This article appears in the following Annals of Oncology issue: ESMO Clinical Recommendations [View the issue table of contents]
ESMO clinical recommendations |
Invasive bladder cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up
1 Department of Medical Oncology, University Hospital del Mar
2 Department of Medical Oncology, Instituto Oncológico Teknon, Barcelona, Spain
3 Department of Oncology, Vaasa Central Hospital, Vaasa and Kuopio University Hospital, Kuopio, Finland
* Correspondence to: ESMO Guidelines Working Group, ESMO Head Office, Via L. Taddei 4, CH-6962 Viganello-Lugano, Switzerland; E-mail: clinicalrecommendations{at}esmo.org
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incidence |
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 Top incidence diagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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The crude incidence of invasive bladder cancer in the European Union is 19.5/100 000/year, the mortality is 7.9/100 000/year; 70% of patients with bladder cancer are >65 years of age.
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diagnosis |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Pathological diagnosis should be made according to the WHO classification (Table 1) from a biopsy obtained by transurethral resection (TUR) of primary tumor. Ninety per cent of bladder carcinomas are transitional cell carcinomas.
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staging and risk assessment |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Complete history and physical examination, blood counts, creatinine, chest X-ray (or CT), CT scan of the abdomen and pelvis, and urine cytology are required. Additional diagnostic tests, such as bone scan, should be performed if clinically indicated.
Cystoscopic examination and TUR with a bimanual examination under anesthesia (EUA), with biopsy and determination of size, and the presence of extravesical extension or invasion of adjacent organs should be performed.
Management of bladder cancer is based on the pathologic findings of the biopsy, with attention to histology, grade and depth of invasion. Patients with invasive bladder cancer should be staged according to the TNM system and be grouped into the categories shown in Table 2.
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treatment of stage I disease |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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TUR is the treatment of choice followed by intravesical therapy or by careful surveillance in patients with low-risk disease. One immediate instillation of chemotherapy after TUR decreases the relative risk of recurrence by 40% [I, A].
Patients with high-risk disease (recurrent, large, deeply invasive, multifocal, poorly differentiated or with carcinoma in situ) can be treated with intravesical bacille Calmette-Guérin (BCG) therapy after initial TUR [I, A] or radical cystectomy. If there is no response to BCG, cystectomy should be considered due to the high risk of progression.
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treatment of stage II and III disease |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Radical cystectomy is the standard treatment for patients with muscle-invasive bladder cancer. Bladder-preserving approaches, with a complete TUR and radiotherapy alone or with concomitant chemotherapy, are reasonable alternatives to cystectomy for patients who are medically unfit for surgery and for patients who seek an alternative [II, A].
Two large randomized trials and a meta-analysis support the use of neo-adjuvant chemotherapy before cystectomy for T2 and T3 disease. The demonstrated survival benefit (5% at 5 years) encourages the use of platinum-based combination chemotherapy for patients with invasive bladder cancer before radical cystectomy or definitive radiotherapy [I, A].
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treatment of stage IV disease |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Platinum-based combination chemotherapy with methotrexate–vinblastine–doxorubicin–cisplatinum or gemcitabine–cisplatinum (GC) prolongs survival [I, A]. Both combinations are equally effective, although GC is less toxic. Patients unfit for cisplatin-based chemotherapy may be palliated with carboplatin-based regimen or single-agent taxane or gemcitabine.
Selected patients with locally advanced disease (T4b N1) may be candidates for cystectomy and lymph node dissection or definitive radiotherapy following systemic therapy.
The role of antiangiogenic therapy is under study in first and second line treatment. Vinflunine appears as an option for second line therapy in patients progressing to first line platinum-based chemotherapy [I, B]. Palliative radiotherapy may be used to reduce symptoms.
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response evaluation |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Response evaluation with cystoscopy and cytology is mandatory following BCG treatment and in patients after bladder preservation strategies. For stage I, a biopsy must be obtained for proof of recurrence and for assessing CR in CIS.
Response evaluation during chemotherapy with the initial radiographic tests is necessary. For evaluating the response to systemic chemotherapy, the RECIST criteria should be used.
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follow-up |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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There is no generally accepted follow-up protocol and therefore the possible alternatives could be as follows: (i) patients treated with a bladder-preservation strategy, cystoscopy and urinary cytology every 3 months during the first 2 years, and every 6 months thereafter; (ii) after cystectomy, clinical control every 3 months during the first 2 years and subsequently every 6 months for 5 years.
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note |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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Levels of evidence [I–V] and grades of recommendation [A–D] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.
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footnotes |
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Approved by the ESMO Guidelines Working Group: August 2002, last update September 2008. This publication supercedes the previously published version—Ann Oncol 2008; 19 (Suppl 2): ii47–ii48.
Conflict of interest: Dr Bellmunt has reported that he is a consultant for the advisory board of Eli Lilly; Dr Albiol and Dr Kataja have reported no conflicts of interest.
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references |
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Topincidencediagnosisstaging and risk assessmenttreatment of stage I...treatment of stage II...treatment of stage IV...response evaluationfollow-upnotereferences |
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