New joint guidelines on the management of bladder cancer issued by the American Urological Association (AUA) and the Society of Urologic Oncology (SUO) validate many long-standing practices used in the management of superficial bladder cancer but also affirm the real benefits associated with newer technologies to better visualize bladder tumors. Most notabable among these newer technologies is blue-light cystoscopy performed with hexaminolevulinate hydrochloride (Cysview, Photocure ASA), the guidelines indicate.
"We are doing very well with superficial bladder cancer, and we are actually doing very well with more advanced muscle-invasive bladder cancer using systemic chemotherapy and the construction of neobladders that dramatically improve quality of life for patients," Leonard Gomella, MD, president of the SUO, told Medscape Medical News. Dr Gomella is the chair of urology at the Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania. He reviewed the new guidelines, but he was not a guideline author.
"And that's the name of the game ― to improve the quantity and the quality of patients' lives. For superficial bladder cancer, our aim is to keep superficial bladder cancers in fact superficial and not allow them to penetrate the muscle and beyond," Dr Gomella said.
The non–muscle invasive bladder cancer (NMIBC) guidelines were published online by the AUA.
Risk-Stratified Clinical Framework
The guidelines, with lead author Sam Chang, MD, Vanderbilt University School of Medicine, Nashville, Tennessee, aim to provide a risk-stratified clinical framework for the management of NMIBC.
The guidelines comprise 38 statements covering all stages of NMIBC management, from diagnosis to surveillance and follow-up. The statements serve as an algorithm to guide practitioners through each of the steps needed to ensure patients are appropriately diagnosed, treated, and followed.
For example, the new guidelines reinforce the benefit of continuing to use an induction course of bacille Calmette-Guérin (BCG) administered to the bladder in appropriate patients with high-grade cancer as well as giving BCG as maintenance therapy.
Guideline authors also recommend administration of a single dose of chemotherapy — usually mitomycin C ― administered to the bladder immediately following surgical resection of the tumor to help prevent recurrence.
As Dr Chang and coauthors point out, survival rates for most patients with NMIBC are favorable.
"However, the rates of recurrence and progression to muscle-invasive bladder cancer (MIBC) are important surrogate endpoints for overall prognosis, as these are major determinants of long-term outcome," the authors write.
"Therefore, the ability to predict risk of recurrence and progression and treat the disease appropriately is important."
Two Main Reasons
"I think these guidelines were done for two main reasons," Gary Steinberg, MD, professor of surgery and chief of urologic oncology, University of Chicago, in Illinois, told Medscape Medical News. He was not involved with writing the guidelines.
In his tertiary care practice in Chicago, Dr Steinberg receives patients with bladder cancer who are referred to him from throughout the Midwest and who were diagnosed and evaluated elsewhere.
"And I can tell you, there is a lack of guideline-following; there is a lack of algorithm-following; there is a lack of rational rhyme or reason as to how patients with bladder cancer get diagnosed and staged and treated, so there is a tremendous need to try and bring all of this disparate information together so we can create algorithms that should be easy to follow," Dr Steinberg explained.
This will lead to not only an earlier diagnosis, he added, but to a better diagnosis and better initial therapies.
Currently, the literature suggests that there may be as much as a 30% excess in mortality among patients who present initially with NMIBC, Dr Steinberg indicated.
"I think this is because patients fall through the cracks," he said.
"There's not enough recognition that high-grade bladder cancer can be life-threatening, and there's not enough follow-through with our biopsy techniques or with our surveillance techniques once patients are treated," Dr Steinberg added.
"So these guidelines set up algorithms for urologists to follow that I think will greatly simplify and standardize management for these patients," he said.
Early Detection Critical
It is not widely known that bladder cancer is the fourth most common cancer in men in the United States, and early detection is critical to optimal outcomes.
"Certainly, our biggest clue a patient might have bladder cancer is gross or microscopic hematuria," Dr Steinberg noted.
Unfortunately, patients presenting with even gross hematuria are often told that they have a urinary tract infraction or that they have passed a kidney stone, he added.
"All too often, bladder cancer is not included in the initial differential diagnosis, especially in women," Dr Steinberg confirmed.
That may well change with more widespread use of blue-light cystoscopy performed with hexaminolevulinate hydrochloride. Hexaminolevulinate hydrochloride is an optical imaging agent indicated for use in the cystoscopic detection of NMIBC.
The new guidelines feature the use of blue-light cystoscopy quite prominently because the technology is inherently superior to white-light cystoscopy for visualization of bladder tumors.
"There are other technologies in the guidelines that are used to visualize bladder tumors, but the one that got the highest level of recommendation was blue-light cystoscopy," Dr Gomella said.
Dr Gomella explained that practitioners who are familiar with the relatively new technique know that it significantly improves detection of NMIBD when used as an adjunct to white-light cytoscopy in comparison with use of white-light cystoscopy alone.
"In particular, most of us who are familiar with the blue-light cystoscopy really feel it's the carcinomas in situ — the flat tumors — where the technology shines, because flat cancers are sometimes not as visible under white-light examination," Dr Gomella said.
Dr Steinberg could not agree more.
"With any endoscopic procedure, we are only as good as our eyes, and despite the fact that we've now got fiber optics, we've got digital optics, we've got all kinds of great optics, the reality is that even with our great new optical instruments, we still get up to 20% of cystoscopies that are called normal when patients in fact do have disease," he said.
In addition, transurethral resections and biopsies performed without blue-light cystoscopy are not nearly as complete as they could or should be, Dr Steinberg suggested.
"So anything you can do to help you visualize the tumor is critically important," he added.
With the use of blue-light cystoscopy and hexaminolevulinate hydrochloride, even flat cancers "light up like a Christmas tree," he said.
This minimizes false negative rates, "so if findings on blue-light cystoscopy are negative, they are truly negative," Dr Steinberg said.
Dr Steinberg has used the technology for 5 years or so, and he has noticed that his false positive rates continue to drop.
"To me, blue-light cystoscopy is an optimal procedure, and the technology has a significant amount of cancer specificity as well, which I think is critically important," he emphasized.
Dr Gomella agrees with Dr Steinberg.
"Essentially, right now, there are only about 75 centers in the US that offer blue-light cystoscopy technology," Dr Gomella said.
"So I think one of the biggest impacts we are going to see from these guidelines is a tremendous interest in identifying those centers that do have this technology and are happy to make it available for their patients."
Dr Gomella has disclosed no relevant financial relationships. Dr Steinberg has served as a consultant, scientific advisor, and/or investigator for Photocure, Taris Biomedical, Cold Genesys, Heat Biologics, Roche/Genentech, UroGen, Merck, Karl Storz, and Telesta.
AUA guideline. April 2016. Full text
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Cite this: New Guidelines on Bladder Cancer Management: AUA/SUO - Medscape - May 10, 2016.