Harry W. Herr, MD

Patients with T1 bladder cancer on re-resection achieve the best possible survival benefit by IRC and thorough pelvic lymph node dissection.

Optimal therapy for locally advancedbladder cancer aimsto prevent local recurrence,reduce the probability of distant metastasis,and improve survival. Radicalcystectomy coupled with a pelviclymph node dissection is the mainstaytreatment of locally invasive bladdercancer, curing the majority ofpatients with organ-confined bladdertumors, about half with extravesicaldisease, and a significant minoritywith lymph node metastases. Althoughradical cystectomy providesgood local and regional control of invasivebladder cancer, the recurrencefreeand overall survival rates are stillonly 63%–72% and 59%–66%, respectively,among all patients. Themajor predictors for disease-specificsurvival of patients following radicalcystectomy for bladder cancer are thepathologic stage of the primary tumorand status of lymph nodes at time ofcystectomy. Freedom from recurrenceat 5 years after cystectomy is 63%–72% for patients with organ-confineddisease and only 25%-37% for non-organ-confined disease.

Lamm describes a success story in oncology that he helped create, namely, the favorable therapeutic effect of intravesical bacillus Calmette-Guérin (BCG) against carcinoma in situ (CIS) of the bladder. Virtually every study conducted over the past decade reports complete responses in 70% or more patients treated with BCG, which are often durable for years [1]. Such results have been documented empirically in prospective controlled trials without complete understanding of the mechanism of action of BCG or the optimal dose and treatment regimen. More importantly, not only may BCG eradicate CIS but also it may delay or prevent tumor progression and improve patient survival [2]. Conversely, patients failing to respond to an adequate trial of BCG therapy are at increased risk for disease progression and death from bladder cancer. We now realize that the natural history of CIS in the bladder has been significantly altered by intravesical BCG.