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Editorial Comment to Exploration of risk factors predicting outcomes for primary T1 high‐grade bladder cancer and validation of the Spanish Urological Club for Oncological Treatment scoring model: Long‐term follow‐up experience at a single institute

Bacillus Calmette–Guérin (BCG) has proven to decrease both progression and recurrence of intermediateand high-risk nonmuscle-invasive bladder cancer (NMIBC). However, 30–50% of patients treated with BCG fail to respond, and 15% of cases progress to muscle-invasive disease. Unfortunately, reliable markers to predict BCG response at early phases are still required, and therefore, the European Organization for Research and Treatment of Cancer and Spanish Urological Club for Oncological Treatment (CUETO) tables are the most suitable tools to predict the evolution. Thus, both models have been included in the European Association Guidelines for prognosis estimation of NMIBC. Recently, Xylinas et al. reported that overall these tables show a poor discrimination in NMIBC patients, and overestimate the risk of disease recurrence and progression in high-risk patients. Nevertheless, the same authors found that the discrimination of the CUETO model increased significantly in BCG-treated patients. In this way, the CUETO tables have been validated in several series of patients using BCG induction or maintenance regimes despite ethnic or geographic differences. In the present study, the CUETO tables have been validated again; now analyzing a local Japanese cohort of patients with high-grade NMIBC treated with BCG induction after transurethral resection and postoperative instillation of epirubicin or pirarubicin. Additionally, specimens obtained by transurethral resection were reassessed independently by two experienced uropathologists to determine the T category and tumor grade according to both the 2004 WHO and 1973 WHO classification, a limitation of the CUETO series, based exclusively on the 1973 WHO grade classification. A concern about the European Organization for Research and Treatment of Cancer and CUETO tables is their poor consistency to define the necessity of an early cystectomy. Both models are able to classify patients in their specific group of risk both for recurrence and progression (four groups for each parameter), and hence, to distinguish a very high-risk group. However, a reliable prediction of progression, and consequently, a proper indication of radical treatment instead of BCG instillations is not provided using these tables. Other prognosis factors, such as the tumor growth pattern, lymphovascular infiltration or even T1 substaging, might be considered to be associated with the CUETO tables. These factors could facilitate the decision of early cystectomy in patients included in the very high-risk group of progression according to the CUETO classification. Furthermore, additional variables related to BCG therapy, such as the duration of treatment, the number of doses or other factors, might influence the tumor evolution. In any case, this new validation study of the CUETO tables reinforces their role as a reliable predictive instrument for patients with a NMIBC treated with BCG, either just on its own or, in the future, almost certainly associated with complementary prognosis factors or biomarkers.