No I have not been treated with BCG, yet. I was diagnosed withTaG2 4 years ago. G1,G2,G3 is old grading system before WHO changed it in 2004 to LG and HG. G2 s in between LG and HG. HG usually goes through BCG treatment. So, I still do not know why my urologist chose TURBT and scheduled cystoscopies as my treatment regimen. I have been involved with a local patients support group and came to know patients at different stages, including those who have gone through BCG treatment. There I have learned that local hospitals can handle well in normal situations, but when it comes to exceptions such as when a patient does not respond well to BCG, or a patient wants a certain urinary diversion, larger hospitals tend to have more experience and more options; an example is the Emory University seems to have been using Bluelight cystoscopy for several years and have been involved bladder cancer related researches.
Yes, I am hoping if it does return Dr. Narayan will provide the best possible treatment. I will let you know how that goes. Thanks for the support. It helps a lot to find people that have gone through the same situations. Did you have BC?
First of all, congratulation for your getting an appointment with Dr. Narayan at Emory Hospital. Probably it is the best decision you have made in dealing with your bladder cancer. I looked at his bio and it looked impressive, including having done his residency in MD Andersons, especially his clinical and research interest is in bladder cancer. I have noticed that he has been involved in the Phase III clinical trial of Nadofaragene firadenovec which is a new treatment for those patients who does not respond to BCG treatment. So, I think he is the perfect urologist for you. Well done. Also, Emory Hospital seems to have blue light cystoscopy. So, they may recommend it if they think necessary. I would not worry much about recurrence as the probability is low to see the recurrence just in 2 months after TRUBT. If it does, and if it CIS, Dr. Narayan would give you the best possible treatment , which is likely BCG, for your situation. Please keep us update. Best
Thanks for the detailed explanation Joe. I am learning a lot by joining this forum. I have made an appointment with an urology oncologist Dr. Narayan at Emory Hospital where they do have BCG but could not find an appointment until March 22nd so I guess I will have to wait couple more months regardless. Hopefully it does not come back again by the time, I am scared that it might recur.
"No Muscularis propria present" means there were not muscle layer samples given to the pathologist . I think this is okay because it was CIS. There are three layers (tissues) in the bladder, i.e. Epithelial Tissue (Ta), Connective Tissue (lamina propria) (T1), Muscle Tissue (Muscularis propria) (T2,3). CIS is known to stay in the epithelial tissue and grow horizontally fist, then progress to the connective tissue. If the pathology report says CIS, the pathologist found tumor in the epithelial tissue only, and did not find in the connective tissue. It is highly unlikely that the tumor progresses from the epithelial tissue (Ta) to the muscle tissue (T2,3)skipping the connective tissue (T1).
So, the second TURBT is not required. AUA guideline recommends the 2nd TURBT as follows. "In a patient with T1 disease, a clinician should perform repeat transurethral resection of the primary tumor site to include muscularis propria within six weeks of the initial TURBT. Strong Recommendation; Evidence Strength: Grade B ". Actually, I had asked my urologist why he did not get muscle tissue when my pathology report said "No Muscularis propria present", then the urologist said because he did not see the tumor had progressed the connective tissue (lamina propria). He has 30 years experience, so I thought he should know what he was doing.
Bladder wash with chemotherapy agent after TURBT
AUA guideline for NMIBC 2021 says "In a patient with suspected or known low- or intermediate-risk bladder cancer, a clinician should consider administration of a single postoperative instillation of intravesical chemotherapy (e.g., gemcitabine, mitomycin C) within 24 hours of TURBT. " I think the rationale is that high risk NMIBC ( HG and CIS) will get intravesical BCG or Intravesical chemotherapy anyway, and it will kill implanted cancer cells anyway, so the wash is not required. On the other hand, urologist may choose TURBT and surveillance by cystoscopy only low risk or intermediate risk (LG). In this case, the wash is known to reduce the future recurrence by 10%. Since the pathology result was CIS, the wash should not be done.
BCG delay due to shortage
I get upset whenever I still hear the delay in BCG treatment because of shortage. I believe patients have right to know the supply chain of BCG and its inventory in every hospital. The information of the supply chain and the inventory level in each hospital is very opaque. I am not sure if it is intention by MERCK or healthy care system. I have read a posting that some health care system in California gives 1/3 dose to alleviate the shortage problem. We know 1/3 dose gives equivalent efficacy. Perhaps, if we give 1/2 dose to everyone till MERCK completes the promised 2nd production line in 5 years. Or FDA should expertise the approval of Tokyo-172 strain, which has been used in the clinical trail for near 4 years. I am pretty sure that if it has any serious efficacy or side effects, the clinical trial would have stopped by now. Anyway, I am very sorry to hear that your BCG is not available there. BCG is very effective, especially for CIS. Dr. Ashish Kamat of MD Anderson presented a webinar in which he said the efficacy of BCG for CIS is 85% complete response rate after 6 weeks induction + 3 weeks maintenance. Usually BCG starts 4-6 weeks after TURBT. 3 months or 15 weeks seem to be long. I also do not know if 3 months is too long. What I know is that the progression rate is >45% if CIS is untreated. I have seen posts some patients chose intervesical chemotherapy, eg. GEMCITABINE as substitute for BCG, also someone was put on Gemcitabine + Docetaxel Sequential chemotherapy till BCG becomes ready and switch back to BCG. This decision requires an expert on non-muscle invasive bladder caner treatment, especially for CIS only patients. I hope you will have an access to BCG soon.
If your urologist has any suspicion that the cancer has spread into the muscle, he/she would do another TURB. If there is no indication of this they may not do it. You may want to discuss this with your urologist.
Diagnosis 2-08 Small papillary TCC; CIS
BCG; BCG maintenance
Vice-President, American Bladder Cancer Society