title: Treatment paradigm shift may improve survival of patients with high risk superficial bladder cancer.
abstract: OBJECTIVE
  Historically patients with recurrent T1 bladder tumors after bacillus Calmette-Guerin have been treated with bladder sparing approaches. Recently a paradigm shift has occurred since patients are increasingly offered radical cystectomy before disease progression to muscle invasion. In this study we explored the effect of this paradigm shift on progression rates and disease specific survival.
  
  
  METHODS
  The historical cohort consisted of 307 patients from 3 prospective intravesical bacillus Calmette-Guerin protocols from 1980 to 1989. An institutional review board approved review identified 589 patients treated with bacillus Calmette-Guerin in a contemporary cohort from 1992 to 2004.
  
  
  RESULTS
  In the historical cohort the 85 patients with documented T1 recurrence were initially treated with repeat transurethral resection and intravesical bacillus Calmette-Guerin. Of these 85 patients 60 had progression to muscle invasive disease. At 5 years after T1 recurrence, the cumulative incidence of progression to T2 disease was 71% (95% CI 61%, 81%) and the cumulative incidence of death from disease was 48% (95% CI 39%, 60%). In the contemporary cohort 129 patients had documented T1 recurrence. In this cohort 65 of the 129 patients with recurrent T1 underwent immediate radical cystectomy. At 5 years after T1 recurrence, the cumulative incidence of progression to muscle invasive disease was 28% (95% CI 20%, 38%) and the cumulative incidence of death from disease was 31% (95% CI 22%, 42%).
  
  
  CONCLUSIONS
  Preemptive radical cystectomy performed for recurrent T1 disease following intravesical bacillus Calmette-Guerin therapy may be associated with better disease specific survival.
authors: Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
authors: Ganesh V
authors: GV
authors: Raj
authors: Harry
authors: H
authors: Herr
authors: Angel M
authors: AM
authors: Serio
authors: Sherri M
authors: SM
authors: Donat
authors: Bernard H
authors: BH
authors: Bochner
authors: Andrew J
authors: AJ
authors: Vickers
authors: Guido
authors: G
authors: Dalbagni
mesh_terms: D000276:Adjuvants, Immunologic / Q000627:therapeutic use*; D000368:Aged; D001500:BCG Vaccine / Q000627:therapeutic use*; D015331:Cohort Studies; D015653:Cystectomy; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*
chemical_list: D000276:Adjuvants, Immunologic; D001500:BCG Vaccine