What did the initial pathology report say? TaHG, T1HG, CIS, Single tumor or multiples, the size?
What does the recent pathology report say?
Did you have the second TURBT after the tumor was diagnosed in High Grade or CIS after the initial TURBT?
If your tumor was CIS initially and if the recurrence was also CIS only, well-known urologists like Dr. Ashish Kamat of MD Anderson suggests continuing with a3 weeks of maintenance BCG treatment even if the cystoscopy at the 6 weeks induction treatment has CIS recurrence. The reason is that when they look at the data, the efficacy (no recurrence and no progression) at the end of the 6 weeks induction course is 55%, but It improves to 80% after the first 3 weeks of maintenance treatment. Dr. Black of the University of British Columbia does not do cystoscopy at the end of 6 weeks induction if the tumor was CIS at the initial diagnosis.
If the initial tumor was diagnosed as T1HG or T1HG + CIC, and if the recurrent tumor was diagnosed T1HG after the initial 6 weeks BCG induction course, then it is considered BCG Unresponsive. A typical recommendation is the removal of the bladder, especially if the patient is young (in 60s or less). But, some urologists may suggest trying intravesical chemotherapy as a bladder preservation strategy such as by Gemcitabine (GEMZER) or Mitomycin. Recently, I have noticed that more hospitals are offering Gemcitabine and Docetaxel which are given sequentially. Gemcitabine plus Docetaxel sequential has shown to give better efficacy than with a single chemo agent.
The Gemcitabine plus Docetaxel sequential intravesical chemotherapy was studied in multi-institution and reported in 2019. 276 patients with recurrence after BCG treatment were included in the study, One and 2-year recurrent free survival were 60% and 46%. Forty-three (15.6%) went on to cystectomy, of whom 11(4%) had progression to muscle invasion.
In 2019, the University of Arizona with Dr. Lamm published the result of their study of Gemcitabine plus Docetaxel sequential (heated). The recurrence-free was 74% at 1 year and 56% at 2 years in the patients BCG did not work. Because the treatment process is more complicated than nonheated Gemcitabine plus Docetaxel sequential treatment, I think most hospitals nonheated Gemcitabine plus Docetaxel sequential treatment. Note that not all hospitals are doing Gemcitabine plus Docetaxel sequential treatment.
There are a few studies for the efficacy of Gemcitabine (GEMZAR) alone for BCG refractory patients.
In Italy, of 20 patients enrolled in the study, 9 (45%) had recurrence-free in a median follow-up of 15.2 months.
In 2013, Memorial and Sloan-Kettering Cancer Center reported that, of 69 patients whose BCG did not work, 27 patients (39%) had a complete response (recurrence and progression-free) with medical follow-up 3.3 years.
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