Guideline for the Management of Nonmuscle Invasive Bladder Cancer (Stages Ta, T1, and Tis): 2007 Update

Abstract

You have accessJournal of UrologyAdult urology1 Dec 2007Guideline for the Management of Nonmuscle Invasive Bladder Cancer (Stages Ta, T1, and Tis): 2007 Update M. Craig Hall, Sam S. Chang, Guido Dalbagni, Raj Som Pruthi, John Derek Seigne, Eila Curlee Skinner, J. Stuart Wolf, and Paul F. Schellhammer M. Craig HallM. Craig Hall , Sam S. ChangSam S. Chang , Guido DalbagniGuido Dalbagni , Raj Som PruthiRaj Som Pruthi , John Derek SeigneJohn Derek Seigne , Eila Curlee SkinnerEila Curlee Skinner , J. Stuart WolfJ. Stuart Wolf , and Paul F. SchellhammerPaul F. Schellhammer View All Author Informationhttps://doi.org/10.1016/j.juro.2007.09.003AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction More than 60,000 new cases of bladder cancer are diagnosed each year in the US accounting for approximately 13,000 deaths annually.1 When initially diagnosed, most bladder cancers are nonmuscle invasive (also referred to as "superficial") – i.e., either noninvasive and confined to the mucosa or invading the lamina propria but not yet invading the detrusor muscle. In 1999, the AUA published a report on the Management of Non-Muscle-Invasive Bladder Cancer (Stages Ta, T1, and Tis) (AUA Guideline) produced by the AUA's Bladder Cancer Clinical Guideline Panel.2 The report provided an evidence-based guideline for the patient with nonmuscle invasive bladder cancer and included management standards, guidelines, and options based on the strength of evidence and expected amount of variation in patient preferences. Since 1999 the field of nonmuscle invasive bladder cancer has changed substantially with regard to the understanding of the molecular biology and clinical behavior of this heterogeneous disease. In addition, the growing body and quality of clinical research methodologies have improved during this period. The more recent publication of randomized controlled trials, the gold standard of treatment evaluation, has allowed the evaluation and comparison of various treatment modalities and has further verified the heterogeneous nature of this disease process. For these reasons, the AUA's PGC elected to update the initial report by appointing a panel to develop a new guideline for the management of nonmuscle invasive bladder cancer founded on evidence-based outcomes in the literature as well as expert opinion. Only topics with sufficient evidence on which to base conclusions have been addressed in this guideline. Index patients defined by the Panel will assist in determining appropriate therapy for different risk categories and are described later in this paper. The European Association of Urology also has supported recent efforts in the development of risk stratification schemes and has included them in Oosterlinck et al's Guidelines for TaT1 (Non-muscle Invasive) Bladder Cancer3 which are similar but not identical to the updated 2007 AUA Guideline. Whereas the complete AUA Guideline for the Management of Nonmuscle Invasive Bladder Cancer: (Stages Ta, T1, and Tis): 2007 Update which includes current information on epidemiology, risk stratification, tumor markers, modes of therapy, and bladder cancer characteristics is available online (http://www.auanet.org) and may answer many questions, this manuscript will focus on the actual treatment algorithm for the clinician and patient based on currently available modalities (table 1). Table 1. Current treatment alternatives Treatment Indication(s) TURBT • Any suspected urothelial carcinoma; can be sole treatment but only in nonmuscle invasive urothelial carcinoma4 Laser ablation therapy • Treatment of select lower- and upper-tract cancer5,6 • Treatment of low-grade papillary tumors • Not appropriate for new lesions prior to tumor staging/grading Conservative management (office fulguration or cystoscopic surveillance) • Low risk and recurrent nonmuscle invasive papillary bladder tumors • Well-documented history of low-grade Ta tumors7–9 Intravesical chemotherapy and immunotherapy (details provided below) • Perioperatively or postoperatively in an adjuvant fashion • To prevent recurrence following TURBT10–18 • Adjunctive therapy in Tis where diffuse tumor prevents complete resection19–22 Intravesical therapies Mechanism of action Immunomodulatory agents BCG • Inflammatory host response; release of cytokines • May be combined with interferons23–27 Interferons • Lymphocyte activation; cytokine release; phagocyte stimulation • Antiproliferative actions • Antiangiogenic19,23 Chemotherapeutic agents Thiotepa • Alkylating agent; cross-links nucleic acids28 Mitomycin C • Antibiotic; inhibits DNA synthesis10–12 Doxorubicin, epirubicin, valrubicin • Intercalating agents; inhibits DNA synthesis29–31 Gemcitabine • Deoxycytidine analog; inhibits DNA synthesis32–36 Methodology The methodology of this guideline update was similar to that used in the previous guideline. The intention was to determine the impact of the various av