NICE guidelines bladder cancer

Bladder cancer diagnosis and management

• 7th most common cancer in the UK. 

• Male:female ratio 3-4:1 

• In 2011 5081 people died of bladder ca

• Peak incidence > 60 year-olds

Risk factors 

• Increasing age 

• Smoking

• Exposure to industrial chemicals 

Symptoms:
Visible or non-visible blood in the urine

75-80% of bladder ca are non-muscle invasive

Diagnosing and staging bladder cancer 
Diagnosis: 

• CT/MRI staging before TURBT if MIBC is suspected at cystoscopy. 

• Offer white-light TURBT + one of  (1-phtodynamic diagnosis, 2- narrow-band imaging, cytology or a urinary biomarker test (UroVysion using (FISH), ImmunoCyt or NMP22)

• Offer a single dose of intravesical mitomycin C given at the same time as the first TURBT

Non-muscle-invasive-bladder-cancer (NMIBC)

Prognostic markers and risk classification

Important factors to consider:

• Recurrence history 

• Size and number of cancers 

• Histological type, grade, stage and presence (or absence) of flat urothelium, detrusor muscle (muscularis propria), and carcinoma in situ

• The risk category

• Predicted risk of recurrence and progression (using a risk prediction tool)

High risk NMIBC

Offer BCG or radical cystectomy

discussion with the patient should include

• Type, stage, grade of cancer

• Presence of CIS

• Presence of variant pathology

• Prostatic urethra or bladder neck status 

• Number of tumours 

• Risk of progression to muscle invasion, metastases and death

• Risk of understaging 

• Benefits of both treatments, including survival rates and likelihood of further treatment 

• Risks of both treatments 

• Comorbidities and life expectancy

• Impact on QOL, body image, sexual and urinary function

Follow up for NMIBC 

Low risk 
Discharge if no recurrence within 12 months

Intermediate-risk NMIBC
Cystoscopic follow-up at 3,9 and 18 months, and once a year thereafter.

Treating MIBC

Neoadjuvant chemotherapy for newly diagnosed MIBC

Offer neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy (RC) or Rx

Radical therapy for MIBC

Offer RC or Rx


Staging 

• Further TURBT within 6 weeks if no detrusor muscle present

• CT/MRI for MIBC, High risk NMIBC assessed for radical treatment 

• Consider CT Urography for people with new or recurrent high-risk NMIBC or MIBC to check upper tracts

• Consider CT thorax for people with MIBC 

• Consider FDG-PET scan if there are indeterminate findings on CT/MRI or high risk for metastases (T3b disease) 

Treating NMIBC 

Risk classification in NMIBC 

 

 

Treatment: 

Intermediate risk NMIBC 

• Offer 6 doses of intravesical Mitomycin C 
• If recurs refer to MDT

  

High risk NMIBC

• Offer another TURBT ASAP no later than 6 weeks after 1st resection
• Offer the choice of BCG or RC

BCG: 

• Offer induction and maintenance 
• If induction fails refer to MDT
• MDT should assess suitability of RC, or further intravesical therapy (if RC is unsuitable or declined or if the recurrence intermediate or low-risk) 

 Recurrent NMIBC 

Consider fulguration without biopsy if 

• No previous intermediate or high risk history
• Disease free interval of at least 6 months 
• Solitary papillary recurrence  
• Tumour diameter of 3 mm or less

Managing side effects of treatment  

• Don't offer prophylaxis before BCG
• Seek MDT advice if antispasmodics or non-opiate analgesia are not controlling bladder toxicity post BCG and cystoscopy is normal. 

Follow-up NMIBC 

Low-risk NMIBC

• Offer cystoscopy at 3 and 12 mo 
• Dont use urinary biomarkers or cytology 
• Discharge to primary care if no recurrence within 12 mo

Intermediate risk NMIBC

• Offer cystoscopy at 3,6,9, and 18 mo and once a year thereafter
• Discharge to primary care after 5 yrs of f/u if disease free 

 High risk NMIBC

• cystoscopy every 3 mo for the first 2 yrs then every 6 mo for the next 2 yrs then once a yr thereafter 

Treating MIBC

Neoadjuvant chemotherapy 

Offer it (cisplatin based)

Radical therapy

RC or Rx

RC

Offer stoma or continent diversion (neo bladder or catheterisable reservoir)

Contraindications to continent diversion

• cognitive impairment
• impaired renal function 
• significant bowel disease

Offer opportunity to have discussions with a stoma care nurse

Adjuvant chemotherapy after RC for MIBC or LN(+) bladder ca

Consider adjuvant cisplatin combination chemo after RC for people with diagnosis of 

MIBC

LN (+) BC

for whom neoadjuvant chemo was not suitable 

• muscle invasion was not shown on pre-cystectomy biopsies

Radical Rx 

• Use a radiosensitiser (mitomycin + fluorouracil [5-FU]) 
• 64 Gy in 32 fractions over 6.5 weeks 
• 55 Gy in 20 fractions over 4 weeks 

Follow up after treatment for MIBC 

After RC 

• Annual imaging of upper tracts for HN, stones and cancer and (GFR)
• CT C/A/P at 6,12 and 24 mo after RC 
• Annual monitoring of metabolic acidosis and B12 and folate deficiency 
• For men with a defunctioned urethra, urethral washing for cytology and/or urethroscopy annually for 5 years. 

After radical Rx 

• Rigid cystoscopy 3 mo after completion of Rx followed by rigid or flexi
• Every 3 mo for hte first 2 yrs then
• Every 6 mo for hte next 2 yrs then 
• Every yr thereafter
• Upper tract imaging every year for 5 years 
• CT C/A/P 6,12,24 mo after Rx 

Managing locally advanced or metastatic MIBC 

First-line chemotherapy 

• Offer a cisplatin-based chemotherapy (cisplatin + gemcitabine, or MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) in combination with G-CSF (granulocyte-colony stimulating factor) if 
• ECOG performance status of 0 or 1
• eGFR of 60 or more

•  Offer carboplatin + gemcitabine to people with ECOG 0-2 if cisplatin is unsuitable because

• ECOG >=2
• GFR <60
• Comorbidity

Second-line chemo

• Gemcitabine + cisplatin or accelerated high dose MVAC + G-CSF if progression after 1st line chemo if 
• GFR >=60
• ECOG 0-1 

Consider 2nd line chemo with carboplatin + paclitaxel or gemcitabine + paclitaxel if cisplatin based chemo is not suitable. 

Managing symptoms of locally advanced or metastatic bladder cancer

Bladder symptoms 

• Offer palliative hypofractionated Rx for haematuria, dysuria, frequency or nocturia

Loin pain and symptoms of renal failure 

• Discuss 
• prognosis 
• advantages and disadvantages of Tx options including best supportive care

•  Consider percutaneous nephrostomy or retrograde stenting to 
• Relieve pain
• Treat AKI
• Improve renal function before further treatment 

Intractable bleeding 

• Consider hypofractionated Rx or embolisation 

Pelvic pain

• Consider in addition to best supportive care 

• hypofractionated Rx if no previous Rx to pelvis
• Nerve block
• Palliative chemotherapy

Specialist palliative care for people with incurable bladder cancer

• Refer to urology MDT
• Tell the primary care team within 24hrs 
• A member of the urology MDT should discuss prognosis and management with pt
• Discuss palliative care services