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Question 6#

Regarding non-muscle-invasive bladder cancer and adjuvant chemo/immunotherapy, which of the following statement is FALSE?

A) Recent evidence suggests no statistically significant benefit from early postoperative chemotherapeutic instillation in patients with large or recurrent tumours (i.e., intermediate risk) or in those with high-risk NMIBC
B) An EORTC meta-analysis showed that a single, immediate instillation of intravesical chemotherapy after TURBT results in a 11.7% absolute reduction in tumour recurrence (a decrease of 24% in the odds of recurrence). No significant differences in efficacy were noted among the chemotherapeutic agents studied, indicating that the choice of chemotherapeutic drug is optional
C) An EORTC meta-analysis showed that compared to TURBT alone, immediate adjuvant chemotherapy after TURBT significantly improves disease-free survival and reduces progression rates

Correct Answer is C

Comment:

Answer C

The effect of early instillation can be explained by the destruction of circulating tumour cells free within the bladder immediately after TUR, or as an ablative effect (chemoresection) of the residual tumour cells at the resection site. In all single instillation studies, the instillation was administered within 24 hours. In absolute values, the reduction was 11.7% (from 48.4% to 36.7%), which implies a 24.2% decrease in the corresponding relative risk. The majority (80%) of patients in this EORTC meta-analysis showing the benefit of single, immediate instillation of intravesical chemotherapy after TURBT had a single tumour.

No prospective data are available showing that the single instillation significantly reduces recurrence rates in patients with recurrent tumours. Nevertheless, there is significant evidence from one subgroup analysis that an immediate instillation might have an impact on the repeat instillation regimen for treatment of patients who are at intermediate- and high-risk of recurrence.

Immediate instillation of chemotherapy has no reported influence on the progression rate or overall survival of patients with NMIBC. Mitomycin C, epirubicin and doxorubicin have all shown a beneficial effect, and none is superior.

Further Reading:

  1. Sylvester RJ, Oosterlinck W, van der Meijden AP. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: A meta-analysis of published results of randomized clinical trials. J Urol 2004; 171(6 Pt 1): 2186–2190.
  2. Kaasinen E, Rintala E, Hellstrom P, et al. FinnBladder Group. Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma. Eur Urol 2002; 42(2): 167–174.