Sandip Prasad, MD, on patient selection for chemoablation in LG-IR-NMIBC

In this video, Sandip M. Prasad, MD, MPhil, discusses patient characteristics that may make individuals with recurrent, low-grade, intermediate-risk non–muscle-invasive bladder cancer (LG-IR-NMIBC) appropriate candidates for chemoablation with mitomycin for intravesial solution (Zusduri) and shares considerations when counseling patients about a nonsurgical approach. Prasad is the vice chair of urology and director of the genitourinary surgical oncology program at Atlantic Health Morristown Medical Center and Garden State Urology.

Prasad emphasizes that patients should first undergo complete transurethral resection of bladder tumor (TURBT) to establish tumor grade and stage before risk stratification. Among patients with recurrent LG-IR-NMIBC, key features include tumors larger than 3 cm, multifocal disease, and recurrence within 1 year. He notes that efficacy data from the ENVISION trial showed responses across all of these patient groups. In clinical practice, Prasad says he initially considers chemoablation for patients who continue to recur despite existing treatment approaches or those for whom repeat TURBT presents particular challenges, including patients taking chronic anticoagulation or those at increased risk from anesthesia.

“In the end, fortunately, because the efficacy data is so strong, there really isn't a patient population that you should not use Zusduri,” Prasad explained. “I tell most providers, use Zusduri initially in those patients you don't want to operate on. I think most of us know who those patients are in our practices. Once you start off there, you build confidence and comfort.”

When counseling patients, clinicians should discuss the potential benefits of avoiding surgery, including avoiding general anesthesia, an interruption of blood thinners, and the recovery challenges associated with TURBT. Prasad notes that a nonsurgical approach also requires 6 weekly office instillations, which may be a consideration for some patients. He highlights durability as an important potential benefit of chemoablation, with longer-term data suggesting that many patients who achieve a complete response remain disease-free.