Outcomes of BCG vs upfront radical cystectomy for high‐risk non‐muscle‐invasive bladder cancer

Objective To assess the oncological outcomes of patients with high‐risk (HR) and very high‐risk (VHR) non‐muscle‐invasive bladder cancer (NMIBC) treated with upfront radical cystectomy (RC) vs Bacillus Calmette–Guérin (BCG) instillations from a contemporary European multicentre cohort. Patients and Methods We conducted a retrospective analysis of 1491 patients diagnosed with HR‐ or VHR‐NMIBC from a European multicentre database between 2015 and 2024. Patients were included if they received either upfront RC or at least five doses of BCG. A 1:1 propensity score matching (PSM) according to clinically relevant variables was applied. Progression was defined as muscle‐invasive or metastatic disease. Cumulative incidence plots and multivariable competing risk regression models addressing cancer‐specific mortality (CSM) were fitted. Results Among the 1221 patients with HR‐ ( n = 1221 [90%]) or VHR‐NMIBC ( n = 121 [10%]), 87 (7.1%) underwent upfront RC. The median follow‐up was 2.6 years. After PSM (87 vs 87 patients), the 5‐year CSM rate was similar in patients treated with BCG (13%) vs their upfront RC counterparts (16%) (hazard ratio: 1.77, 95% confidence interval [CI] 0.66–4.73; P = 0.3). Of the 1134 patients who initially received BCG, 73 (6.6%) eventually required delayed RC, with 34 (47%) progressing to muscle‐invasive bladder cancer before delayed RC. The 3‐year CSM rate was comparable in upfront RC (13%) vs delayed RC (11%) among non‐progressing patients ( P = 0.3). However, patients who progressed before delayed RC had worse 3‐year CSM relative to those who did not (13% vs 31%, hazard ratio: 0.32, 95% CI 0.13–0.83; P = 0.018). Conclusion Within a European cohort of patients with HR‐ and VHR‐NMIBC, upfront RC was rarely performed. Patients treated with BCG did not exhibit a CSM disadvantage relative to their upfront RC counterparts. After matching, long‐term CSM was similar between BCG therapy and upfront RC. Delayed RC, led to worse outcomes if performed after progression, but matched upfront RC when performed before progression, underscoring importance of timely surgery.