TCC Treatment Flashcards
What determines low risk bladder cancer (50% of TCC)
Low grade, solitary, primary Ta tumor
Progression rate < 5% at 5 years
Tx for low risk bladder cancer?
Single dose mitomycin C after TURBT
After restaging TURBT, wait 3 months for cystoscopy
What determines intermediate risk bladder cancer (35%)
Recurrent or multifocal low grade Ta/T1
Progression < 10% at 5 years
Tx for intermediate risk?
Single dose mitomycin C after TURBT
BCG for 6 weeks +/- maintenance BCG
What determines high risk bladder cancer? (15%)
Any high grade tumor or CIS
Progression rate 25-50% at 5 years
Tx for high risk bladder cancer?
Single dose mitomycin C after TURBT
BCG for 6 weeks with maintenance
Consider early cystectomy (< 3 months)
What is the benefit of mitomycin C?
Reduces recurrence absolutely 12-15% (25-50% relative reduction)
**does not change progression
SE’s of mitomycin C?
Chemical cystitis
Gential/palmer rash (urine irritating)
*Rarely causes retroperitoneal fibrosis if given and bladder perforates
What is the indication for using intravesical Valrubicin (Valstar)?
CIS refractory to BCG and not an adequate surgical candidate
Benefits of valrubicin?
18% disease free at 6 months with durable response > 1 year
- if failure, reconsider cystectomy
MOA of BCG?
immunotherapy; recruiting T1-helper immune response (IL-2, IFN-gamma), neutrophils, T-cells, NK cells
When is BCG started?
Start 2-6 weeks after TURBT for intermediate and high risk patients
What is the BCG schedule?
Weekly treatments for 6 weeks
Maintenance is 3 weeks every 3 months for 3 years, but need at least 1 year of maintenance (high risk recommended 3 years)
If unable to tolerate, reduce dose to 10%
Benefits of BCG?
~25% reduction in risk of NMIBC (Ta, T1, CIS) progression (10% BCG vs 14% controls)
45% reduction in risk of CIS progression
*Superior to intravesical chemotherapy
What are some contraindications of BCG?
traumatic catheter hematuria UTI immunosuppression active autoimmune disease known allergy to BCG
***reflux, positive PPD, h/o treated TB, prosthetic devices are no CI’s