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Guidelines for the Management of Non-muscle-invasive Bladder Cancer
BAUS/BUG for intermediate- and high-risk cases
10
and the EAU for all there is any difference in outcome between intravesical chemotherapy
cases with no muscle in the specimen.
9
The EAU and BAUS/BUG and BCG in this group.
guidelines go further, recommending reTUR for all high-grade tumours
to reduce the chance of understaging. Surveillance Cystoscopies
The EAU guidelines give the most detailed follow-up regimen. For low-risk
Intermediate-risk Group tumours they recommend a cystoscopy at three months, at nine months
The AUA put multifocal and/or large-volume low-grade Ta or and then annually for five years if all results are negative. For high-risk
recurrent low-grade Ta tumours into the intermediate-risk group (T1 is
high-risk) and recommend intravesical BCG or mitomycin C with the
The bladder cancer guidelines of
goal of preventing or delaying recurrence. Maintenance BCG or
mitomycin C are suggested as ‘options’.
8
The EAU place multifocal
the AUA, EAU and BAUS/BUG have
G1T1, G2Ta and single G2T1 tumours into this category.
many similarities, but more research
They recommend treatment after TUR with either intravesical
chemotherapy or BCG, but state that the optimal frequency and
is needed in order to define the
duration of treatment are unknown, suggesting at least six to 12
optimal treatment strategies for
months of intravesical chemotherapy or at least one year of
maintenance intravesical BCG.
9
The BAUS/BUG guidelines place large,
intermediate-risk tumours.
multiple or frequently recurring G1/2Ta and small solitary G2T1
tumours they recommend cystoscopies every three months
for a period of two years, then every four months for one year,
The guidelines also vary in their
biannually for two years and, eventually, annually. They also recommend
a yearly intravenous urogram (IVU). For intermediate-risk cancers they
objectives, with the AUA aiming to
recommend a scheme somewhere between the two.
9
The other two sets
reduce recurrence, whereas the EAU of guidelines recommend regular cystoscopic follow-up,
8,10
with the
and BAUS/BUG aim to reduce
BAUS/BUG agreeing with the EAU guidelines for low-risk tumours.
10
recurrence and progression. Conclusions
Guidelines are a useful tool and aid clinical management by providing a
summary of current best evidence-based practice. They should be used
bladder cancers in this group. They recommend intravesical in conjunction with the multidisciplinary team meeting and should not
chemotherapy as the treatment.
10
replace it. It is important they are updated regularly. The bladder cancer
guidelines of the AUA, EAU and BAUS/BUG have many similarities
Agreement is needed when defining this risk group and more research (see Figure 1), but more research is needed in order to define
is required in order to build on the existing evidence base. This will the optimal treatment strategies for intermediate-risk tumours and the
help define the optimal maintenance regimes and determine whether optimal maintenance regimes for intravesical chemotherapy and BCG. ■
1. Kirkali Z, Chan T, Manoharan M, et al., Bladder Cancer: Association Education and Research, Inc. Presentation at the recurrence in high-risk superficial bladder cancer: a meta-
Epidemiology, staging, grading and diagnosis, Urology, 2005; AUA annual meeting, 2007. analysis of randomised trials, BJU Int, 2004;93:485–90.
66(Suppl. 6A):4–34. 9. Oosterlinck W, van der Meijden A, Sylvester R, et al., Guidelines 15. Rischmann P, Improving compliance of BCG Immunotherapy:
2. Sylvester RJ, van der Meijden AP, Oosterlinck W, et al., on TaT1 (non-muscle-invasive) bladder cancer, European Practical approaches to managing side effects, Eur Urol Suppl,
Predicting recurrence and progression in individual patients Association of Urology Guidelines, 2006. 2006;5:660–62.
with stage TaT1 bladder cancer using EORTC risk tables: a 10. British Association of Urological Surgeons (BAUS) Section of 16. Martinez-Pineiro JA, Flores N, Isorna S, et al., Long-term follow-
combined analysis of 2,596 patients from seven EORTC trials, Oncology and British Uro–ocncology Group (BUG), MDT (Multi- up of a randomised prospective trial comparing a standard
Eur Urol, 2006;49:466–77. Disciplinary Team) guidance for managing bladder cancer, 81mg dose of intravesical bacille Calmette-Guérin with a
3. Palou J, Patient risk profiles: Prognostic factors of recurrence http://www.bauslibrary.co.uk/PDFS/BSONC/MDT%20 reduced dose of 27mg in superficial bladder cancer, BJU Int,
and progression, Eur Urol Suppl, 2006;5:648–53. guidance%20for%20bladder%20cancer.pdf, 2007. 2002; 89: 671–80.
4. Botteman MF, Pashos CL, Redaelli A, et al., The health 11. Hinotsu S, Akaza H, Ohashi Y, Kotake T, Intravesical 17. Martinez-Pineiro JA, Martinez-Pineiro L, Solsona E, et al., Has a
economics of bladder cancer: a comprehensive review of the chemotherapy for maximum prophylaxis of new early-phase threefold decreased dose of bacillus Calmette-Guérin the same
published literature, Pharmacoeconomics, 2003;21:1315–30. superficial bladder carcinoma treated by transurethral resection: efficacy against recurrences and progression of T1G3 and Tis
5. Sylvester R, Oosterlinck W, van der Meijden A, A single post- a combined analysis of trials by the Japanese Urological Cancer bladder tumours than the standard dose?, Results of a
operative instillation of chemotherapy decreases the risk of Research Group using smoothed hazard function, Cancer, 1999; prospective randomised trial, J Urol, 2005;174:1242–7.
recurrence in patients with stage TaT1 bladder cancer: a meta- 86:1818–26. 18. Lamm DL, Blumenstein BA, Crissman JD, et al., Maintenance
analysis of published results of randomised clinical trials, J Urol, 12. Friedrich MG, Pichlmeier U, Schwaibold H, et al., Long-term bacillus Calmette-Guérin immunotherapy for recurrent Ta, T1
2004;171:2186–90. intravesical adjuvant chemotherapy further reduces recurrence and carcinoma in situ transitional cell carcinoma of the bladder:
6. Bohle A, Jocham D, Bock PR, Intravesical bacillus Calmette- rate compared with short-term intravesical chemotherapy and a randomised Southwest Oncology Group Study, J Urol, 2000;
Guérin versus mitomycin C for superficial bladder cancer: a short-term therapy with bacillus Calmette-Guérin (BCG) in 163:1124–9.
formal meta-analysis of comparative studies on recurrence and patients with non-muscle-invasive bladder carcinoma, Eur Urol, 19. Sivalingam S, Probert JL, Schwaibold H, The role of repeat
toxicity, J Urol, 2003;169:90–95. 2007;52(4):1123–9. transurethral resection in the management of high-risk
7. Sylvester RJ, van der Meijden APM, Lamm DL, Intravesical 13. Pawinski A, Sylvester R, Kurth KH, et al., A combined analysis superficial transitional cell bladder cancer, BJU Int, 2005;96:
bacillus Calmette-Guérin reduces the risk of progression in of European Organisation for Research and Treatment of 759–62.
patients with superficial bladder cancer: a combined analysis of Cancer and Medical Research Council randomised clinical trials 20. Herr HW, Donat SM, A re-staging transurethral resection
the published results of randomised clinical trials, J Urol, 2002; for the prophylactic treatment of stage TaT1 bladder cancer, predicts early progression of superficial bladder cancer, BJU Int,
168:1964–70. J Urol, 1996;156:1934–41. 2006;97:1194–8.
8. Chang SS, et al., AUA Bladder Cancer Guidelines Update Panel, 14. Shelley MD, Wilt TJ, Court J, et al., Intravesical bacillus
Bladder Cancer Guidelines Update. American Urological Calmette-Guérin is superior to mitomycin C in reducing tumour
EUROPEAN GENITO-URINARY DISEASE 2007 27
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