Radical Cystectomy after BCG Immunotherapy for High-Risk Nonmuscle-Invasive Bladder Cancer in Patients with Previous Prostate Radiotherapy

Purpose. Intravesical Bacillus Calmette-Guerin (BCG) immunotherapy is indicated for high-grade nonmuscle-invasive bladder cancer (NMIBC). The efficacy of BCG in patients with a history of previous pelvic radiotherapy (RT) may be diminished. We evaluated the outcomes of radical cystectomy for BCG-treated recurrent bladder cancer in patients with a history of RT for prostate cancer (PC). Methods. A retrospective chart review was performed to identify patients with primary NMIBC. We compared the outcomes of three groups of patients who underwent radical cystectomy for BCG-refractory NMIBC: those with a history of RT for PC, those who previously underwent radical prostatectomy (RP), and a cohort without PC or RT exposure. Results. From 1996 to 2008, 53 patients underwent radical cystectomy for recurrent NMIBC despite BCG. Those with previous pelvic RT were more likely to have a higher pathologic stage and decreased recurrence-free survival compared to the groups without prior RT exposure. Conclusion. Response rates for intravesical BCG therapy may be impaired in those with prior prostate radiotherapy. Patients with a history of RT who undergo radical cystectomy after failed BCG are more likely to be pathologically upstaged and have decreased recurrence-free survival. Earlier consideration of radical cystectomy may be warranted for those with NMIBC who previously received RT for PC. 1. Introduction In 2012, over 240,000 American men will be diagnosed with prostate cancer [1]. Approximately 28% will receive some form of radiation therapy (RT) [2]. Pelvic radiation may be associated with an elevated risk of secondary bladder malignancies that may be seen as early as five years after exposure [3]. Intravesical BCG therapy is a standard treatment for high-risk nonmuscle-invasive bladder cancer (NMIBC) (clinical stages Ta, Tis, and T1) [4]. We have previously shown that 50% of patients with NMIBC who were previously exposed to prostate RT will have a durable response to intravesical BCG. We now report our experience with radical cystectomy after failed BCG immunotherapy for high-risk NMIBC in men with and without a prior history of RT for PC. 2. Methods With institutional review board approval, we retrospectively identified all patients who underwent radical cystectomy for recurrent/persistent high-risk NMIBC urothelial carcinoma and received intravesical BCG therapy from a dataset of nearly 1500 cystectomy patients at two academic medical centers from 1995 to 2008. We divided this cohort into three groups based on the history of PC and its associated treatment