management

Last reviewed 01/2018

The management of urothelial cancer is dependent on the site of the tumour:

• bladder
• upper urinary tract
• urethra

Non-muscle-invasive bladder cancer

• management usually depends upon the risk category - risk categories in non-muscle-invasive bladder cancer (1)

  LOW RISK

  Urothelial cancer with any of: solitary pTaG1 with a diameter of less than 3 cm solitary pTaG2 (low grade) with a diameter of less than 3 cm any papillary urothelial neoplasm of low malignant potential

  INTERMEDIATE RISK

  Urothelial cancer with any of: solitary pTaG1 with a diameter of more than 3 cm multifocal pTaG1 solitary pTaG2 (low grade) with a diameter of more than 3 cm multifocal pTaG2 (low grade) pTaG2 (high grade) any pTaG2 (grade not further specified) any low-risk non-muscle-invasive bladder cancer recurring within 12 months of last tumour occurrence

  HIGH RISK

  Urothelial cancer with any of: pTaG3 pT1G2 pT1G3 pTis (Cis) aggressive variants of urothelial carcinoma, for example micropapillary or nested variants

• low risk non-muscle-invasive bladder cancer
  • standard initial therapy for solitary Ta and T1 papillary bladder tumours
    • complete macroscopic transurethral resection (TUR) including a part of the underlying muscle
      • if there is a suspicion that the initial resection was incomplete then consider a second TUR
        • TUR alone as a therapeutic option
          • only possible if
            • tumour growth is limited to the superficial muscle layer and
            • re-staging biopsies are negative for residual tumour
        • people with suspected bladder cancer should be offered a single dose of intravesical mitomycin C given at the same time as the first TURBT
• Intermediate-risk non-muscle-invasive bladder cancer
  • people with newly diagnosed intermediate-risk non-muscle-invasive bladder cancer should be offered a course of at least 6 doses of intravesical mitomycin C
• if intermediate-risk non-muscle-invasive bladder cancer recurs after a course of intravesical mitomycin C, refer the person's care to a specialist urology multidisciplinary team
• high-risk non-muscle-invasive bladder cancer
  • if the first TURBT shows high-risk non-muscle-invasive bladder cancer, then another TURBT should be offered as soon as possible and no later than 6 weeks after the first resection
  • choice of intravesical BCG (Bacille Calmette-Guérin) or radical cystectomy should be offered to people with high-risk non-muscle-invasive bladder cancer, and base the choice on a full discussion with the person, the clinical nurse specialist and a urologist who performs both intravesical BCG and radical cystectomy

Invasive tumours:

Treating muscle-invasive bladder cancer

• neoadjuvant chemotherapy for newly diagnosed muscle-invasive urothelial bladder cancer
  • neoadjuvant chemotherapy using a cisplatin combination regimen should be offered before radical cystectomy or radical radiotherapy to people with newly diagnosed muscle-invasive urothelial bladder cancer for whom cisplatin-based chemotherapy is suitable
    • ensure that they have an opportunity to discuss the risks and benefits with an oncologist who treats bladder cancer
• radical therapy for muscle-invasive urothelial bladder cancer
  • a choice of radical cystectomy or radiotherapy with a radiosensitiser should be offered to people with muscle-invasive urothelial bladder cancer for whom radical therapy is suitable
    • ensure that the choice is based on a full discussion between the person and a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist

Managing locally advanced or metastatic muscle-invasive bladder cancer

• first line chemotherapy
  • cisplatin-based chemotherapy regimen (such as cisplatin in combination with gemcitabine, or accelerated [high-dose] methotrexate, vinblastine, doxorubicin and cisplatin [MVAC] in combination with granulocyte-colony stimulating factor [G-CSF]) should be offered to people with locally advanced or metastatic urothelial bladder cancer who are otherwise physically fit (have an Eastern Cooperative Oncology Group [ECOG] performance status of 0 or 1) and have adequate renal function (typically defined as a glomerular filtration rate [GFR] of 60 ml/min/1.73m2 or more)
  • carboplatin in combination with gemcitabine should be offered to people with locally advanced or metastatic urothelial bladder cancer with an ECOG performance status of 0-2 if a cisplatin-based chemotherapy regimen is unsuitable, for example, because of ECOG performance status, inadequate renal function (typically defined as a GFR of less than 60 ml/min/1.73m2) or comorbidies

Reference:

• 1) NICE (February 2015). Bladder cancer: diagnosis and management of bladder cancer