Geez Dan, you just posted what may by *the*most controversial findings ever published on the topic of intravesical therapy.
I asked our advisors about this report when it first appeared last November?, and the replies were (paraphrased) "it's not true that survival rates are going down" and "this is a very prejudicial report done on one small cohort."
Lord knows the uro-oncology community is now using intravesical chemo as the first line tx for almost everything. I'm sure Dr. Lambert ruffled more than a few feathers with this one...
What also strikes me is the low number of tx's administered, .53 and 1.2? I know so many folks who get dozens of treatments, and are alive and well many many years later. On the other hand we've seen too many Ta high grade tumors invade, with disastrous results, as well as the occasional low grade tumor that morphs into something more sinister.
I don't know what to make of this...it's very scary. That is why my sister still goes for cystos 8+ yrs post diagnosis of her Ta,G1 tumor (3cm, recur was 4cm).
I think it's good to draw a line under these statistics for people and the survival advantage of an early cystectomy was THE main factor for me when I went for mine last October. There were other considerations but it was the one I kept going back to. I still think you should do the thing you feel most comfortable with so long as you have all the facts at your disposal. I also think these statistics highlight the fact that even with a cystectomy at an early stage things don't always work out. My consultant here in the UK certainly favours the early surgical approach and he's done well by me.
BERKELEY, CA (UroToday.com) - According to the British Journal of Urology in a recent article by Lambert and collaborators the increased use of intravesical treatments for non-muscle invasive bladder cancer is associated with worse survival in patients with T1 disease despite cystectomy for disease progression or persistent disease after intravesical therapy.
The researchers used the Urologic Oncology database at Columbia University. Out of 505 total patients who underwent a radical cystectomy from 1990-present 104 had initial T1 disease. The authors divided the group into two time periods: before1998 (early) and after 1998 (late). The mean number of intravesical treatments per patient increased from 0.53 to 1.2 in the early and late groups, respectively (p=0.016). 28 of 38 (74%) patients in the early group and 20 of 47(43%) patients in the late group underwent cystectomy without any intravesical therapy (p=0.004).
The disease-free survival for patients who had a radical cystectomy in the early vs. late group at 5 years was 70% and 40%, respectively. Additionally, the early group had a worse overall and cancer specific survival than the late group. The survival curves were statistically controlled for confounders including date of surgery, age, and gender.
The authors hypothesize that prolonged use of intravesical therapy to preserve bladder function may forestall definitive therapy and result in potentially preventable deaths. They recommend early cystectomy in those patients who have initial high risk tumor characteristics or who have early failure to intravesical therapy.
Lambert EH, Pierorazio PM, Olsson CA, Benson MC, McKiernan JM and Poon S
Dx 7/04, CIS + T1G3, Age 50
Cystectomy 8/05 USC/Norris
So far, so good (kow)