Issues in the detection and management of bladder cancer were discussed in the second-day plenary session of the 8th EAU Section of Urological Oncology (ESOU) Meeting (CEM) held today in London, the United Kingdom.Topics covered during the session included management strategies for metastatic disease, active surveillance for non-muscle invasive bladder cancer (NMIBC), haematuria and the EAU Guidelines on bladder cancer, amongst others.
John Kelly (London, UK) discussed microscopic haematuria, examining its incidence and role in detecting bladder cancer, bladder cancer screening, and the need for a biomarker directed cystoscopy. "At what point can we ignore haematuria?" asked Kelly. He said the answer remains elusive although there are indications that too many patients receive unnecessary investigations. He noted that there are no trials evaluating the effectiveness of investigations to determine the underlying cause of haematuria.
"There is a need to adopt meaningful investigations and establish an algorithm to be tested, altered and improved," added Kelly.
Meanwhile, discussing the efficiency of blue light cystoscopy and narrow band imaging (NBI), Theo De Reijke (Amsterdam, the Netherlands) spoke on the cost effectiveness of these devices and their efficiency in diagnosing bladder cancer. Regarding photo dynamic diagnosis (PDD) De Reijke said studies showed that PDD has better detection rates and less residual tumours, although specificity is low compared to cystoscopy. On NBI-TURB, these procedures led to a significant reduction in the number of residual tumours, but confirmation is needed in prospective randomised studies.
Jeremy Crew (Oxford, UK) lectured on active surveillance as an option for NMIBC, prefacing his talk by saying that there is little data on the subject, and underscoring the medical slogan of `do no harm.` He said the benefits of active surveillance is the absence of morbidity and surgery as against the disadvantage of progression risk and the patient`s psychological anxiety. He discussed several active surveillance trials which showed some data on disease progression and tumour growth rates.
"Low-risk NMICB can be safely managed by periods of active surveillance (AS), and patients can be counseled about it," said Crew, adding however that no high-level evidence exists for AS and that prospective randomised trials are still needed. He also mentioned increased use of office fulguration, the standard AS should be compared against with. In support of AS as an option, Crew noted that a re-design of urological services may be necessary.
George Thalmann (Berne, Switzerland) discussed G3pT1 disease or poorly differentiated (G3) cancers which are known to have a worse prognosis than other superficial bladder tumours. In his concluding remarks, Thalmann noted the following:
- Immediate cystectomy for all primary T1G3 bladder cancers may result in overtreatment;
- Even with an immediate radical cystectopmy for all patients with T1G3 bladder cancers, 5-year survival is only around 80%;
- Adjuvant BCG, if after second TUR, bladder (after 10-20 days, + mapping biopsies) is negative for invasive (T1) bladder cancer;
- Radical cystectomy, in cases with early (3-6 months) and/or multimodal T1G3 recurrences (+TiS).
In the debate on EAU Guidelines, Maurizio Brausi (Modena, Italy) and Marko Babjuk (Prague, Czech Republic) discussed early Re-TUR in NMIBC, with Brausi challenging the EAU guidelines against the pro arguments forwarded by Babjuk. Salient points in the debate were as follows:
- Guidelines recommendations should be focused and critically discussed;
- The idea of second TUR is coming from unsuccessful intial procedures;
- The quality of TUR (including re TUR) is essential for the fate of the patient; and
- Evaluate your initial TUR.
- More concentration in improving surgery (TUR) than collecting old data and re-doing TUR;
- TUR teaching programme as part of the standard urological training;
- Good cooperation with (dedicated) pathologists;
- New technology (bipolar electroscope) to reduce tissue charring and Exvix to improve the correct diagnosis and Cis;
- The initial TUR is extremely important for the final outcome of our patients.
By: Joel Vega