ORLANDO, FL (UroToday.com) - Dr. O’Donnell argued for optimizing BCG therapy in patients failing an initial round of intravesical therapy. For low risk patients, there is small risk of disease progression and thus treatment is not needed. Selection of the best candidates has the highest responses. Advanced age has a negative impact on response to therapy. He pointed out that re TUR optimizes tumor staging and control for T1 lesions. Then one should treat with BCG at 2-6 weeks post TUR. Six weekly treatments is still most common and maintenance for at least one year after induction is rewired for optimal durable efficacy and progression reduction. RE induction with 3 additional treatments improves outcomes. The benefits for BCG treatment over MMC are with maintenance therapy.

Decreasing BCG dwell time to less than 30 minutes and reducing the dose to 1⁄2 or 1⁄4 strength results in decreased local toxicity. Mechanistic considerations to improve BCG efficacy includes reducing inhibitory modulators such a s interferon-alpha with NSAIDs. Co-factors can be stimulated with GMCSF. Also, identifying BCG resistance mechanisms such as poor immune responders would be useful. COX-2 inhibitors may enhance effector processes. BCG attachment with anti-fibrinolytic therapy has been recently reported to improve outcomes in an animal model and clinical trial EACA is one such agent.

He stated that there is a window, less that 24 months to offer salvage therapy. Untreated CIS has an annual 7% progression rate per year, but since half fail with BCG the number increases to 15% per year. The progression rate in one trial was 8%, but the mortality rate was only 1%. A 2-year window is supported by DR. Herr’s data as beyond 2 years the disease specific survival rate drops from 92% to 56%. Re-treatment with BCG or BCG interferon demonstrates a response rate of up to 69%. However, he defined those at risk for disease progression that should go on to cystectomy and emphasized the <2 year window to ensure a high cure rate.

Presented by Michael O’Donnell, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.