Opinion
Video
Case 2: A 68-Year-Old Woman With Non–Muscle-Invasive Bladder Cancer
Author(s):
Panelists discuss how to manage the treatment of a 68-year-old woman with painless intermittent hematuria and positive cytology for high-grade urothelial cancer, addressing gender differences in diagnosis timing, the importance of repeat transurethral resection (TURBT) procedures, BCG therapy options, and considerations for radical cystectomy with pelvic organ preservation when BCG fails.
Video content above is prompted by the following:
Case 2: 68-Year-Old Woman With Non–Muscle Invasive Bladder Cancer
Key Discussion Themes:
- Gender differences in bladder cancer diagnosis and management
- Panel noted women are often diagnosed later due to symptoms being misattributed to other conditions
- When accounting for stage at diagnosis, outcomes do not differ by gender
- Treatment approach and assessment do not fundamentally differ based on sex
- Management of T1 high-grade bladder cancer with carcinoma in situ
- Discussion of repeat TURBT importance
- BCG induction and maintenance therapy as standard treatment
- Management of BCG-unresponsive disease
- Radical cystectomy considerations in women
- Pelvic organ-sparing approach discussed for female patients
- Preservation of vagina, uterus, and ovaries when oncologically appropriate
- Discussion of sexual function consideration regardless of current activity status
- Pembrolizumab for BCG-unresponsive disease
- FDA approval in 2020 based on KEYNOTE-57 study
- 41% of patients showed response at 3 months
- Limited current use as monotherapy in clinical practice
Notable Expert Insights:
Dr Murray on pembrolizumab counseling: “I split treatments into those we continue to put inside your bladder that patients are familiar with, and then pembrolizumab, which is FDA approved but administered as an IV therapy by medical oncologists. I emphasize that urology still owns this disease and patients must continue cystoscopy every 3 months.”
Dr Schmidt on radical cystectomy in women: “I most generally will try to preserve the entire pelvic floor, including the vagina, if the tumor allows. I don’t think you need to remove the ovaries or uterus, and that will contribute to improved quality of life after radical cystectomy. Even when patients say they’re not sexually active, I don’t make my decision based on that because people’s life circumstances change.”
Dr Chang on BCG-unresponsive disease: “I’m not going to give this patient more BCG, period. I look for alternatives, trials, different medications especially with repeat high-grade disease. I definitely revisit the role of radical cystectomy.”
Panel consensus on pembrolizumab use: The panel noted minimal current use of pembrolizumab as monotherapy for BCG-unresponsive disease, despite its approval. They acknowledged its historical importance in establishing systemic immune modulation in this space and potential for combination therapy in the future.
