Contemporary Treatment Guidelines on Bladder Cancer Tony Wu. Division of Urology Kaohsiung Veterans General Hospital

AUA 2007 guidelines EAU 2008 guidelines NCCN guidelines v.2.2008

Index Patient #1 Patient presents with an abnormal growth on the urothelium Standard: biopsy should be obtained Standard:complete eradication of all visible tumors Standard: periodic surveillance cystoscopy Option: immediate single dose intravesical chemotherapy AUA

Index Patient #2 Small volume, low-grade Ta bladder cancer Recommendation: Single dose intravesical chemotherapy immediately postoperatively Single dose MMC: 17% fewer recurrences Multiple doses:no additional benefit AUA

Index Patient #3 Multifocal / large volume, low-grade Ta or Recurrent low-grade Ta bladder cancer Recommendation: An induction course of intravesical BCG or MMC BCG:24%, MMC:3% fewer recurrences Option: Maintenance BCG or MMC BCG:31%, MMC:18% fewer recurrences Affect progression ??? AUA

BCG Maintenance Therapy SWOG regimens 6-wk induction course of BCG 3-wk maintenance courses at 3, 6, 12, 18, 24, 30, 36 months

Index Patient #4 High-grade Ta, T1, and/or CIS Standard: For T1 patients repeat resection should be performed prior to additional intravesical therapy In the absence of muscularis propria in specimen, 20% to 40% of patients will have either residual tumor and/or unrecognized muscle invasive disease Recommendation: BCG induction + maintenance AUA

Index Patient #4 Option: Cystectomy should be considered for initial therapy in select patients It is not certain whether intravesical therapy alters risk of progression high cure rate associated with cystectomy large tumor size, high-grade, tumor location in a site poorly accessible to complete resection, diffuse disease, the presence of carcinoma in situ, infiltration of lymphatic or vascular spaces, and prostatic urethral involvement AUA

Second TUR Indicated when multiple and/or large tumors are present, or when specimen contained no muscle tissue. When high-grade, T1 tumor has been detected at the initial TUR. Second TUR can increase recurrence-free and progression-free survival (level of evidence: 2a). Most authors recommend resection at 2-6 weeks after the initial TUR. The procedure should include a resection of the primary tumor site. EAU

EAU

Risk of recurrence and progression EAU http://www.eortc.org/tools/bladdercalculator/default.htm

EAU

NCCN guideline Ta,low-grade Ta,high-grade, or T1,low-grade: Observation Single dose chemotheapy within 24 hrs Ta,high-grade, or T1,low-grade: BCG instillation T1, high-grade: Re-TUR: positive: BCG or cystectomy negative:BCG Cystectomy

Index Patient #5 High-grade Ta, T1, CIS recurred after prior intravesical therapy Standard: For T1 patients without muscularis propria in specimen, repeat resection should be performed prior to additional intravesical therapy Recommendation: Cystectomy should be considered as a therapeutic alternative Option: Further intravesical therapy AUA

Adjuvant Chemotherapy

Not-resectable Tumor

Metastatic Disease