Background: Non-muscle-invasive bladder cancer (NMIBC) presents a significant therapeutic challenge, particularly during Bacillus Calmette-Guérin (BCG) shortages. High-risk NMIBC can progress to more severe forms in 25% of patients, necessitating optimal treatment based on risk stratification.
Key Points:
- Risk Stratification: International guidelines vary slightly in categorizing NMIBC as low, intermediate, or high-risk.
- Treatment Options:
- Low-Risk NMIBC: A single post-operative instillation of chemotherapy with Mitomycin C (MMC) or Gemcitabine improves relapse-free survival (RFS).
- Intermediate/High-Risk NMIBC: Historically treated with induction and maintenance intravesical BCG, the gold standard.
- BCG Shortage Alternatives:
- Intravesical MMC and Gemcitabine have shown similar efficacy to BCG in smaller studies.
- Methods to potentiate MMC’s effects and modify BCG delivery (dose reduction, abbreviated or omitted maintenance) without reducing efficacy.
- Radical Cystectomy: Early data suggest that proceeding directly to this surgery may not adversely affect long-term quality of life.
- New Therapies: Emphasis on access to new systemic and intravesical treatments for BCG-recurrent or unresponsive disease, potentially improving survival outcomes and alleviating BCG shortages, especially when used with molecularly defined biomarkers.
Conclusion: Effective treatment of NMIBC requires adapting to current challenges, such as BCG shortages, by considering alternative therapies and optimizing treatment strategies based on risk stratification.
