All High-Grade Ta Tumors Should Be Classified as High Risk: Bacillus Calmette-Guérin Response in High-Grade Ta Tumors

Abstract

Purpose: There is variation amongst guidelines with respect to risk stratification of Ta tumors, specifically high-grade (HG) Ta tumors. We sought to investigate the response of all Ta tumors to bacillus Calmette-Gu erin (BCG) and compare response rates based on European Association of Urology (EAU) classification as intermediate-(IR) or high-risk (HR). Materials and Methods: An institutional review of all patients who received adequate BCG from 2000e2018 was conducted. EAU 2021 prognostic risk groups were used to stratify patients including by the newly proposed adverse risk factors. Results: When patient with Ta tumors were stratified into IR and HR, 37 (16%) had IR low-grade (LG) Ta, 92 (40%) had IR HG Ta and 101 (44%) had HR HG Ta tumors. BCG unresponsiveness developed in 13% of HR HG Ta tumors and 14% of IR HG Ta tumors compared to 0.0% of IR LG Ta tumors (p[0.003). While no patients with IR LG Ta tumors progressed, progression rates were similar in HR HG Ta and IR HG Ta tumors (T2: 5.9% and 6.5%; T1: 13% and 13%, respectively). Rates of recurrence, BCG unresponsiveness and progression were similar, irrespective of number of EAU risk factors present (p[0.9, p[0.8 and p[0.9, respectively). Conclusions: All HG Ta tumors, regardless of EAU risk stratification, have inferior response to BCG and increased rates of progression compared to IR LG Ta tumors. EAU clinical risk factors did not improve prediction of oncologic outcomes among HG Ta patients who received adequate BCG. These data support consideration of all HG tumors as high risk.

Cancer-Specific Survival of Patients with Non-Muscle-Invasive Bladder Cancer: A Population-Based Analysis

“… 14 Nevertheless, Bree et al concluded that all TaHG tumors should be regarded as high-risk as they confer a significantly higher progression risk (approximately 6% TaHG progress to ≥ T2) than intermediate-risk low-grade Ta when treated with BCG. 15 We believe that in light of this real-world data, TaHG should be always regarded as high-risk due to the substantial 9.2% CSM in the long-term observation.…”

Sex Remains Negative Prognostic Factor in Contemporary Cohort of High-Risk Non-Muscle-Invasive Bladder Cancer

“…In a retrospective analysis of patients with Ta high-grade UBC long-term risk of disease, progression and recurrence were similar to those with T1 tumors (including low- and high-grade tumors) [ 27 ]. Furthermore, analyzing the risk of disease progression after BCG immunotherapy, Bree et al support consideration of all high-grade UBC as the high-risk group of NMIBC regardless of stage [ 28 ]. Since the application of the WHO 2004/2016 bladder cancer grading system, the proportion of T1 UBC diagnoses documented as low-grade has declined significantly but still varies widely by institution.…”

This Month in Adult Urology

“…Bree et al (page 284) from Houston, Texas and Harrisburg, Pennsylvania examine these issues of risk (intermediate vs high) specifically for those diagnosed with high-grade Ta disease in a timely retrospective review of registry data from a tertiary care referral center. 6 They demonstrate that rates of recurrence, bacillus Calmette-Gu erin (BCG) unresponsive disease and progression were similar despite being differentiated into European Association of Urology intermediate or high risk. The authors conclude that all high-grade Ta tumors have inferior response to adequate BCG (and increased progression) compared to intermediate-risk low-grade tumors.…”