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(Drug information on 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 purchased by writing the Guideline Division, American Urological Association, 1120 North Charles Street, Baltimore, MD 21201; by faxing a request to 410-223-4375; or by phoning 410-223-4367.