ASCO GU 2018: Lessons Learned From New Guidelines and How They Have Changed Management of Muscle-Invasive Bladder Cancer

San Francisco, CA (UroToday.com)  Dr. Holzbeierlein began his discussion on the new muscle-invasive bladder cancer (MIBC) guidelines,1 a collaborative multi-disciplinary effort led by Dr. Sam Chang that involved input from all the major organizations, including AUA, ASCO, ASTRO, and patient advocates. The final analysis was built on prior work by Dr. Chou’s AHRQ systematic reviews (through 2015).

All recommendations were given A, B or C grades, if there was sufficient evidence in the literature. For those recommendations with no real studies to support it, but which the panel thought was important to consider, they were given “clinical principle” or “expert opinion” designations.

Some key guidelines recommendations for the consensus are highlighted below. For full guidelines, refer to the cited document.

Diagnosis

1. An experienced GU pathologist should review the histopathology whenever a variant histology is suspected or muscle invasion is equivocal (Clinical Principle)
2. All the subsequent recommendations in the consensus should be considered on a case-by-case basis for patients with variant histology, as the recommendations are for urothelial carcinoma specifically (Expert Opinion)

MIBC management
1. For patients with newly diagnosed MIBC, curative treatment options should be discussed in a multidisciplinary manner (surgery, chemotherapy, radiation) prior to decision making regarding treatment. (Clinical Principle)
2. Radical cystectomy and bilateral pelvic lymphadenectomy should be offered for all patients with surgically resectable non-metastatic cM0 disease (Grade B)
3. Neoadjuvant chemotherapy (NAC) should be offered to all eligible patients prior to cystectomy (Grade B)
4. Clinicians should NOT prescribe carboplatin-based NAC for clinically resectable cM0 MIBC – patients ineligible for cisplatin based chemotherapy should proceed to cystectomy. (Expert opinion)
5. Radical cystectomy should be performed as soon as possible following recovery from NAC, but no specific timeline is recommended or known (Expert Opinion)
6. Eligible patients who were not able to or did not receive NAC for non-organ confined pT3-4N+ disease should be offered adjuvant cisplatin-based chemotherapy (Grade C)
7. Mu-opioid antagonist should be used to accelerate GI recovery after cystectomy in eligible patients (Grade B)
8. Perioperative VTE prophylaxis should be given to RC patients (Grade B)

Bladder sparing therapy for MIBC
1. For patients with MIBC who wish to spare their bladder or who are ineligible for RC, bladder sparing should be offered (Clinical principle).
- Many comments were made to highlight that this is a select group of patients
- The preferred approach – maximal TUR, systemic chemotherapy, radiotherapy, ongoing surveillance
2. For patients undergoing bladder sparing, they should be offered maximal TUR, chemotherapy combined with external beam radiotherapy, and cystoscopic surveillance (Grade B)
3. Radiation-sensitizing agents should include cisplatin or 5-FU and mitomycin (Grade B)
4. For patients under consideration, maximal TURBT and assessment for multifocal disease or CIS should be performed (Grade C)
5. Regular surveillance with cystoscopy, abdominal + chest imaging, and urine cytology should be performed (Grade C)
6. Patients medically fit for a RC should NOT undergo partial cystectomy or maximal TURBT as primary curative therapy (Grade C)

Primary radiation therapy
1. Radiation therapy alone should NOT be offered to men with MIBC (Grade C)

However, there are several areas of key research that need to be undertaken to move the field forward. Some of the other speakers address those concerns / questions in their talks.

Presented by: Jeff Holzbeierlein, MD, FACS, University of Kansas

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, February 8-10, 2018 - San Francisco, CA

Reference:
1. Chang SS, Bochner BH, Chou R, Dreicer R, Kamat AM, Lerner SP, Lotan Y, Meeks JJ, Michalski JM, Morgan TM, Quale DZ, Rosenberg JE, Zietman AL, Holzbeierlein JM. Treatment of Nonmetastatic Muscle-Invasive Bladder Cancer: American Urological Association/American Society of Clinical Oncology/American Society for Radiation Oncology/Society of Urologic Oncology Clinical Practice Guideline Summary. J Oncol Pract. 2017 Sep;13(9):621-625. doi: 10.1200/JOP.2017.024919. Epub 2017 Aug 10. No abstract available
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