Predictors and prognostic implications of clinical decisions in patients with primary high-risk non-muscle-invasive bladder cancer – results of a cross country retrospective study

Abstract

Adjuvant diagnostic and therapeutic procedures are available to reduce the risk of recurrence or progression in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). However, their indications and efficacy remain a matter of debate. The aim of this study was to analyze therapeutic decisions in patients with primary high-risk NMIBC and to analyze the adherence to clinical guidelines in this field. 545 consecutive patients, aged a median of 70.3 years, diagnosed with primary high-risk NMIBC in thirteen urological institutions, were enrolled into this retrospective study. Diagnostic and therapeutic decisions after transurethral resection (TUR) were recorded, and predictive factors were analyzed. Restaging TUR was offered to 260 patients (47.7%), up-front intravesical Bacillus Calmette-Guerin (BCG) therapy to 74 patients (13.6%), immediate radical cystectomy to 38 patients (7.0%), and intravesical chemotherapy with the maintenance therapy to 12 patients (2.2%). No additional procedure was performed in 161 patients (29.5%). The strongest predictive factor for restaging TUR was G3 or high-grade cancer (RR 1.68, p<0.01), for upfront BCG therapy it was carcinoma in situ (RR 3.20, p=0.01), for immediate cystectomy it was stage T1 tumor (RR 3.71, p<0.01), for no additional procedures it was G2 or low-grade cancer (RR 2.18, p<0.01). Clinical management of patients with high-risk NMIBC is suboptimal and not standardized. As this can directly influence patients’ survival, urgent improvement of urological care in this field should be considered.