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Stage 0 Bladder Cancer

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    A randomized study of patients with superficial bladder cancer also reported a decrease in tumor recurrence in patients given intravesical and percutaneous BCG compared with controls.[7] Two nonconsecutive 6-week treatment courses with BCG may be necessary to obtain optimal response.[8] Patients with a T1 tumor at the 3-month evaluation after a 6-week course of BCG and patients with Tis that persists after a second 6-week BCG course have a high likelihood of developing muscle-invasive disease and should be considered for cystectomy.[8,9,10]

    Another randomized study that compared intravesical and subcutaneous BCG with intravesical doxorubicin showed better response rates and freedom from recurrence with the BCG regimen for recurrent papillary tumors as well as for Tis.[11] A randomized trial from the Swedish-Norwegian Bladder Cancer Group compared 2 years of intravesical treatment with mitomycin C versus BCG. No difference was observed in tumor progression or overall survival (OS) between the two arms at 5 years.[12][Level of evidence: 1iiDii] Although BCG may not prolong OS for Tis disease, it appears to afford complete response rates of about 70%, thereby decreasing the need for salvage cystectomy.[13]

    Studies show that intravesical BCG delays tumor recurrence and tumor progression.[6,14] Preliminary results from a prospective randomized trial suggest that maintenance BCG, when given to patients who are disease-free after a 6-week induction course, improves survival.[15] One study that compared mitomycin with interferon-α-2b showed an improved outcome with mitomycin, even though interferon was better tolerated.[16]

    Standard treatment options:

    1. TUR with fulguration.[17]
    2. TUR with fulguration followed by intravesical BCG. BCG is the treatment of choice for Tis.[5,7,9,13,14]
    3. TUR with fulguration followed by intravesical chemotherapy.[2,11,17]
    4. Segmental cystectomy (rarely indicated).[17]
    5. Radical cystectomy in selected patients with extensive or refractory superficial tumor.[17,18]

    Treatment options under clinical evaluation:

    1. Photodynamic therapy after intravenous hematoporphyrin derivative appears capable of completely eradicating tumors in 50% of the treated patients who were in a small study with minimal follow-up.[19] Further evaluation of this technique is needed.
    2. Intravesical interferon-alpha-2a has shown activity against papillary tumors and Tis both as primary treatment and as secondary treatment after failure of other intravesical agents.[20]
    3. Use of chemoprevention agents after treatment to prevent recurrence.[21]
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