Intravesical therapy for transitional cell carcinoma of the bladder: the community practice

OBJECTIVES: To assess how the community urologist employs intravesical therapy in patients with transitional cell carcinoma (TCC) of the bladder because most data on intravesical therapy reflect the experience of major referral centers. METHODS: The medical records of 234 consecutive patients with TCC were reviewed. Sixty-nine patients received intravesical treatment before referral. The initial pathologic findings, the indication for treatment (eg, grade and stage, initial versus recurrent tumor), the schedule of intravesical therapy, and the drug selected for each course of treatment were assessed. RESULTS: A total of 1 39 courses of intravesical treatment were given to 69 patients; thus, the avarage number of courses was 2.02 per patient. The drug used was bacillus Calmette-Guerin (BCG) in 81 (58%), mitomycin C in 34 (24%), thiotepa in 16 (12%), Adriamycin in 4 (3%), and unknown in 4 (3%). Intravesical treatment was given after transurethral resection of the initial tumor in 33 patients; the initial pathologic finding was high grade (ie, grade 3 or carcinoma in situ) and/or Stage T1 in 22, TaG1-G2 in 9, and unknown in 2. One course of treatment was administered to 34 patients (49%) and two or more courses to 35 patients (51%). Eleven patients with TaG 1 -2 tumors were treated repetitively despite failure, with an average of 3.5 courses per patient; the drug used was BCG in 44%. Nineteen percent of patients received maintenance therapy. Intravesical therapy had to be discontinued in 10 patients because of side effects; 8 patients (12%) developed small contracted bladders and severe irritative symptoms, 3 required cystectomy despite the lack of bladder cancer. CONCLUSIONS: Intravesical therapy in community practice conforms with the generally accepted indications for high-grade and T1 disease. However, the use of BCG for low-grade TCC appears to be quite common. Repeated courses may result in significant side effects. We emphasize that excessive treatment should be avoided for low-grade, Ta lesions and BCG reserved for patients with TaG3, carcinoma in situ, or T1 TCC.