Non-muscle-invasive Bladder Cancer

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

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M. Babjuk (Chair), A. Böhle, M. Burger, E. Compérat, E. Kaasinen, J. Palou, M. Rouprêt, B.W.G. van Rhijn, S.F. Shariat, R. Sylvester, R. Zigeuner
Guidelines Associates: O. Capoun, D. Cohen, V. Hernández, V. Soukup

1.INTRODUCTION

1.1.Aim and scope

This overview represents the updated European Association of Urology (EAU) guidelines for Non-muscle-invasive Bladder Cancer (NMIBC) Ta, T1 and CIS. The information presented is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical guidance on the clinical management of NMIBC with a focus on clinical presentation and recommendations.

Separate EAU guidelines documents are available addressing upper tract urothelial carcinomas (UTUCs) [1], muscle-invasive and metastatic bladder cancer (MIBC) [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.

1.2.Panel composition

The EAU Guidelines Panel on NMIBC consists of an international multidisciplinary group of clinicians, including a pathologist and a statistician. Members of this panel have been selected based on their expertise and to represent the professionals treating patients suspected of harbouring bladder cancer.

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: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.

1.3.Available publications

A quick reference document (Pocket guidelines) is available, both in print and in a number of versions for mobile devices, presenting the main findings of the NMIBC Guidelines. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available, as are a number of translations of all versions of the EAU NMIBC Guidelines. All documents can be accessed on the EAU website.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU Guidelines on Bladder Cancer were first published in 2000. This 2016 NMIBC guidelines document presents a limited update of the 2015 full text document.

1.4.2.Summary of changes

Key changes in this 2016 print:

1.4.2.1.Changes in recommendation

  • In Section 5.16 – a recommendation has been added:

Recommendations for TURB and/or biopsies, tumour classification and pathology report

GR

In patients suspected of harbouring bladder cancer TURB followed by pathology investigation of the obtained specimen(s) is recommended as a diagnostic procedure and initial treatment step.

A

TURB=transurethral resection of the bladder.

Section 7.2.1.1 - A single, immediate, post-operative intravesical instillation of chemotherapy – has been expanded to include the findings of systematic review and individual patient data meta-analysis of randomized trials comparing a single immediate instillation of chemotherapy after transurethral resection with transurethral resection alone in patients with stage pTa-pT1 urothelial carcinoma of the bladder: Which patients benefit from the instillation? [4].

The recommendations as presented in Section 7.5 and Table 7.6 - Treatment recommendations in Ta, T1 tumours and CIS according to risk stratification - have been adapted. The recommendation grade did not change.

Section 7.5 Recommendations for adjuvant therapy in Ta, T1 tumours and for therapy of CIS

GR

In patients with tumours presumed to be at low risk and in those presumed to be at intermediate risk with previous low recurrence rate (less than or equal to one recurrence per year) and expected EORTC recurrence score < 5, one immediate chemotherapy instillation is recommended.

A

CIS=carcinoma in situ; EORTC=European Organization for Research and Treatment of Cancer.

Table 7.6 - Treatment recommendations in Ta, T1 tumours and CIS according to risk stratification

Risk category

Definition

Treatment recommendation

Intermediate-risk tumours

All cases between categories of low and high risk

In patients with previous low recurrence rate (less than or equal to one recurrence per year) and expected EORTC recurrence score < 5, one immediate instillation of intravesical chemotherapy after TURB.

In all patients either 1-year full-dose BCG treatment (induction plus 3-weekly instillations at 3,6 and 12 months), or instillations of chemotherapy (the optimal schedule is not known) for a maximum of 1 year.

BCG=Bacillus Calmette-Guérin; EORTC=European Organization for Research and Treatment of Cancer;

TURB=transurethral resection of the bladder.

1.4.2.2.Summary of evidence

  • Section 3.4 - A summary of evidence has been added to Chapter 3 – Epidemiology, aetiology and pathology.
  • Section 4.7 – A summary of evidence has been added to Chapter 4 – Staging and classification systems.
  • Section 5.15 - Summary of evidence has been added to Chapter 5 – Diagnosis.
  • Section 6.4 – A summary of evidence has been added to Chapter 6 – Predicting disease recurrence and progression.
  • Section 7.2.1.4 – A summary of evidence has been added to Section 7.2.1 Intravesical chemotherapy.
  • Section 7.2.2.7 – A summary of evidence has been added to Section 7.2.2 Intravesical bacillus Calmette Guérin immunotherapy.
  • Section 7.2.4.5 – A summary of evidence has been added to Section 7.2.4 Specific aspects of treatment of CIS.
  • Section 7.3.4 – A Summary of evidence has been added to Section 7.3 Treatment failure of intravesical therapy.
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