Page 1 - Management of non-muscle invasive bladder cancer

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cUa gUidelines
Original research

CUA guidelines on the management of non-muscle invasive bladder

cancer

Wassim Kassouf, MD, CM, FRCSC; Samer L. Traboulsi, MD; Girish S. Kulkarni, MD, FRCSC;
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Rodney H. Breau, MD, FRCSC; Alexandre Zlotta, MD, FRCSC; Andrew Fairey, MD, FRCSC;
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Alan So, MD, FRCSC; Louis Lacombe, MD, FRCSC; Ricardo Rendon, MD, FRCSC; Armen G. Aprikian, MD, FRCSC; *
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D. Robert Siemens, MD, FRCSC; Jonathan I. Izawa, MD, FRCSC; Peter Black, MD, FRCSC #
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* Division of Urology, McGill University, Montreal, QC; Division of Urology, University of Toronto, Toronto, ON; Division of Urology, University of Ottawa, Ottawa, ON; Division of Urology, University of
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Alberta, Edmonton, AB; Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Division of Urology, Laval University, Quebec, QC; Division of Urology, Dalhousie University,
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Halifax, NS; Department of Urology, Queen’s University, Kingston, ON; Division of Urology, Western University, London, ON
Cite as: Can Urol Assoc J 2015;9(9-10):E690-704. http://dx.doi.org/10.5489/cuaj.3320 Methods
Published online October 13, 2015.
We update the previously published 2009 Canadian
Introduction guidelines on the management of NMIBC, emphasizing
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intravesical therapy. We conducted a comprehensive
literature search using Medline and Pubmed. Pre-existing
According to the Canadian Cancer Society, bladder cancer is sections were updated after the literature review from
the fifth most common cancer overall, accounting for 7800 January 2009 to September 2014. A search from January
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cases/year. The most common type of histology is urothelial 1998 to September 2014 was completed for newly added
carcinoma (greater than 90%), followed by adenocarcinoma, sections in these guidelines. A keyword search and MeSH
squamous cell, and small cell carcinoma. Risk factors associ- search, or a combination of both, was used to retrieve high-
ated with bladder cancer include smoking, chronic inflam- quality studies, emphasizing randomized controlled trials.
matory changes in the bladder (due to persistent bladder In addition, the guidelines from the European Association
stones, recurrent urinary tract infections, chronic indwelling of Urology, the American Urological Association, and the
catheters or schistosomiasis), and chemotherapeutic expo- National Comprehensive Cancer Network were considered
sure, such as cyclophosphamide. 2-7 Other risk factors include for comparison. 19-21 References have been assigned a level
pelvic irradiation, occupational exposure to chemicals from of evidence, and recommendations have been graded using
the aromatic amine family, and chronic phenacetin use. 8-11 the Oxford Centre for Evidence-based Medicine. Figure 1
Lynch syndrome (hereditary nonpolyposis colon cancer) is summarizes the management in an algorithm.
associated with extracolonic cancers, including bladder can-
cer in 6% to 7% of cases. 12-14 Non-muscle invasive bladder Prognostic factors for recurrence and progression of
cancer (NMIBC) accounts for about 75% to 80% of all inci- NMIBC
dent bladder cancer cases; Ta accounts for most NMIBC
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(60%), whereas T1 and Tis (carcinoma in situ [CIS]) account
for 30% and 10%, respectively. The associated long-term • Prognostic factors for recurrence and progression
survival and recurring nature of NMIBC create a major eco- include stage, grade, presence of concomitant CIS,
nomic burden on healthcare systems. As measured on the tumour size, prior recurrence rate, and number of
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basis of cumulative per patient cost from diagnosis until tumours (Level of Evidence 2a)
death, bladder cancer is the most expensive human cancer • Other factors include variant histology, and presence
to treat. 17 The management of NMIBC has changed over of lymphovascular invasion (Level of Evidence 3)
the last decade.
Stage and grade

The overall rate of recurrence for NMIBC is 60% to 70%, and
the overall rate of progression to a higher stage or grade is

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