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

San Francisco, CA ( 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. 


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