Risk Adapted Management of Low-Grade Bladder Tumors: Recommendations from the International Bladder Cancer Group.

Bladder cancer is the most expensive cancer worldwide in terms of cost incurred by patients and health care systems. Around half new patients have low-grade, papillary tumors. These patients are frequently over-treated and undergo costly therapy and invasive procedures even though they possess very low-risk for progression and mortality. Furthermore, many of these patients are included in clinical trials for more aggressive bladder cancers which confounds results and drug approval. Herein we provide contemporary update and recommendations for the diagnosis and management of low-grade non-muscle-invasive bladder cancer based on current literature and expert consensus of the International Bladder Cancer Group.

We reviewed published trials, guidelines, meta-analyses, and reviews (as of March 2019) and provided recommendations on baseline evaluations, treatment, end points, study design, and surveillance protocols.

Low-grade Ta bladder cancer poses minimal risk to patient in terms of progression and disease specific survival. Thus, to minimize patient morbidity this entity should be managed appropriately. After initial diagnosis of low-grade Ta tumor, subsequent stable, low-grade appearing recurrences can be managed conservatively with office cystoscopy and fulguration or even followed using an active surveillance protocol. Intravesical therapy other than single dose perioperative chemotherapy instillation should be used judiciously, and only after assigning appropriate risk points. Routine use of urinary cytology is recommended and surveillance cystoscopy may be discontinued after 5-years. Clinical studies in this group of patients should focus on recurrence rates, and time to recurrence, rather than progression events.

The International Bladder Cancer Group has developed formal recommendations regarding diagnosis, treatment and surveillance of low-grade non-muscle invasive bladder cancer to minimize morbidity and encourage uniformity among studies in this disease.

BJU international. 2020 Jan 16 [Epub ahead of print]

Justin T Matulay, Mark Soloway, J Alfred Witjes, Roger Buckley, Raj Persad, Donald L Lamm, Andreas Boehle, Joan Palou, Marc Colombel, Maurizio Brausi, Ashish M Kamat

University of Texas MD Anderson Cancer Center, Houston, TX, USA., Memorial Cancer Institute, Memorial Hospital, Hollywood, FL, USA., Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands., North York General Hospital, Toronto, Ontario, Canada., Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom., University of Arizona and BCG Oncology, Phoenix, AZ, USA., University of Luebeck, Germany., Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain., Claude Bernard University, Hôpital Edouard Herriot, Lyon, France., Azienda Unità Sanitaria Locale di Modena, Modena, Italy.