Drop the Juul, pick up the gem.

Top Line: There's any easy way to reduce recurrence after a transurethral resection of bladder tumor (TURBT) for low grade, non-muscle invasive bladder (NMIBC) cancer.
The Study: What’s cooler than Juuling? Pretty much anything, including intravesical gemcitabine for NMIBC. Patients with low grade Ta-T1 tumors represent a large proportion of all newly diagnosed bladder cancer. The current recommendation in this setting is either surveliiance or intravesical chemo, with mitomycin-C generally considered the “go-to." But this drug can be toxic, expensive, and few urologists actually use it. Enter SWOG S0337 that sought to determine if gemcitabine would be a better treatment than the real-world de facto treatment called observation. It randomized 406 patients with clinically suspected low-grade NMIBC upfront to a 60-minute intravesical infusion of gemcitabine versus saline. Note this was performed before any path report, immediately post-TURBT. After they did look at path, they discovered that just over 60% actually had low-grade NMIBC. Another 10% had no cancer while 25% had high-grade NMIBC. For the entire cohort, gemcitabine significantly reduced the rate of recurrence of any bladder cancer at four years (47→ 35%). For those who truly had a low-grade NMIBC, that improvement was even more dramatic (54→ 34%). Patients with high-grade tumors went on to further therapy, so there was no additional benefit in this subset. Importantly, the toxicity of gemcitabine was just about the same as saline (aka pee).
Bottom Line: For patients with a suspected low-grade NMIBC, intravesical gemcitabine has minimal toxicity and reduces the absolute recurrence rate by 10-20%. | Messing, JAMA 2018

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