BALTIMOREPhysicians should consider using intravesical
chemotherapy or immunotherapy as adjuvant therapy following surgery
for non-muscle-invasive bladder cancer, according to new treatment
guidelines released by the American Urological Association (AUA).
The fact that the peer-reviewed published data show that the
use of intravesical agents after surgery lowers the probability of
recurrence but not progression is the most important finding that we
made, panel chair Joseph A. Smith, Jr., MD, of the Vanderbilt
University Medical Center, said in a news release.
The guidelines report was produced by the AUA Bladder Cancer Clinical
Guidelines Panel, a group of bladder cancer experts that analyzed
published outcomes data to assess treatments and develop practice
policy recommendations. A guidelines summary was published in the Journal
of Urology (Nov. 1999).
Recommendations were made for three types of index patients: A
patient who presents with an abnormal growth on the urothelium but
has not yet been diagnosed with bladder cancer; a patient with
established bladder cancer of any grade, stage Ta or T1, with or
without carcinoma in situ, who has not had prior intravesical
therapy; and a patient with carcinoma in situ or an aggressive cancer
that has begun to penetrate the bladder wall, who has had at least
one course of intravesical therapy.
Panel policy recommendations were categorized into three grades of
flexibility as determined by the strength of the available evidence
and the expected amount of variation in patient preferences:
Standards, which have the least flexibility; guidelines, which have
significantly more flexibility; and options, which have the most flexibility.
The guidelines recommend as a standard that physicians should discuss
with all three types of index patients treatment alternatives and the
benefits and risks of each alternative.
For the index patient who presents to a physician with an abnormal
growth on the urothelium but has not yet been diagnosed with bladder
cancer, the panel recommends as a standard that a biopsy should be
obtained for pathologic analysis. Once a diagnosis of bladder cancer
has been established, the panel recommends as a standard that
complete eradication of all tumors should be performed if surgically
feasible and if the patients medical condition permits.
After endoscopic removal of low-grade bladder cancer, the panel
recommends adjuvant intravesical chemotherapy or immunotherapy as an option.
The panel recommends as a guideline intravesical use of BCG or
mitomycin C (Mutamycin) for treatment of carcinoma in situ and for
use after removal of tumors that have begun to penetrate the bladder
wall and high-grade Ta tumors.
Because there is some risk of progression to muscle-invasive disease
even after intravesical therapy, the report states that, as an
option, bladder removal may be considered as initial treatment in
certain patients based on such factors as tumor size, grade, and location.
In patients with carcinoma in situ or high-grade tumors who have had
at least one course of intravesical therapy, the panel states that
cystectomy and further intravesical therapy may be considered as
options for cancers that have persisted or recurred.
To Order the Bladder Cancer Guidelines
The complete Bladder Cancer Clinical Guidelines Report can be