Non-muscle-invasive Bladder Cancer

10. PRAGMATIC DEINTENSIFICATION STRATEGY IN NMIBC

The challenges that face contemporary management of patients with NMIBC are a direct corollary to the global burden of an aging population and the rising cost of healthcare provision. It is therefore vital that healthcare systems and clinical processes are both effective and efficient, while being cognisant and respectful of impacts on patient QoL as well as family or other informal caregivers [476].

With improvements and the wider conscious efforts to improve the quality of NMIBC care, recurrence and progression rates have fallen in the recent past. However, as these improvements come with added complexity and cost to healthcare, clinicians must consider commensurate de-intensification of interventions along the pathway of selected patients. Utilisation of contemporary definitions of progression, for instance will also ensure interventions are targeted towards appropriate and pragmatic outcomes [415].

Approaches to healthcare, particularly in the elderly and frail, must be realistic. Scotland, for example, introduced a national “Realistic Medicine” programme with several pragmatic principles in this regard, creating an environment emphasising shared-decision making [477]. A multi-disciplinary oversight with expert clinician involvement is essential to making this work, and expected to facilitate effective diagnostic and therapeutic interventions, safeguarding patients from healthcare-related harm. Additionally, processes of audit-feedback and achieving benchmarks must be central to ensuring real-world translation of effective interventions.

The guidelines panel have therefore considered several of these aspects within some of the sections, where interventions could be de-intensified based on a shared-decision making process in fully informed and consenting patients:

1. Resection of Detrusor Muscle can be avoided in patients with low grade Ta NMIBC –
   Section 5.10
2. The single post-TURB chemotherapy instillation (SI-IVC) is very effective in reducing recurrence in patients with low grade Ta NMIBC. Cystoscopic prediction of this group of patients will allow for selective utilisation of SI-IVC – Section 7.4.2.1.
3. Selective re-TURB in high-risk NMIBC – Section 5.13
4. Active Surveillance in recurrent LGTa – Section 7.3 and/or Office fulguration for recurrent LGTa – Section 7.2 and/or Chemo-ablation in recurrence LGTa – Section 7.5
5. BCG instead of cystectomy as an option for very high-risk NMIBC – Section 7.6 and new evidence in favour of BCG in this group of patients [478].
6. Bladder preservation options for BCG un-responsive disease – Section 7.9.2.
7. Reduced frequency/intensity of surveillance (cystoscopy and CTU) in NMIBC or cystoscopy in case of haematuria only – Section 8.1.2
8. Consideration of “doing nothing” and taking a supportive approach in selected frail patients. Perhaps using PROMS/PREMS for monitoring remotely instead – Section 9.1.