Update on Managing Non–Muscle-Invasive Bladder Cancer
Posted: Friday, October 30, 2020
Philippe E. Spiess, MD, MS, FRCS(C), Assistant Chief of Surgical Services, Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, and Vice-Chair of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bladder Cancer panel, called the treatment of non–muscle-invasive bladder cancer “rapidly evolving,” during the NCCN 2020 Virtual Annual Conference, highlights of which were published in JNCCN–Journal of the National Comprehensive Cancer Network. The most notable revision to the 2020 NCCN Guidelines for this genitourinary cancer is the addition of pembrolizumab to the treatment of high-risk patients who do not respond to bacillus Calmette-Guérin (BCG).
“Now that our definitions of BCG-unresponsive disease are much more rigorous, I definitely think there likely will be some novel strategies adopted in years to come,” commented Dr. Spiess.
In a brief discussion of the epidemiology of bladder cancer, Dr. Spiess noted that although it is a cancer that tends to affect elderly patients, the younger population also has its share of cases. “Risk factors such as smoking are very critical in the potential development of this malignancy,” Dr. Spiess stated.
In terms of treatment options, the NCCN Guidelines indicate that for patients with high-grade Ta non–muscle-invasive bladder cancer, BCG is the preferred option after re-resection, followed by intravesical chemotherapy or observation. As for patients with T1 tumors, repeat transurethral resection is advised, or cystectomy can be considered for high-grade tumors; if no residual disease is present, BCG is preferred.
As for the recent addition of pembrolizumab to the NCCN Guidelines for recurrent or persistent disease, its inclusion is based on results from the KEYNOTE-057 trial (ClinicalTrials.gov identifier NCT02625961). In this phase II study, the 3-month response rate was 40.2%. Furthermore, Dr. Spiess noted that immunotherapy combinations are currently being studied in both BCG-resistant and BCG-naive patient populations with non–muscle-invasive bladder cancer.
Disclosure: Dr. Spiess reported no conflicts of interest.