerance showed a 90% EFS with surveillance, with no cancer-related deaths.
• MIBC patients had poor outcomes, with 3- and 5-year CSS rates of 66% and 0% respectively.

Conclusions:

• BSTs can be a viable alternative to RC for BCG unresponsive/exposed disease, provided recurrence risk is accepted.
• Formal guidance for BST in BCG intolerance is warranted, showing excellent outcomes with surveillance.
• Upstaging to MIBC is a critical factor impacting survival in BCG failure patients.