A Review of Current Guidelines and Best Practice Recommendations for the Management of Nonmuscle Invasive Bladder Cancer by the International Bladder Cancer Group
Abstract
Purpose:
Although the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines all provide an excellent evidence-based framework for the management of nonmuscle invasive bladder cancer, these guidelines vary with respect to important issues such as risk level definitions and management strategies for these risk categories. Therefore, we built on the existing framework provided by current guidelines, and provide consensus on the definitions of low, intermediate and high risk nonmuscle invasive bladder cancer, as well as practical recommendations for the treatment of patients in each of these risk categories.
Materials and Methods:
An international committee of experts on bladder cancer management identified and analyzed the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines as well as the published English language literature related to the treatment and management of nonmuscle invasive bladder cancer available as of April 2010.
Results:
Based on review of the current guidelines and literature, the International Bladder Cancer Group developed practical recommendations for the management of nonmuscle invasive bladder cancer.
Conclusions:
Complete transurethral bladder tumor resection is recommended for all patients with nonmuscle invasive bladder cancer. For low risk disease a single, immediate chemotherapeutic instillation after transurethral bladder tumor resection is recommended. For intermediate or high risk disease there is no significant benefit from an immediate, postoperative chemotherapeutic instillation. For intermediate risk disease intravesical bacillus Calmette-Guérin with maintenance or intravesical chemotherapy is recommended. For high risk disease bacillus Calmette-Guérin induction plus maintenance is recommended. The appropriate management of recurrence depends on the patient level of risk as well as previous treatment, while the management of treatment failure depends on the type of failure as well as the level of risk for recurrence and disease progression.
References
- 1 : European Association of Urology guidelines on TaT1 (non-muscle invasive) bladder cancer: Update March 2009. Arnhem, the Netherlands: European Association of Urology2009. http://www.uroweb.org/professional-resources/guidelines/online. Accessed January 9, 2010. Google Scholar
- 2 : International consultation on bladder tumours. Urology2005; 66: 1. Google Scholar
- 3 : Clinical practice guidelines in oncology: bladder cancer including upper tract tumors and urothelial carcinoma of the prostate: Version 2. Jenkintown, Pennsylvania: NCCN2010. www.nccn.org. Accessed March 27, 2010. Google Scholar
- 4 : Guideline for the management of nonmuscle invasive bladder cancer (stages Ta,T1, and Tis): 2007 update. Linthicum, Maryland: American Urological Association2007. www.auanet.org. Accessed February 18, 2010. Google Scholar
- 5 : Guidelines for the management of nonmuscle invasive bladder cancer (stages Ta, T1, and Tis): 2007 update. J Urol2007; 178: 2314. Link, Google Scholar
- 6 : Clinical practice recommendations for the management of non-muscle invasive bladder cancer. Eur Urol2008; 7: 651. Google Scholar
- 7 : Low-grade Ta (noninvasive) urothelial carcinoma of the bladder. Urology2005; 66: 75. Google Scholar
- 8 : Management of stage T1 tumors of the bladder: International Consensus Panel. Urology2005; 66: 108. Google Scholar
- 9 : High-grade Ta urothelial carcinoma and carcinoma in situ of the bladder. Urology2005; 66: 90. Google Scholar
- 10 : Current approaches to the management of non-muscle invasive bladder cancer: comparison of current guidelines and recommendations. Eur Urol2008; 7: 637. Google Scholar
- 11 : High-risk superficial bladder cancer: transurethral resection alone in selected patients with T1 tumor. Semin Urol Oncol1997; 15: 142. Google Scholar
- 12 : Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur Urol2002; 41: 523. Google Scholar
- 13 : “Complete transurethral resection of bladder tumor”: are the guidelines being followed?. Urology2010; 75: 365. Google Scholar
- 14 : The role of pathology review of transurethral bladder tumor resection specimens in the modern era. J Urol2010; 183: 921. Link, Google Scholar
- 15 : A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomized clinical trials. J Urol2004; 171: 2186. Link, Google Scholar
- 16 : Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma. Eur Urol2002; 42: 167. Google Scholar
- 17 : Intravesical adjuvant chemotherapy for superficial transitional cell bladder carcinoma: results of 2 European Organization for Research and Treatment of Cancer randomized trials with mitomycin C and doxorubicin comparing early versus delayed instillations and short-term versus long-term treatment. J Urol1995; 153: 934. Link, Google Scholar
- 18 : Results of a randomized, double blind prospective study of intravesical chemoprophylaxis with 2 drugs: adriamycin and mitomycin; and 2 ways of initiating the instillations: early and late: Effect on recurrence and progression. Arch Esp Urol1992; 45: 1001. Google Scholar
- 19 : One immediate postoperative instillation of chemotherapy in low risk Ta, T1 bladder cancer patients: Is it always safe?. Eur Urol2004; 46: 336. Google Scholar
- 20 : Challenging the EAU guidelines on non-muscle-invasive bladder cancer (NMIBC): single immediate instillation of chemotherapy after transurethral resection of NMIBC and chemotherapy versus bacillus Calmette-Guérin in treatment of intermediate-risk tumours. Eur Urol2010; 9: 406. Google Scholar
- 21 : Should all patients with non-muscle-invasive bladder cancer receive early intravesical chemotherapy after transurethral resection?: The results of a prospective randomised multicentre study. Eur Urol2009; 55: 773. Google Scholar
- 22 : Single postoperative instillation of gemcitabine in patients with non-muscle-invasive transitional cell carcinoma of the bladder: a randomised, double-blind, placebo-controlled phase III multicentre study. Eur Urol2009; 56: 495. Google Scholar
- 23 : Should all patients receive single chemotherapeutic agent instillation after bladder tumour resection?. BJU Int2009; 104: 170. Google Scholar
- 24 : Comparison of three schedules of intravesical epirubicin in patients with non-muscle-invasive bladder cancer. Eur Urol2008; 53: 984. Google Scholar
- 25 : A single instillation of epirubicin after transurethral resection of bladder tumors prevents only small recurrences. J Urol2008; 179: 101. Link, Google Scholar
- 26 : Can early single dose instillation of epirubicin improve bacillus Calmette-Guerin efficacy in patients with nonmuscle invasive high risk bladder cancer?: Results from a prospective, randomized, double-blind controlled study. J Urol2008; 180: 110. Link, Google Scholar
- 27 : Effectiveness of a single immediate mitomycin C instillation in patients with low risk superficial bladder cancer: short and long-term followup. J Urol1999; 161: 1120. Link, Google Scholar
- 28 : Influence of thiotepa and doxorubicin instillation at time of transurethral surgical treatment of bladder cancer on tumor recurrence: a prospective, randomized, double-blind, controlled trial. J Urol1983; 129: 505. Link, Google Scholar
- 29 : Correlation of cystoscopy with histology of recurrent papillary tumors of the bladder. J Urol2002; 168: 978. Link, Google Scholar
- 30 : A plea for cold biopsy, fulguration and immediate bladder instillation with Epirubicin in small superficial bladder tumors: Data from the EORTC GU Group Study 30863. Eur Urol1993; 23: 457. Google Scholar
- 31 : A combined analysis of European Organization for Research and Treatment of Cancer, and Medical Research Council randomized clinical trials for the prophylactic treatment of stage TaT1 bladder cancer: European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group and the Medical Research Council Working Party on Superficial Bladder Cancer. J Urol1996; 156: 1934. Link, Google Scholar
- 32 : Apparent failure of current intravesical chemotherapy prophylaxis to influence the long-term course of superficial transitional cell carcinoma of the bladder. J Urol1995; 153: 1444. Link, Google Scholar
- 33 : The schedule and duration of intravesical chemotherapy in patients with non-muscle-invasive bladder cancer: a systematic review of the published results of randomized clinical trials. Eur Urol2008; 53: 709. Google Scholar
- 34 : Long-term efficacy results of EORTC genito-urinary group randomized phase 3 study 30911 comparing intravesical instillations of epirubicin, bacillus Calmette-Guérin, and bacillus Calmette-Guérin plus isoniazid in patients with intermediate- and high-risk stage Ta T1 urothelial carcinoma of the bladder. Eur Urol2010; 57: 766. Google Scholar
- 35 : An individual patient data meta-analysis of the long-term outcome of randomised studies comparing intravesical mitomycin C versus bacillus Calmette-Guérin for non-muscle-invasive bladder cancer. Eur Urol2009; 56: 247. Google Scholar
- 36 : EAU guidelines on the diagnosis and treatment of urothelial carcinoma in situ. Eur Urol2005; 48: 363. Google Scholar
- 37 : Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. J Urol2002; 168: 1964. Link, Google Scholar
- 38 : Intravesical bacille Calmette-Guérin versus mitomycin C in superficial bladder cancer: formal meta-analysis of comparative studies on tumor progression. Urology2004; 63: 682. Google Scholar
- 39 : Intravesical bacillus Calmette-Guerin versus mitomycin C for superficial bladder cancer: a formal meta-analysis of comparative studies on recurrence and toxicity. J Urol2003; 169: 90. Link, Google Scholar
- 40 : T1G3 bladder tumours: the case for radical cystectomy. Eur Urol2004; 45: 406. Google Scholar
- 41 : Management of clinical T1 bladder transitional cell carcinoma by radical cystectomy. Urol Oncol2004; 22: 290. Google Scholar
- 42 : Intracavitary Bacillus Calmette-Guerin in the treatment of superficial bladder tumors. J Urol1976; 116: 180. Abstract, Google Scholar
- 43 : Maintenance bacillus Calmette-Guerin immunotherapy for recurrent TA, T1 and carcinoma in situ transitional cell carcinoma of the bladder: a randomized Southwest Oncology Group Study. J Urol2000; 163: 1124. Link, Google Scholar
- 44 : Defining bacillus Calmette-Guerin refractory superficial bladder tumors. J Urol2003; 169: 1706. Link, Google Scholar
- 45 : Does early cystectomy improve the survival of patients with high risk superficial bladder tumors?. J Urol2001; 166: 1296. Link, Google Scholar
