Diane Z. Quale
A first-ever collaboration between the American Urological Association (AUA) and other prominent urological groups has created a multidisciplinary set of guidelines on treating patients with nonmetastatic muscle-invasive bladder cancer (MIBC).1
These new guidelines provide a riskstratified clinical framework so that urologists and oncologists treating patients with MIBC can better diagnose, treat, and manage the disease.
The guideline statements included input from the AUA, ASCO, the Society of Urologic Oncology, the American Society for Radiation Oncology, and the president of the Bladder Cancer Advocacy Network, Diane Z. Quale. This first-of-its-kind collaboration offers clinicians evidence-based A, B, and C recommendations; clinical principle statements that all clinicians or urologists generally agree upon; and expert opinions that express the unanimous conclusions of the panelists.
There is a clinical need for improved management of patients with MIBC, as 79,030 new cases of bladder cancer and 16,870 deaths from the disease are predicted for 2017 in the United States (Figure).2
“Approximately 25% of newly diagnosed patients have muscle-invasive disease, and that rate hasn’t changed over the past 25 years. In addition, the overall prognosis of patients with muscle-invasive disease has not changed in the last 30 years and is primarily based on stage,” said Jeffrey M. Holzbeierlein, MD, who served as a panelist for formation of the guidelines. He is director of urologic oncology at the University of Kansas Medical Center, in his presentation of the guidelines.
Figure. Estimated New Genitourinary Cancer Cases and Deaths in the United States, 20172
Initial Evaluation and Counseling
The first series of guidelines includes statements regarding the need for staging evaluation during physical examination of patients under anesthesia. “The panel felt that this was an important component of identifying patients [whose tumors] might be resectable, and, of course, you would do this if you suspect MIBC at the time of [transurethral resection of bladder tumor (TURBT)]. Also, since there are a lot of comorbidities, this is a critical component to assess patients to determine what they might be candidates for in terms of treatment,” Holzbeierlein said.
Although imaging and lab evaluation are critical components of staging patients with MIBC, the panel did not recommend any specific imaging modalities. The panel, however, did agree that cross-section imaging of the abdomen and pelvis should be done with intravenous contrast, as well as recognized that there are no data to support any single imaging modality over another. The guidelines do not recommend PET scans, as the panel felt there was insufficient evidence to support their superiority over CT scans. They did note that PET imaging should be reserved for patients with abnormal chest, abdominal, or pelvic images that require further evaluation or in cases where a lymph node biopsy is not feasible.
Although chest imaging is somewhat controversial, the new guidelines recommend a chest CT scan if the patient has a history of smoking. “We do recognize that we are seeing increased amounts of variant histology, and when that is suspected, we recommended a review by a dedicated GU pathologist, as the definitive histology can change treatment in up to one-third of patients,” Holzbeierlein commented.
The guidelines recommend that patients receive an explanation of all treatment options that are available, including surgery, chemotherapy, and radiotherapy. “We recognize that not all clinicians have the ability to provide 3 different disciplines, but certainly 1 clinician can provide an explanation of the multidisciplinary approaches to treatment options that are available,” he said.
The implications of various treatments on quality of life should also be discussed with the patient, and this is expressed as a clinical principle in the guidelines.1