STOCKHOLM, SWEDEN (UroToday.com) - In non-muscle-invasive bladder cancer (NMIBC), the progression rate depends upon the risk stratification. While cystectomy is considered the gold standard for treatment of MIBC, it can cause significant over-treatment in a large number of patients with NMIBC. However, once progression of urothelial cancer has occurred, then cystectomy is no longer curative. Therefore, the optimal timing of radical cystectomy in NMIBC patients is critical.
Currently there is no strong nomogram or any method, with sufficient evidence, that can be used for prediction progression of NMIBC. Dr. P. Gontero from Turin, Italy, presented a state-of-the art plenary lecture on how to avoid cystectomy being too late in non-muscle-invasive bladder cancer. He commenced his talk by showing evidence from a 2005 meta-analysis study by Sylveter and colleagues that even though NMIBC is usually considered a disease with a favorable prognosis, a portion of them will show immediate or late aggressive features. Studies have shown that up to 50% of high-grade T1 NMIBC patients develop muscle-invasive disease, and it is critical to identify and treat them aggressively before the progression occurs. He stated that the simplest way that urologists can predict if NMIBC is destined to progress is by integration of stage, grade, and known clinical prognostic factors (number of tumors, size, presence of hydroureter, etc.). He went on to explain that knowing an individual patient has a 21% chance of progression still leaves too high of a margin for over-treatment when a decision like cystectomy has to be made. He presented recent data from a multi-institutional study of BCG-treated patients (n=2,530), with median follow-up of 5.2 years, by Gontero, et al. He showed that in that study, the 3 factors statistically significant in effecting progression from NMIBC to MIBC were age > 70, tumor size > 3.0 cm, and presence of CIS (~60% risk of progression when all 3 present). Lastly, he stated that cystectomy should be considered when a) persistent T1 disease is present at re-stage TUR, b) T1 high grade + tumor > 3cm + age 70, or, c) T1 high grade + female gender or CIS in prostatic urethra.
Currently there is a need of new predictive tools which integrate clinical prognosticators (molecular markers, new diagnostic techniques) in the setting of prospective studies for high-risk NMIBC patients. As urologists, if there is one thing that we should always keep in mind, it is that we should absolutely minimize the risk of down-staging with a re-TURBT anytime a T1 or high-grade bladder cancer is detected at initial TUR, as it is crucial for patient outcomes.
Presented by P. Gontero at the 29th Annual European Association of Urology (EAU) Congress - April 11 - 15, 2014 - Stockholmsmässan - Stockholm, Sweden.
Written by Reza Mehrazin, MD, medical writer for UroToday.com