Bladder Cancer Academy 2017: AUA Guidelines: Muscle-Invasive Bladder Cancer

Schaumburg, IL ( Dr. Sam Chang presented the recently published (2017) AUA guidelines on muscle invasive bladder cancer (MIBC). This guideline provides a risk-stratified, clinical framework for the management of MIBC and is the product of a multidisciplinary collaboration between the AUA, the American Society of Clinical Oncology (ASCO), American Society for Radiation Oncology (ASTRO) and the Society of Urologic Oncology (SUO).

There are 79,030 new cases of bladder cancer and 16,870 bladder cancer deaths predicted for 2017 in the U.S. Approximately 25% of newly diagnosed patients have MIBC, a rate that has not changed over the last 10 years. The overall prognosis of patients with MIBC has not changed in the last 30 years. In patients who undergo radical cystectomy (RC), systemic recurrence rates vary by stage, with pT2 and node positive patients having a systemic recurrence rate of 20% and 70%, respectively. Most recurrences occur within the first 2-3 three years after RC, and at this time, most patients with recurrence after RC are not cured with current systemic therapies. The dominant pathologic predictors for recurrence and survival are tumor stage and nodal status. Other prognostic factors include gender, hydronephrosis, lymphovascular invasion (LVI), soft tissue margin status, and molecular subtyping characteristics.

There is also a significant impact of treatment choices on outcome with the type and timing of therapy playing an important role.

Initial evaluation and counseling includes history and physical examination, staging (Imaging and laboratory evaluation), review of suspected variant histology by an experienced GU pathologist, discussion of curative treatment options and implications for quality of life (QUL). All patients should be seen by a multi-disciplinary team discussing all treatment options including surgery, chemotherapy and radiotherapy. 

Cisplatin-based neoadjuvant chemotherapy (NAC) to eligible RC patients prior to surgery should be offered. This should be based on comorbidities profile and performance status. Carboplatin-based NAC should be offered to cisplatin-ineligible patients, and timing of RC following NAC should be discussed as well. Lastly, the option of cisplatin-based adjuvant chemotherapy (AC) should be mentioned. 

Unfortunately, there are no validated predictive factors or clinical characteristics associated with an increased/decreased probability of response for cisplatin-based NAC. Moreoverm, the best regimen and duration for cisplatin-based NAC remains undefined.

RC includes bilateral pelvic lymphadenectomy and for males it entails removal of the bladder, prostate, and seminal vesicles; while for females it includes the bladder, uterus, fallopian tubes, ovaries, and the anterior vaginal wall. Only for patients with organ confined disease should sexual function preserving procedures be considered. 

Standard lymphadenectomy template involving removal of the nodes in the internal iliac, external iliac and obturator regions, is the minimum required.

Possible urinary diversions include Ileal conduit, continent cutaneous, and orthotopic neobladder. For orthotopic diversions, a negative urethral margin must be verified. The choice of urinary diversion has a significant impact on long-term QOL, and each type of diversion is associated with its own unique potential complications. 

Before RC, optimization of patient performance status in accordance with enhanced recovery (ERAS) pathway principles must be attempted. This includes nutritional counseling, smoking cessation, bowel preparation, pharmacologic thromboembolic prophylaxis, μ -opioid antagonist therapy, and care of urinary diversion.

Patients who desire to retain the bladder and patients unfit for RC may undergo bladder preservation treatment. This includes maximal debulking TURBT with assessment of multifocal disease/carcinoma in situ, systemic chemotherapy, radiation therapy, and ongoing cystoscopy to evaluate response. Those who are biopsy-proven complete responders to bladder preserving protocols remain at risk for both invasive and non-invasive recurrences as well as new tumors in the upper tracts. Recurrences may be successfully managed by prompt salvage therapy. Patients who are fit and consent to RC should not undergo maximal TURBT/partial cystectomy as primary curative therapy nor primary radiotherapy. If bladder preservation treatment fails, salvage surgical treatment must be performed

Surveillance and follow-up of RC patients include frequent patient imaging, laboratory assessment and inspection of the urethral remnant as a site for potential recurrence. Participating in a cancer support group/individual counseling is recommended and adoption of healthy lifestyle habits is beneficial.

It is important to recognize unique clinical characteristics such as variant histology that may require divergence from standard evaluation and management. 

Dr. Chang concluded his presentation stating several key areas for future research. These include:
  • Detection & markers: Enhanced detection of bladder cancer cells via imaging technology is needed to identify patients with high-risk disease.
  • Therapy: The rapid introduction of novel immunotherapeutic agents into the therapeutic armamentarium has begun to show promise. 
  • Surveillance: the role of specific imaging tests and laboratory studies as well as their appropriate interval has yet to be established, and future studies are needed to define a patient specific approach.
Presented By: Sam Chang, MD, Vanderbilt University Medical Center, Nashville, TN

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre
Twitter: @GoldbergHanan

at the 2017 Bladder Cancer Academy - June 9 - 10 - Schaumburg, Illinois, USA