Bladder Ca guide provides risk-stratified framework

San Diego-A recently released guideline on diagnosis and treatment of nonmuscle-invasive bladder cancer (NMIBC) from the AUA and the Society of Urologic Oncology provides practitioners with a risk-stratified clinical framework to aid treatment decisions and surveillance strategies, said Sam S. Chang, MD, MBA.

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Dr. ChangDr. Chang, chair of the NMIBC guideline panel, presented highlights during a plenary session at the AUA annual meeting in San Diego.  

“In an attempt to avoid a one-size-fits-all strategy, we wanted to take into account that the risk of recurrence and/or progression of NMIBC depends on several clinical and pathologic factors, and so we tried to personalize treatment choices and follow-up protocols,” said Dr. Chang, professor of urologic surgery and oncology, Vanderbilt University Medical Center, Nashville, TN.

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The guideline, which includes 38 statements, was developed based on a weighted review of data. It uses a risk stratification system that builds on schemes from the European Organization for Research and Treatment of Cancer and the Spanish Urological Club for Oncological Treatment by incorporating lymphovascular invasion, prostatic urethral involvement, variant histologies, and response to bacillus Calmette–Guérin (BCG). The risk-stratified treatment recommendations are summarized in an easy-to-follow flow chart.

Next: Evaluation and diagnosis

Evaluation and diagnosis

The guideline emphasizes the importance of documenting tumor size, configuration, location, number, and mucosal abnormalities at the time of transurethral resection of bladder tumor (TURBT). An initial upper tract evaluation is also recommended, as is utilization of an experienced genitourinary pathologist to interpret more difficult histologies.

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Use of blue light cystoscopy is recommended at the time of TURBT based on evidence that it increases detection rates and decreases recurrence rates.

The guideline states urinary biomarkers should not be used in place of cystoscopic evaluation or routinely performed when following patients with low-risk cancer and a normal cystoscopy, but may be used to evaluate response to intravesical chemotherapy and to help adjudicate equivocal cytology.

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Repeat TURBT within 6 weeks of the initial procedure should be considered in patients with high-risk, high-grade Ta tumors and is recommended with inclusion of muscularis propria in patients with T1 disease.

Next: Management

Management

A single postoperative course of intravesical chemotherapy should be considered for patients with low- or intermediate-risk NMIBC except if perforation is suspected or the resection was extensive. A single initial 6-week induction course of BCG is recommended for patients with high-risk cancer.

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“There is no evidence to support use of a single strain or strength of BCG or its use in combination therapy,” Dr. Chang said.

He observed that for BCG maintenance after complete response to the induction course, the guideline diverges from the SWOG protocol and recommends a 1-year course for intermediate-risk patients. Three years of maintenance is recommended for high-risk patients, assuming tolerability.

Prostatic urethral biopsy and an upper tract evaluation should be considered before continuing with intravesical therapy in intermediate- and high-risk patients with persistent disease, recurrent disease, or positive cytology following intravesical therapy.

A second course of BCG should be offered to intermediate- or high-risk patients with persistent or recurrent Ta or carcinoma in situ disease, whereas radical cystectomy should be offered after a single course of induction intravesical BCG to those with high-grade T1 disease.

“While we understood this second course is important, the panel also recommended against prescribing additional BCG to intolerant patients or those with documented recurrence of high-grade, nonmuscle-invasive disease and/or CIS within 6 months of two induction courses of BCG or induction BCG plus maintenance. And clinical trial enrollment is advocated for patients with persistent or recurrent intermediate- or high-risk disease unwilling or unfit for cystectomy after two courses of BCG,” Dr. Chang said.

The guideline advocates bladder conservation for patients with low- and intermediate-risk Ta NMIBC, but considering initial radical cystectomy for high-risk patients and those with variant histology as well as in high-risk patients with recurrent disease within 1 year of follow-up.

Recommendations for performing cystoscopy and upper tract imaging are also risk stratified.

The full guideline is accessible on the AUA website.

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