Current Evaluation and Treatment Pathways for Low-Grade, Intermediate-Risk NMIBC

A roundtable discussion, moderated by Christopher Wallis, MD, PhD, FRCSC, focused on patient selection and treatment considerations for non-muscle invasive bladder cancer, including recent data from SUO 2023. Dr. Wallis was joined by Sia Daneshmand, MD; Piyush Agarwal, MD; and Sima Porten, MD, MPH.

In the next segment of the roundtable series, the panel delves into current evaluation and treatment pathways for low-grade, intermediate-risk disease, including considerations for ablation, repeated histologic evaluation, and in-office flexible scope biopsy fulguration.

View the next segment on Emerging Therapies in Pretreated NMIBC.

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Dr. Wallis: Let’s examine our current guidelines and treatment paradigms. Dr. Daneshmand, how do you approach a patient with intermediate-risk non-muscle invasive bladder cancer?

Dr. Daneshmand: For intermediate risk, the AUA guidelines recommend either chemotherapy or immunotherapy, specifically BCG. Due to the BCG shortage, the standard of care is shifting towards chemotherapy, with gemcitabine gaining preference over mitomycin due to its lower side effect profile. Currently, the standard for intermediate-risk involves intravesical chemotherapy induction, possibly followed by maintenance therapy. While some still use BCG, especially for high-grade tumors, I lean towards gemcitabine.

Dr. Wallis: And you’re doing upfront 6 inductions once weekly?

Dr. Daneshmand: Yes, 6 inductions.

Dr. Wallis: And then monthly maintenance?

Dr. Daneshmand: Monthly maintenance for about a year.

Dr. Wallis: Similar in Chicago?

Dr. Agarwal: I might be an outlier. For stable intermediate-risk patients, periodic surveillance is an option. If recurrence is observed, we perform perioperative gemcitabine. Intravesical gemcitabine is considered for patients troubled by frequent recurrences, with induction and potential maintenance. However, this approach is rare due to the infrequency of bulky intermediate-risk tumors.

Dr. Wallis: Dr. Porten, what’s happening in San Francisco?

Dr. Porten: It depends on the patient’s disease course. For large low-grade TA solitary tumors, I discuss adjuvant intravesical gemcitabine induction to reduce future recurrence. Long-term stable intermittent recurrences prompt discussions about surveillance and patient-specific factors influencing treatment decisions.

Dr. Wallis: When you see recurrent tumors in someone with known low-grade histology, is repeated histologic evaluation necessary? What’s the value in it?

Dr. Daneshmand: The progression rates are low, but I prefer doing a biopsy before ablating small tumors in the office. Documenting and ensuring no progression is crucial. Biopsies are essential, and flexible blue light cystoscopy aids in office biopsy procedures.

Dr. Wallis: Dr. Agarwal, can you walk us through in-office flexible scope biopsy fulguration?

Dr. Agarwal: Blue light is helpful, and I use flexible cold cup biopsy forceps to take a deep bite of the largest tumor. A Bugbee is used for cautery, and smaller tumors are cauterized. I aim to minimize bladder neck entry to reduce patient discomfort. Intravesical Lidocaine is rarely used, and the procedure lasts about 90 minutes.

Dr. Wallis: And you do this during diagnostic cystoscopy?

Dr. Agarwal: Yes, ideally on the same day, but due to clinic flow, it’s often on a separate day.

Dr. Wallis: Dr. Porten, how do you perform in-office biopsy fulguration?

Dr. Porten: Depending on tumor size, I either pull it through the scope or take the whole scope out. Suction devices with flexible blue light cystoscopy enhance biopsy rates. Bladder distension, not overdistension, is crucial for patient comfort.

Dr. Daneshmand: When dealing with small specimens and the era of molecular diagnostics, sending small tissue samples for FGFR3 testing becomes challenging. Creating cell blocks from cytology is a workaround.

Dr. Wallis: Moving to adjuvant therapy, Dr. Porten, can you explain the principles?

Dr. Porten: Adjuvant therapy aims to prevent recurrence, ideally starting 2 to 6 weeks post-resection. It keeps the patient disease-free after surgical clearance.

Dr. Wallis: Dr. Agarwal, transitioning to chemoablation, what does it mean?

Dr. Agarwal: Chemoablation involves treating visible tumors with chemotherapeutics to potentially ablate them, eliminating the need for resection. Studies with mitomycin support this idea, exploring its application as an alternative to resection.