Muscle-invasive and Metastatic Bladder Cancer

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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J.A. Witjes (Chair), M. Bruins, E. Compérat, N.C. Cowan, G. Gakis, V. Hernández, T. Lebret, A. Lorch, M.J. Ribal (Vice-chair), A.G. van der Heijden, E. Veskimäe
Guidelines Associates: E. Linares Espinós, M. Rouanne, Y. Neuzillet

1.INTRODUCTION

1.1.Aims and scope

The European Association of Urology (EAU) Guidelines Panel for Muscle-invasive and Metastatic Bladder Cancer (MIBC) have prepared these guidelines to help urologists assess the evidence-based management of MIBC and to incorporate guideline recommendations into their clinical practice.

Separate EAU guidelines documents are available addressing upper urinary tract tumours [1], non-muscle-invasive bladder cancer (TaT1 and carcinoma in situ) (NMIBC) [2], and primary urethral carcinomas [3].

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account.

Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel Composition

The EAU Guidelines Panel consists of an international multidisciplinary group of clinicians, including urologists, a pathologist, a radiologist and an oncologist.

All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/bladdercancermuscle-invasive-and-metastatic/?type=panel.

1.3.Available publications

A quick reference document (Pocket Guidelines) is available, both in print and as an app for iOS and Android devices. These are abridged versions which may require consultation together with the full text version.

Several scientific publications are available (the most recent paper dating back to 2017 [4]), as are a number of translations of all versions of the EAU MIBC Guidelines. All documents are accessible through the EAU website: http://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU published its first guidelines on bladder cancer in 2000. This document covered both superficial (non-muscle-invasive) bladder cancer and MIBC. Since these conditions require different treatment strategies, it was decided to give each condition its own guidelines, resulting in the first publication of the MIBC Guidelines in 2004. This 2018 document presents a limited update of the 2017 version.

1.4.2.Summary of changes

New relevant references have been identified through a structured assessment of the literature and incorporated in the various chapters of the 2018 EAU MIBC Guidelines.

Key changes in the 2018 print are:


Section 5.2 – Imaging for staging of MIBC. This section has been aligned with the EAU Guidelines on Urothelial Carcinoma of the Upper Urinary Tract (UTUC) [1].

5.2.6 Summary of evidence and guidelines for staging in muscle-invasive bladder cancer

Summary of evidence

LE

The diagnosis of upper tract urothelial carcinoma depends on computed tomography urography and ureteroscopy.

2

Recommendations

Strength rating

Perform a computed tomography urography for upper tract evaluation and for staging.

Strong

For upper tract evaluation, use diagnostic ureteroscopy and biopsy only in cases where additional information will impact treatment decisions.

Strong


Section 7.4.3.1 – Pelvic organ preservation techniques in men. The systematic review (SR) this section is based on has been published [5].

Section 7.4.3.2 – Pelvic organ preservation techniques in women. The SR this section is based on has been published [6].

Section 7.6.4 – Multimodality bladder-preserving treatment. This section was revised, to include new data, however, the recommendations did not change.

Section 7.8.10 – Role of immunotherapy. Two additional subsections have been added and new recommendations have been included.

7.8.11 Summary of evidence and guidelines for metastatic disease

Summary of evidence

LE

PD-1 inhibitor pembrolizumab has been approved for patients that have progressed during, or after, previous platinum-based chemotherapy based on the results of a phase-III trial.

1b

PD-1 inhibitor nivolumab has been approved for patients that have progressed during or after previous platinum-based chemotherapy based on the results of a phase-II trial.

2a

PD-1 inhibitor pembrolizumab has been approved for patients with advanced or metastatic urothelial cancer ineligible for cisplatin-based first-line chemotherapy based on the results of a phase-II trial.

2a

PD-L1 inhibitor atezolizumab has been approved for patients with advanced or metastatic urothelial cancer ineligible for cisplatin-based first-line chemotherapy based on the results of a phase-II trial.

2a

Recommendations

Strength rating

First-line treatment in patients ineligible (unfit) for cisplatin:

Use checkpoint inhibitors pembrolizumab or atezolizumab.

Strong

Use carboplatin combination chemotherapy.

Weak

Second-line treatment

Offer checkpoint inhibitors pembrolizumab or atezolizumab to patients progressing during, or after, platinum-based combination chemotherapy for metastatic disease. Alternatively, offer treatment within a clinical trial setting.

Strong

Offer checkpoint inhibitor nivolumab to patients progressing during or after platinum-based combination chemotherapy for metastatic disease. Alternatively, offer treatment within a clinical trial setting.

Strong

Subsequent treatment

Only offer vinflunine to patients for metastatic disease as second-line treatment if immunotherapy or combination chemotherapy is not feasible. Alternatively, offer vinflunine as subsequent treatment line, or offer treatment within a clinical trial setting or best supportive care.

Weak


Figure 7.2 - Flow chart for the management of metastatic urothelial cancer, was completely revised.


Chapter 8 – Follow-up, has been completely revised.

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