Dr Lotan on Factors Informing Treatment Selection in BCG-Unresponsive NMIBC

Yair Lotan, MD, professor, urology, chief, Urologic Oncology; Jane and John Justin Distinguished Chair in Urology, UT Southwestern Medical Center; medical director, Urology Clinic, UT Southwestern, Parkland Health and Hospital System, discusses factors informing treatment selection for patients with Bacillus Calmette–Guérin (BCG)–unresponsive non-muscle invasive bladder cancer (NMIBC).

Balancing the associated adverse effects and potential efficacy of treatments against the associated risks is a crucial part of the conversation between oncologists and patients, particularly when discussing treatment options for bladder cancer, Lotan begins. The ultimate decision rests with the patient and depends on several factors, including age, comorbidities, surgical risks, and life expectancy, he emphasizes. For example, a patient with a longer life expectancy might opt for a more aggressive treatment with a higher cure rate, even if it comes with a greater morbidity risk, Lotan says.

The presence of disease invasion also plays a key role in treatment decision-making, Lotan continues. Patients with T1 disease that has invaded the lamina propria face a higher risk of disease progression compared with those who have noninvasive disease confined to the mucosa, Lotan states. He adds that the presence of invasive disease may prompt patients to consider more aggressive interventions. Additionally, the decision-making process can be influenced by the natural history of the disease and the patient’s overall prognosis, he notes.

Another factor that affects treatment selection is the response to initial treatment, Lotan adds. If a patient’s disease recurs after they have received noninvasive therapeutic options, they may need to reconsider their treatment plan, he explains. In some cases, patients initially resist more aggressive treatments, such as bladder removal, but after multiple unsuccessful attempts with other therapies, they may ultimately opt for surgery, Lotan says. Ongoing disease evaluation supports personalized, evolving treatment discussions that adapt to patients’ changing circumstances and preferences, he concludes.