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Guidelines for the Management of Non-muscle-invasive Bladder Cancer
a report by
Benjamin E Ayres
and Rajendra A Persad
1. Urology Registrar (ST3), South Thames Region; 2. Consultant Urologist, Head Cancer Clinician,
United Bristol Hospitals NHS Trust and Bristol Urological Institute
Non-muscle-invasive bladder cancer, stages Ta, T1 and carcinoma in Clinicians also need to be aware that these guidelines are readily available
situ (CIS), accounts for about 70% of all bladder cancers.
They are a to the public on the Internet. The guidelines are not all the same, despite
heterogeneous group of tumours with high rates of recurrence but many similarities, and may confuse patients and challenge clinicians to
varying rates of progression to muscle invasion and a variable assess the evidence in order to decide what course to follow. Before
prognosis. For single small, low-grade tumours not invading the lamina discussing the similarities and differences between the guidelines, we will
propria (G1pTa), the European Organisation for Research and summarise the evidence base behind them.
Treatment of Cancer (EORTC) risk tables
give a probability of
Level I evidence in the form of meta-analyses has shown the beneficial
Many studies have reported that
effect of a single instillation of intravesical chemotherapy (mitomycin
recurrence rates, particularly at
C, epirubicin and doxorubicin) within 24 hours of transurethral
resection (TUR) of bladder tumours. A meta-analysis of seven
three months after treatment,
randomised trials involving a total of 1,476 patients reported a 39%
are influenced by tumour size,
reduction in the risk of recurrence.
They found that 8.5 patients
needed to be treated to prevent one recurrence. Mitomycin C,
multiplicity and previous recurrence.
epirubicin and doxorubicin were all shown to be beneficial. The panel
responsible for the AUA guidelines reviewed 178 articles published
progression of 0.8% at five years. In contrast, for a single small, between 1998 and 2007 and, based on meta-analyses of these
high-grade tumour invading the lamina propria (G3pT1), the five-year studies, found that a single post-operative dose of intravesical
progression rate is 17%, resulting in a much poorer prognosis. Many chemotherapy reduced the risk of tumour recurrence by 17%.
studies have reported that recurrence rates are influenced by tumour there was no superior chemotherapy agent with respect to efficacy.
size, multiplicity and previous recurrence.
Due to these high Data from five randomised trials show that this reduction in recurrence
recurrence rates and the possibility of progression, patients require lasts for about 500 days, and less in multiple tumours.
long-term surveillance with cystoscopies, resulting in bladder
cancer being the most expensive cancer in the US based on cost Maintenance chemotherapy is recommended for intermediate-risk non-
muscle-invasive bladder cancers, but the frequency and duration of
treatment remains unclear. A recent study reported a significantly
Over the last decade many studies have been published reporting better recurrence-free rate of 86.1% if maintenance mitomycin C was
reductions in recurrence rates with intravesical chemotherapy
and given once monthly for three years following a six-week induction
with some also reporting a reduction in progression
with the latter.
Recently, updated guidelines have been presented
Benjamin E Ayres is a Urology Registrar (ST3) in the South
separately by the American Urological Association (AUA),
Thames region. His research projects include investigating the
European Association of Urology (EAU)
and the British Association of
expression of cytochrome P450 isoenzymes in patients with
Urological Surgeons (BAUS)/British Uro-oncology Group (BUG)
bladder cancer at both the Bristol Royal Infirmary and
Pittsburgh University, and working with the British
treatment of non-muscle-invasive bladder cancer dependent on Association of Urological Surgeons’ (BAUS) Section of
tumour stage, grade, size, multiplicity and previous recurrence.
Oncology and South West Public Health Observatory
(SWPHO) on a new urological cancer database.
Rajendra A Persad is a Consultant Urologist and Lead
These guidelines are useful for several reasons. They summarise the
Cancer Clinician at the United Bristol Hospitals Healthcare
evidence behind the treatments, often based on meta-analyses Trust and Consultant Senior Lecturer at the Bristol Urological
(level I evidence), and therefore not only promote evidence-
Institute. His interests include urological oncology,
reconstructive surgery and prosthetic surgery for erectile
based medical practice but also enable education and continuing
dysfunction. He has a number of research interests, including
professional development. They should also enhance standards
the molecular epidemiology and genetics of prostate cancer,
early detection of prostate cancer and minimally invasive
of care and inform patient choice. They are guidelines, though, and
approaches to treatment of prostate disease.
do not replace the need for multidisciplinary team meetings
and individual case discussions. However, they can complement
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