Bladder Cancer: New Guidelines for the Treatment of MIBC, NMIBC

Bladder Cancer: New Guidelines for the Treatment of MIBC, NMIBC
A review of the AUA's first MIBC clinical guidelines and recent updates to the AUA/SUO NMIBC guidelines

The American Urological Association (AUA) recently issued its first clinical guidelines for MIBC (non-metastatic muscle-invasive urothelial bladder cancer) and updated the AUA/Society of Urologic Oncology (SUO)’s NMIBC (non-muscle invasive bladder cancer) guidelines. Both guidelines provide a risk-stratified, evidence-based framework for best practices in treating these conditions.

“Guidelines provide an essential algorithm for all treating physicians to provide optimal diagnostic evaluation, treatment options, and surveillance protocol information,” said Sam S. Chang, Patricia and Rodes Hart Endowed Chair of Urologic Surgery at Vanderbilt University Medical Center. Chang chaired the development of the MIBC guidelines endorsed by the AUA/SUO.

New MIBC Guidelines

The new clinical guidelines for MIBC (2017) represent a first concerted, multi-institutional effort at delineating a clinical framework for treating MIBC. In developing the guidelines, the AUA collaborated with the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO) and the SUO. The collaboration stems from clinical recognition that MIBC — which carries a significant risk of mortality that has not changed in several decades — requires effective multidisciplinary collaboration throughout evaluation, consideration of multi-modal treatment (with emphasis on bladder preserving regimens) and patient follow up.

“This is truly a collaborative effort that brought in leaders from all disciplines across the U.S.,” Chang said.

Chang emphasizing the following points in the MIBC guidelines:

  • Initial evaluation, including imaging; in some cases, certain tests such as a PET scan should not be performed up front
  •  Neoadjuvant chemotherapy before surgery is identified as treatment of choice
  • Outside of surgery in combination with chemotherapy, the role of multi-modal, bladder preserving approaches (e.g., radiation therapy, chemotherapy and aggressive transurethral resection) is recognized as potentially curative for carefully selected patients
  • Follow-up strategy; understanding risks of recurrence and distance spread
  • Specific recommendations for chemotherapy regimens in association with radiation therapy (e.g., platinum-based therapy or 5-FU/combined with 5 mitomycin C)

Chang remarks that patient advocates informed both the MIBC and NMIBC guidelines. “This really opened many of our eyes to the importance of patients’ desires and needs, and to understanding that we need to attempt to optimize therapy for each individual patient.”

Updates to NMIBC Guidelines

As with the new MIBC guidelines, recently updated NMIBC guidelines from the AUA/SUO (2016) recommend best practices in the areas of diagnosis, evaluation, treatment parameters and patient follow up.

Chang highlights several points:

  • Risk stratification; recognition that not every test may be required for every patient
  • Diagnosis and/or surveillance; use of enhanced cystoscopy (e.g., blue light cystoscopy)
  • Diagnosis; the use of upper urinary tract imaging and/or prostatic urethral biopsies alongside enhanced cystoscopy, ureteroscopy or random bladder biopsies
  • Post-operative intravesical chemotherapy; updated recommendations for patients with high-, intermediate- and low-risk disease
  • Urinary biomarkers; research does not support their use in replacing cystoscopic surveillance; for low-risk patients, urinary biomarkers should not be used during routine surveillance
  • BCG; currently, evidence is insufficient to recommend a particular strain, strength or combination; BCG is not recommended continually beyond two courses
  • Surveillance and follow up; for high-risk and intermediate patients, continuous careful evaluation with shorter intervals between cystoscopic evaluation; for low-risk patients, reduced surveillance, when appropriate

Looking to the Future of MIBC and NMIBC Treatment

Chang noted that, in providing an evidence-based assessment of current bladder cancer treatments, the MIBC and NMIBC guidelines also identify many areas for further research and innovation.

These areas include:

  • Further advancements in enhanced cystoscopy
  • Robotic resection technologies for bladder tumors
  • Novel agents to improve BCG efficacy or manage BCG failures
  • The use of less-common, potentially less-toxic agents for chemotherapy prior to radical cystectomy
  • Identification of a better urinary biomarker
  • Improving pre-surgical and post-treatment regimens (e.g., nutrition and exercise) to optimize long-term outcomes
  • Immunotherapy, including \in earlier-stage and non-invasive bladder cancers

Chang said he is pleased that many of these innovations are advancing so rapidly, particularly within his home institution. “We’ve got exciting things going on at Vanderbilt, not only with diagnosis and evaluation but also treatment for both invasive and non-invasive bladder cancer patients.”

Listen to an audio interview with Sam S. Chang, M.D., about the MIBC and NMIBC guidelines.