Treating high-grade T1 bladder cancer in the elderly. Is intravesical instillation of BCG worth?

Background and aims. The mechanism of action of intravesical Bacille Calmette-Guerin (BCG) is supposed to be linked to the efficiency of the immune system. Since senesce could negatively affect the immune system efficiency, BCG efficacy in the elderly has been questioned. The present study aimed to determine whether elderly patients (≥ 70y) with high-grade T1 bladder cancer (BC) benefit from adjuvant intravesical instillation of BCG. Methods. Study population consisted of 183 patients (median age 79y); 65 received BCG, both induction and one-year maintenance, and 118 did not. Follow-up consisted of urine cytology and cystoscopy every 3 months for the first two years, every 6 months for the third year, and then yearly. Chest/abdomen computed tomography was performed every year to rule out upper tract or metastatic disease. Results. Mean follow-up was 45 months (range 1-177). Kaplan-Meier plots pointed out that treated patients had significantly better recurrent-free survival (RFS) and progression-free survival (PFS) than the untreated ones. The 40-month cancer-specific survival was 86.2% in treated and 79.7% in untreated patients, but such difference was not statistically significant. Multivariate Cox’s proportional hazard regression analysis pointed out that BCG treatment was the only significant independent predictor of RFS and PFS. There was no serious BCG-related adverse reaction; 2 (3.1%) patients suffered moderate flu-like or lower urinary tract symptoms that resolved with symptomatic treatment. Conclusions. Intravesical BCG proved to be safe and beneficial in elderly patients with high-grade T1 BC. Age per se should not be considered a contraindication to such treatment.