The impact of age in patients with non-muscle-invasive bladder cancer treated with Bacillus Calmette-Guérin.
Academic Article
Overview
abstract
INTRODUCTION: Age >70 years is considered an adverse prognostic factor in the current EAU NMIBC risk stratification. Whether poorer outcomes in older adults reflect differences in tumor biology or reduced access to guideline-concordant Bacillus Calmette-Guérin (BCG) therapy remains unclear. We evaluated the relationship between age, BCG adherence, and oncological outcomes in a contemporary multicenter cohort. METHODS: We retrospectively analyzed 1,741 patients with intermediate-, high-, or very high-risk non-muscle-invasive bladder cancer (NMIBC) treated with Bacillus Calmette-Guérin (BCG) at European tertiary referral centers between 2005 and 2024. Adequate BCG was defined according to International Bladder Cancer Group (IBCG) criteria. Multivariable linear, logistic, Cox, and Fine-Gray competing-risk regression models assessed the association between age and (1) BCG delivery and (2) recurrence, high-grade recurrence, progression, and cancer-specific mortality (CSM) among adequately treated patients, adjusting for standard clinicopathologic variables. RESULTS: Among 1,317 (77%) patients with ≥1 year of follow-up and no early high-grade recurrence, increasing age was associated with lower BCG delivery (per 10 years: β -0.83 for number of instillations; OR 0.76 for adequate treatment; OR 0.87 for 1-year completion; all P < 0.05). Findings were similar when dichotomizing age at 70 years. No significant interaction was observed between age and BCG adequacy for oncological endpoints. Median follow-up was 40 months (IQR: 21-70). Among adequately treated patients (n = 1,296, 74%), 5-year risks for ≤70 vs. >70 years were comparable for any recurrence (28% vs. 30%; aHR: 1.12, 95% CI: 0.91-1.37), high-grade recurrence (22% vs. 25%; aHR: 1.27, 95% CI: 0.93-1.52), progression (11% vs. 13%; aHR: 1.04, 95% CI: 0.67-1.63), and CSM (5% vs. 8%; aHR: 1.90, 95% CI: 0.95-3.79). CONCLUSIONS: Older age was associated with reduced adherence to BCG schedules, but not with worse oncological outcomes when adequate BCG was delivered. These findings indicate that age itself does not appear to diminish BCG effectiveness. Efforts to optimize treatment adherence, rather than age-based de-escalation, should be prioritized in the management of older NMIBC patients.
