European Urology

Gee JR, Jarrard DF, Bruskewitz RC, et al
BJU Int 2009;103:736–9
Expert's summary:
The authors reviewed a series of 154 patients who received intravesical bacillus Calmette-Guérin (BCG) at the University of Wisconsin from 1991 to 2003. Carcinoma in situ and/or high-grade papillary bladder cancer was present in 46 patients, and 43 of them had data available for review. Of those 43 patients, 20 were taking 81 mg or 325 mg of aspirin. Recurrence-free survival was significantly better in patients taking aspirin (p = 0.03). Multivariable analysis including smoking history and use of maintenance BCG confirmed the beneficial effect of aspirin on the risk of recurrence. The rates of progression were not significantly different between the patients who took aspirin and those who did not.
Expert's comments:
Intravesical BCG is the mainstay for treating high-risk non–muscle-invasive bladder cancer (NMIBC). I recommend using an intensive maintenance schedule [1] and lowering the dose when patients experience toxicity. With this strategy, most patients will be able to complete a 3-yr course of treatment.

This report suggests that adding aspirin to BCG may decrease the rate of bladder cancer recurrence. The authors hypothesize that nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin may have activity in bladder cancer prevention. Another recent retrospective analysis evaluated the use of aspirin, clopidrogel, and warfarin in patients receiving intravesical BCG [2]. In multivariable analysis, none of the drugs was associated with tumor recurrence, but warfarin was significantly associated with an increased risk of progression to open surgery, whereas aspirin was significantly associated with a decreased risk of progression to open surgery.

Fibronectin and fibrin clot appear to be important for BCG activity [3]. Earlier publications have not reached consensus about the effect of fibrin clot inhibitors on the efficacy of BCG, but these reports combined the use of a variety of fibrin clot inhibitors, including aspirin, into one group. Although interesting, the information is based on retrospective analyses of uncontrolled data. One only has to think back to the recent controversy regarding statin use and BCG efficacy to be reminded that this type of analysis should be viewed with skepticism [4].

At this point, the data are insufficient to recommend that patients receiving BCG should start aspirin or stop warfarin. Multiple variables, including dose, schedule, tumor sensitivity, and host response, can alter BCG response [5]. Although treatment with BCG is often empirical, it remains an effective intravesical therapy for NMIBC.

Conflicts of interest

The author has nothing to disclose.