Editorial Comment from Dr Ide to Substratification of patients with highest‐risk non‐muscle invasive bladder cancer helps to identify the candidates for immediate radical cystectomy: A two‐center study

Abstract

Therefore, immediate radical cystectomy (RC) is an option for patients with high-grade T1 bladder cancer. However, immediate RC in all patients will result in overtreatment. 2 Recently, a variation in the biological aggressiveness of highgrade T1 bladder cancer has been identified. In the 2017 European Association of Urology guideline, high-grade T1 cancer was classified as high risk or highest risk. However, even for the highest-risk cancers, the probability of muscle invasion is up to 40% at 5 years in the 2021 European Association of Urology non-muscle invasive bladder cancer scoring model. In clinical practice, establishing a method for selection of patients with high-grade T1 bladder cancer who are suitable for immediate RC is an urgent unmet need.In this study, Tao et al. retrospectively evaluated 262 patients with high-grade primary T1 bladder cancer and found that multiple tumors, concomitant carcinoma in situ, and lymphovascular invasion were significantly associated with recurrence and progression of cancer using multivariable Cox analysis. 3 The authors also predict that patients with two or three risk factors would have poor progression-free survival and strongly recommend immediate RC for these patients. They suggest that bladder-sparing treatment may be worthwhile in patients with up to one risk factor if they are unwilling to undergo RC.In the real-world setting, even though it is estimated that more than 60% of patients with high-grade T1 bladder cancer have additional risk factors for progression, fewer than 10% of these patients undergo immediate RC. 4 In addition to reluctance on the part of patients, many urologists may prefer to perform bladder-sparing treatment, such as intravesical bacillus Calmette-Guerin (BCG) immunotherapy, until progression. However, predictors of the efficacy of intravesical BCG treatment have not yet been established. Moreover, the opportunity for a complete cure may be missed if RC is delayed in preference to intravesical therapy. This study demonstrated that substratification of high-grade T1 bladder cancer based on the number of risk factors enabled more accurate categorization of patients and better surgical decision-making. Strategies that include assessment of molecular and clinicopathological factors to identify patients at risk of failure of bladder-sparing treatments are also needed in the future.