Case 3: A 49-Year-Old Man With Recurrent Non–Muscle-Invasive Bladder Cancer

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Case 3: 49-Year-Old Man With Non–Muscle-Invasive Bladder Cancer

Key Discussion Themes:

• Young-onset bladder cancer considerations
  • Defined as 50 years or younger based on colorectal literature
  • Growing concern particularly among veterans (Veterans Affairs has designated bladder cancer as service-related)
  • Balancing long-term quality of life with aggressive disease management
• Management of recurrent disease after BCG
  • Approach to low-grade vs high-grade recurrences
  • Importance of continued surveillance imaging, including upper tracts
  • Treatment sequencing considerations for multiple recurrences
• Intravesical gemcitabine/docetaxel therapy
  • Practical aspects of administration schedule
  • Maintenance therapy importance for chemotherapy efficacy
  • Logistical challenges in community practice settings
• Third-line therapy options for BCG-unresponsive disease
  • Available FDA-approved options: nadofaragene firadenovec, oportuzumab monatox (N-803), pembrolizumab
  • Revisiting radical cystectomy discussion at each recurrence
  • Importance of thorough evaluation including prostatic urethra and upper tracts

Notable Expert Insights:

Dr Murray on managing young patients with bladder cancer: “I focus more on those percentages of the possibility of progression of disease because the patient has so many more years to live. With a good TURBT and complete resection, I’m going to give BCG just like I would for older patients.”

Panel perspective on low-grade recurrence after BCG: The panel agreed that low-grade recurrence after BCG for initial high-grade disease represents a “win” scenario that doesn’t warrant radical cystectomy but requires careful monitoring including cytology and upper tract imaging.

Dr Chang on individualized treatment decisions: “It’s a combination of how risk-averse the individual is and how risk-averse the treating physician is. You attempt to individualize and personalize care, get as much information as possible. It is really tough for those in practice that don’t see a lot of bladder cancer patients to navigate the nuances of therapy.”

Dr Schmidt on available treatments for BCG-unresponsive disease: “We could switch therapy. If going the intravesical route, we have gemcitabine/docetaxel as our de facto standard. Valrubicin is still used in Europe and Canada. We also have newer approved agents including nadofaragene [firadenovec], N-803, and oportuzumab monatox. Some receive pembrolizumab systemically. Radical cystectomy may still be on the table.”

Panel consensus on treatment goals: “The goal should be no patient with non-invasive disease should die of their cancer.” The panel emphasized thorough evaluation of prostatic urethra and upper tracts at every recurrence to ensure bladder-sparing approaches remain safe.