Newly released clinical practice guidelines for the diagnosis and management of non-muscle invasive bladder cancer (NMIBC) may enable clinicians to provide patients with more individualized treatment.
The guidelines, developed by the American Urological Association (AUA) and the Society for Urologic Oncology (SUO), make 38 recommendations regarding diagnosis, risk stratification, surgical intervention, and intravesical therapy.
“We’ve come a long way in understanding bladder cancer and how to treat and manage this disease and this guideline takes our knowledge one step further by refining our approach and allowing us to provide more individualized treatment to our patients,” said Sam S. Chang, MD, in an AUA press release. Dr Chang, of Vanderbilt University Medical Center in Nashville, TN, led the AUA/SUO panel that developed the guidelines.
With respect to diagnosis, the guidelines state that at the time of transurethral resection (TUR) of suspected bladder cancer, a clinician should perform a thorough cystoscopic examination of a patient’s entire urethra and bladder that evaluates and documents tumor size, location, configuration, number, and mucosal abnormalities. At initial diagnosis, when technically feasible, clinicians should perform complete visual resection of the tumor. As part of an initial evaluation of a bladder cancer patient, clinicians should perform upper urinary tract imaging.
“In a patient with a history of NMIBC with normal cystoscopy and positive cytology, a clinician should consider prostatic urethral biopsies and upper tract imaging, as well as enhanced cystoscopic techniques (blue light cystoscopy, when available), ureteroscopy, or random bladder biopsies,” the guidelines state.
At the time of each cancer occurrence or recurrence, clinicians should assign a clinical stage and classify a patient as low-, intermediate-, or high-risk.
The guidelines also address the use of urinary biomarkers following a diagnosis of bladder cancer. In surveillance of NMIBC, the guidelines strongly recommend that clinicians not use urinary biomarkers in place of cystoscopic evaluation. Clinicians should not routinely use a urinary biomarker or cytology during surveillance in a patient with a history of low-risk cancer and normal cystoscopic findings. In a patient with NMIBC, a clinician may use biomarkers to assess response to intravesical bacillus Calmette-Guérin (BCG) and adjudicate equivocal cytology.
For NMIBC patients who underwent an incomplete initial resection (not all visible tumor treated), clinician should perform repeat TUR or endoscopic treatment of all remaining tumor if technically feasible.
For patients with known or suspected low- or intermediate-risk tumors, clinicians should consider administering a single postoperative instillation of intravesical chemotherapy, such as mitomycin C or epirubicin, within 24 hours of TUR. Clinicians should not use postoperative chemotherapy for patients with a suspected perforation or extensive resection.
In addition, clinicians should not administer induction intravesical therapy in low-risk patients.
For intermediate-risk patients, clinicians should consider administration of a 6 week course of induction intravesical chemotherapy or immunotherapy.
The guidelines strongly recommend administration of a 6-week induction course of BCG to high-risk patients with newly diagnosed carcinoma in situ, high-grade T1, or high-risk Ta urothelial carcinoma.
Gary D. Steinberg, MD, Director of Urologic Oncology at the University of Chicago Medical Center, praised the new guidelines, saying they provide urologists with standardized algorithms that can enhance management of NMIBC.
“One of the major problems we have with the management of non-muscle-invasive bladder cancer in the United States is that it is all over the map,” Dr. Steinberg told Renal & Urology News.
Dr. Steinberg, who was not involved in the development of the new guidelines, commented that, too often, urologists do not get serious about bladder cancer until it is muscle invasive. Patients show red flags before the cancer advances to that point, he said, but if patients are not managed according to a standardized algorithm, “you never learn what these red flags are, or what they mean, or what the implications are.”
By the time tumors become muscle invasive, 50% of patients already have microscopic metastatic disease, he said.
“I think the guidelines just do a very nice job of creating algorithms that are easy to follow, easy to understand for all urologists.”
Urologists could do a better job diagnosing and staging of tumors, which is important for charting the management course, Dr. Steinberg said. Enhanced detection with cystoscopy, notably blue light cystoscopy—which is mentioned for the first time in the bladder cancer guidelines—is a key element in the patient workup, he said.
Blue light cystoscopy was FDA approved in 2010 in the United States, but has been adopted slowly. The technology involves the use of hexaminolevulinate HCL, an imaging agent that enhances visual contrast between benign and malignant cells compared with white light cystoscopy.
“Once you begin using it, to me, it’s like the difference between watching television in black and white versus watching in color and high-def,” Dr. Steinberg said.
An important aspect of blue light cystoscopy is its specificity for bladder cancer, which sets it apart from other cystoscopic technologies, such as narrowband imaging (NBI). NBI is specific for blood vessels and is used to detect hypervascularity, which is assumed to indicate bladder cancer. That is not necessarily the case, Dr. Steinberg said, especially in patients who have had prior cystoscopies and biopsies, inflammation, infection, and intravesical therapy.
Blue light cystoscopy enhances surgeons’ ability to do a better transurethral resection so that patients are diagnosed and staged more accurately. Improved resection, he said, can help in deciding on subsequent prophylactic measures, such as intravesical BCG.