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Preferred Treatment for Invasive Bladder Cancer: Intravesical Immunotherapy or Radical Cystectomy?

By: Joseph Cupolo
Posted: Tuesday, February 16, 2021

Results from the BRAVO-Feasibility study, in which treatment with intravesical immunotherapy (Bacillus Calmette-Guerin) or radical cystectomy was compared in patients with high-grade non–muscle invasive bladder cancer, suggested no major differences between the two therapeutic options. “What is relevant about this study,” said James W F. Catto, MBChB, PhD, of the University of Sheffield, UK, and colleagues in the Journal of Clinical Oncology, “is that around 10% of patients with high-grade non–muscle invasive bladder cancer have a lethal disease and may be better treated by primary radical treatment. Conversely, many are suitable for bladder preservation and may maintain their prediagnosis quality of life.”

According to the researchers, clinicians, as well as patients, are not clear as to which of the two treatment options is preferred. Although intravesical immunotherapy avoids bladder removal, it leaves patients at risk of disease progression and may affect health-related quality of life through local symptoms and anxiety. Conversely, radical cystectomy removes the risk of local disease progression, but it may be considered overtreatment for nonprogressing tumors. In addition, many patients may develop postoperative complications from radical cystectomy, and approximately 3% die 90 days after surgery.

In total, 407 patients were screened, and 215 (52.8%) were found eligible for inclusion in the study. Consequently, 25 patients were randomly assigned to receive intravesical immunotherapy and 25, to radical cystectomy. Of note, the researchers discovered that their findings reflected a 14% difference in bladder cancer–specific survival between patients receiving intravesical immunotherapy and radical cystectomy, that metastatic bladder cancer is present in cystectomy specimens in approximately 5% of cases, and that long-term cancer-specific survival rates approximate 90% in patients who underwent radical cystectomy.

Even with these data, the researchers maintained: “Although these findings may suggest that radical cystectomy has superior oncological outcomes with limited impact of health-related quality of life, our data do not support radical cystectomy as the standard of care for all patients.” 

Disclosure: For full disclosures of the study authors, visit ascopubs.org.



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