AUA 2018: Adherence to Bladder Cancer Guidelines and Issues with Implementation

San Francisco, CA (UroToday.com) To start the bladder cancer session at the SUO session, Dr. de Vere White discussed adherence to guidelines and implementation. As he notes, the goals of treating non-invasive papillary carcinoma (Ta) disease is to stop recurrence, whereas for T1 is to stop progression and reduce mortality.  

The AUA/SUO, European and Asian guidelines all give the following guideline statements:

  1. ‘Immediate post-op intravesical therapy for low risk NMIBC’ a grade B with moderate qualifying statement. A 2004 meta-analysis of seven randomized trials (n=1,476) showed that with a median follow-up of 3.4 years, 36.7% receiving 1 postoperative instillation of epirubicin, mitomycin C, thiotepa or pirarubicin had recurrence compared to 48.4% with TUR alone. This lead to a decrease of 39% in the odds of recurrence with chemotherapy (OR 0.61, p <0.0001) 1. However, utilization is poor with only 9% of patients treated at teaching hospitals receiving appropriate immediate post-op intravesical therapy. This is starting to improve (but remains poor), as Dr. De Vere White notes that rates were 1.7% in 2005-2006, 9.6% in 2011-2012, and 12.6% in 2013-2014.
  2. ‘Intravesical BCG for high-risk NMIBC’ a grade B with strong qualifying statement. BCG is most effective for post-TUR residual papillary tumors, with reported response rates of 61%. Ten-year progression free survival for TUR + BCG is 62% compared to 37% for TUR + delayed or no BCG.
  3. ‘Repeated TURBT for T1 NMIBC’ a grade B with strong qualifying statement. Assessment of post-re TUR specimens notes that 48% had persistent NMIBC, where up to 30% will be upgraded to muscle-invasive disease. Previous studies have suggested that a second TUR vs one TUR decreases recurrence (26% vs 63%) and progression (4% vs 12%) but appropriately and truly staging the patient. Among patients with T1 disease, adherence to T1 re-resection rates is variable, with reports as low as 15% (and 10% subsequently receiving BCG).
Dr. de Vere White notes that feedback to providers does in fact improve adherence to NMIBC guidelines. At his institution, in 2014-2015, nearly 70% of patients with low-grade tumors receiving immediate intravesical chemotherapy, more than 70% received a re-resection for T1 disease, and 90% of T1 patients received intravesical chemotherapy. Ways to improve adherence according to Dr. De Vere White is educate our AUA members with home study courses, instructional courses, plenary sessions, state-of-the art talks, featured articles, and re-certification. Finally, he challenged the members of the SUO to lead the charge for guideline compliance. 

References:

1. Sylverster RJ, Oosterlinck W, van der Meijden AP. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage TaT1 bladder cancer: A Meta-analysis of published results of randomized clinical trials. J Urol 2004;171:2186-2190.


Presented by: Ralph de Vere White, University California-Davis, Sacramento, CA

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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