FIG. 30:  But suppose a physician decides to undertake radical treatment and immunotherapy.  As illustrated in this Figure, there is some equipoise. 

BCG offers lower morbidity potentially, but one must be careful in the disease staging.  I believe that an induction course of BCG represents a good first approach to treatment.  If the patient is given an induction course of (typically) 6 + 3 doses  and they do respond, then they have triaged to a tumor with a more favorable outcome compared with those who do not respond.  In other words, I think this can be used as a trial of therapy to understand the disease. 

I believe that physicians should be careful of using BCG in younger patients.  Most of the research shows that BCG failure progression rates are directly correlated with longevity of follow-up.  Therefore, while it is appealing to undertake a bladder-sparing approach in younger patients, especially as it will preserve sexual function, caution is necessary because these patients are at greatest risks of long-term progression. 

Conversely, radical cystectomy is appealing in that follow-up of these patients is much simpler.  It also probably has a higher cure rate. However, it has a much bigger impact on quality of life.

The balance between these two treatment approaches is currently very fine and there is no clear guidance as to which approach is the better option.  Personally I find myself in equipoise about the treatment choice for most patients in this scenario, and I would advocate clinicians to counsel their patients accordingly.