Immediate cystectomy in T1 bladder cancer improves cancer-specific outcomes

Non-muscle invasive bladder cancer (BCa) (NMIBC) is commonly treated with bacillus Calmette-Guérin (BCG) therapy. However, the optimal timing of radical cystectomy for patients with stage T1 disease remains uncertain. This study aimed to evaluate the long-term cancer outcomes of patients who underwent immediate radical cystectomy compared to those who received delayed radical cystectomy after BCG induction. A retrospective cohort study was conducted utilizing the Surveillance, Epidemiology, and End Results-Medicare database, focusing on patients diagnosed with T1 NMIBC. The cohort consisted of 143 individuals who underwent immediate radical cystectomy and 325 individuals who underwent delayed radical cystectomy following BCG induction. The co-primary endpoints of this study was disease-specific survival and 5-year progression-free survival. Disease progression was defined as the occurrence of systemic chemotherapy, utilization of checkpoint inhibitors, development of metastasis, or death attributed to cancer. Patients who underwent immediate radical cystectomy had a shorter median time from BCa diagnosis to cystectomy (56.0 vs. 445.0 days, p<0.001). In terms of disease-specific survival, a higher percentage of patients in the immediate radical cystectomy group were alive at 5-year follow-up (65.7% vs. 58.5%, p=0.02). The 5-year progression-free survival rate was significantly better in immediate radical cystectomy compared to delayed radical cystectomy (40.6% vs. 64.0%, p<0.001). A multivariable analysis revealed immediate radical cystectomy remained significantly associated with a lower risk of 5-year disease progression (hazard ratio 0.52, 95% confidence Interval 0.34–0.78, p=0.002). A sensitivity analysis of all T1 patients, regardless of the amount of BCG received, confirmed the association between disease-specific survival and immediate radical cystectomy. This study suggests that patients with T1 NMIBC who undergo immediate radical cystectomy have improved long-term cancer outcomes compared to those who receive delayed radical cystectomy after BCG induction. These findings support the consideration of immediate radical cystectomy as a treatment strategy for T1 BCa.