Review – Bladder CancerEuropean Association of Urology Guidelines on Non–muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ)
Introduction
This overview represents the updated European Association of Urology (EAU) guidelines for non–muscle-invasive bladder cancer (NMIBC), comprising Ta, T1, and carcinoma in situ (CIS). The information presented is limited to urothelial carcinoma, unless otherwise specified. The aim is to provide practical recommendations for clinical management of NMIBC, with a focus on clinical presentation and recommendations.
It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions that also take the personal values and references/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.
Section snippets
Evidence acquisition
For the 2021 NMIBC guidelines, new and relevant evidence has been identified, collated, and appraised through a structured assessment of the literature.
A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the previous version was published in 2020 was performed. Excluded from the search were basic research studies, case series, reports, and editorial comments. Only articles published in the English language and addressing adults were included. Excluded
Epidemiology
Bladder cancer (BC) is the tenth most commonly diagnosed cancer worldwide [3]. The age-standardised incidence rate (per 100 000 person-years) is 9.5 for men and 2.4 for women worldwide, and 20 for men and 4.6 for women in the EU [3].
Worldwide, the BC age-standardised mortality rate (per 100 000 person-years) was 3.3 for men versus 0.86 for women [3]. The incidence and mortality of BC have decreased in some registries, possibly reflecting a decrease in the impact of causative agents [4].
Definition of NMIBC
Papillary tumours confined to the mucosa and invading the lamina propria are classified as stage Ta and T1, respectively, according to the TNM classification system [15]. Flat, high-grade tumours confined to the mucosa are classified as CIS (Tis). All of these tumours are grouped under the heading of NMIBC. The term non–muscle-invasive BC, however, represents a group definition; all tumours should be characterised according to their stage, grade, and further pathological characteristics. The
Patient history
A focused patient history is mandatory.
Signs and symptoms
Haematuria is the most common finding in NMIBC. Visible haematuria was found to be associated with higher-stage disease compared to nonvisible haematuria [29]. CIS might be suspected in patients with lower urinary tract symptoms, especially irritative voiding.
Physical examination
A focused urological examination is mandatory, although it does not reveal NMIBC.
Imaging
Computed tomography (CT) urography is used to detect papillary tumours in the urinary tract, indicated by filling
Ta and T1 tumours
Treatment should take into account a patient’s prognosis. In order to predict the risk of disease recurrence and/or progression, several prognostic models for specified patient populations have been introduced.
Counselling on smoking cessation
Smoking increases the risk of tumour recurrence and progression [82] (LE: 3). While it is still controversial whether smoking cessation in BC will favourably influence the outcome of BC treatment, patients should be counselled to stop smoking because of the general risks connected to tobacco smoking [83] (LE: 3).
Adjuvant treatment
Although TURB by itself can eradicate a Ta/T1 tumour completely, these tumours commonly recur and can progress to MIBC. It is therefore necessary to consider adjuvant therapy for all
Follow-up of patients with NMIBC
Owing to the risk of recurrence and progression, patients with NMIBC need surveillance following therapy. The frequency and duration of cystoscopy and imaging follow-up should reflect the individual patient’s degree of risk (see the guidelines in Table 14).
When planning the follow-up schedule and methods, the following points should be considered:
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Prompt detection of muscle-invasive and HG/G3 non–muscle-invasive recurrence is crucial because a delay in diagnosis and therapy can be
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