Progression of Disease after Bacillus Calmette-Guérin Therapy: Refining Patient Selection for Neoadjuvant Chemotherapy before Radical Cystectomy

Patrick J. Hensley, Kelly K. Bree, Matthew T. Campbell, Omar Alhalabi, Andrea Kokorovic, Tanner Miest, Graciela M. Nogueras-Gonzalez, Jianjun Gao, Arlene O. Siefker-Radtke, Charles C. Guo, Neema Navai, Colin P. Dinney, Ashish M. Kamat

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Purpose:Data from the pre-neoadjuvant chemotherapy (NAC) era suggests patients who progress on bacillus Calmette-Guérin (BCG) to muscle-invasive bladder cancer (P-MIBC) exhibit worse outcomes compared to de novo MIBC (D-MIBC). Herein, we investigate whether P-MIBC is an independent poor risk factor in the setting of contemporary NAC use.Materials and Methods:A review of patients who underwent radical cystectomy (RC) for cT2-3 MIBC from 2005 to 2018 was performed. Patients were stratified into high risk (lymphovascular invasion, variant histology, hydronephrosis, cT3b) vs low risk (no risk factors) and P-MIBC (≤pT1 treated with at least induction BCG who progressed to ≥cT2) vs D-MIBC.Results:Among 801 patients who underwent RC 20.3% had P-MIBC and 79.7% had D-MIBC. In low-risk patients treated without NAC, P-MIBC was associated with pathological upstaging (64.9% vs 42.7%, p=0.004) and worse overall (OS, p=0.006) and cancer-specific survival (CSS, p=0.001) compared to D-MIBC. P-MIBC status conferred uniformly poor survival outcomes to patients who did not receive NAC compared to D-MIBC without NAC (median OS 51.5 months [95% CI 40.0-81.0] vs 85.1 months [95% CI 62.8-96.0], p=0.040; median CSS not reached, p=0.014). However, P-MIBC status did not remain a negative prognostic factor in the setting of NAC (median OS 90.5 months [95% CI 34.0-not estimable] vs 87.8 months [95% CI 68.7-not estimable], p=0.606; median CSS not reached, p=0.448).Conclusions:P-MIBC confers a poor prognosis when managed with RC alone. Treatment with NAC results in equivalent pathological response and survival outcomes compared to D-MIBC. P-MIBC should be included in risk-stratified approaches to NAC selection.

Original languageEnglish
Pages (from-to)1258-1266
Number of pages9
JournalJournal of Urology
Issue number5
StatePublished - Nov 1 2021

Bibliographical note

Funding Information:
Funding: This research was supported by the Wayne B. Duddlesten Professorship in Cancer Research, the Raymond and Maria Floyd Bladder Cancer Research Foundation Grant to AMK, NIH/NCI UTMD Anderson SPORE in Genitourinary Cancer (Bladder) (P50CA091846) to CPD, the Cancer Center Support Grant (NCI Grant P30 CA016672), and a Urology Care Foundation Research Scholars Award to PJH (IRG 85-001-25).

Publisher Copyright:
© 2021 Lippincott Williams and Wilkins. All rights reserved.


  • cystectomy
  • mycobacterium bovis
  • neoadjuvant therapy
  • urinary bladder neoplasms

ASJC Scopus subject areas

  • Urology


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