Office-based Management of Nonmuscle Invasive Bladder Cancer

Key points

Natural history of noninvasive bladder cancer

Over 2.7 million people live with bladder cancer,¹ and over 380,000 incident bladder tumors were identified annually worldwide in 2008,² including 73,000 tumors in the United States.³ In fact, bladder cancer is the fifth most common cancer in the United States. The worldwide age-standardized rate (ASR) for bladder cancer is 10.1 cases per 100,000 men and 2.5 cases per 100,000 women, with a mortality rate of 4 deaths per 100,000 men and 1.1 deaths per 100,000 women.⁴ Most bladder tumors

Cost of management of low-grade bladder cancer

Depending on the model and breadth of features included, bladder cancer has been estimated as the most expensive cancer to health care systems, with a mean cost to Medicare of $96,000 to $187,000 per patient in 2001.¹⁵ In the United States, the total estimated cost in 2006 was $206 billion, with predicted productivity loss of $17.9 billion, and cancer-related morbidity of $110 billion.¹⁶ The majority of the cost for bladder cancer is hospital-based transurethral resection of a bladder tumor

Identification of patients for office-based management of bladder cancer

The critical factor to determine the suitability of office-based management of bladder cancer is an accurate assessment of risk of progression. Although the initial identification of bladder cancer occurs in the office, the authors recommend outpatient TUR with examination under anesthesia for complete and accurate staging. Based on TUR pathology, tumors amenable to office-based management are papillomas, PUNLMP, and TaLG tumors. The main concern with office-based management is missing

Effectiveness and tolerability of office-based management

Herr described the use of office-based cystoscopy with fulguration in 69 patients with both high- and low-grade lesions, some of which demonstrated invasion.²⁴ Of the 32% of patients who required TUR, 5 had CIS, and 3 had muscle invasion. Office-based fulguration was the only intervention in 68% of patients, with 30% of patients requiring repeat treatment. In a prospective study of 267 patients carefully selected (as per the Donat criteria), office-based fulguration was the only intervention

Watchful waiting of identified bladder tumors

Some patients with small or low-grade bladders tumors may be watched without the need for TUR or cystodiathermy after identification of new tumors. Soloway and colleagues²⁷ described observation of 32 patients with a mean duration of 10.8 months, and patients undergoing an average of 1.8 interval cystoscopies between treatments (range of 1–5). Importantly, the authors described a tumor growth rate of 1.77 mm per month, with a progression rate of 6.7%. Gofrit and colleagues²⁸ described the

Frequency and timing of follow-up and tumor surveillance

No prospective randomized trials have demonstrated sufficient level of evidence to support a specific surveillance protocol for the management of noninvasive bladder tumors. The goals of surveillance would be to minimize the cost and psychological burden of surveillance, tempered by prudent follow-up to prevent growth of tumors necessitating inpatient TUR. From watchful waiting studies, it has been noted that small tumors (<5 mm) may be observed for almost 10 months without intervention.²⁸ Yet,

Voided biomarkers for surveillance

The use of prognostic biomarkers could potentially play a critical role in the management of patients with low-grade bladder cancer. Invasive procedures, such as cystoscopy, could potentially be avoided if a biomarker reliably had a high negative predictive value. There are several biomarkers approved for surveillance by the US Food and Drug Administration. Voided cytology has a long-documented role in the identification of high-grade bladder cancer and can be used to identify patients who

Routine imaging for surveillance

Progression of low-grade bladder cancer to upper tract or extravesical tumors occurs at at a frequency of 40% at 15 years, including upper tract and prostate involvement.³⁷ In low-grade disease, this risk of upper tract progression was 8%, with a median time to development of 29 months.⁸ The EAU recommends no upper tract surveillance for low-risk tumors but yearly surveillance for high-risk bladder cancer.⁴ The rate of upper tract progression increases yearly, and although routine surveillance

Antibiotics, prophylaxis, and drug resistance

Asymptomatic bacteria is commonly found in elderly patients, and those instrumented for malignancy may be at an increased risk for symptomatic infection.³⁹ Patients with bladder cancer will undergo many cystoscopies during their lifetime, and unsupervised use of antibiotics to treat colonization rather than infection, even when given for procedural prophylaxis, may result in multidrug bacterial resistance. Routine use of antibiotics is recommended by the American Urological Association (AUA)

Lifestyle modification

One of the most important lifestyle changes the urologist can contribute to the overall health of patients and potentially decrease the rates of bladder tumor recurrence is counseling for smoking cessation. Duration and intensity of smoking are directly correlated to bladder cancer recurrence in patients with noninvasive bladder cancer.⁴³ Patients report poor knowledge regarding the association with smoking and their bladder cancer, and most describe increased readiness to quit if they knew

Narrow-band imaging

Narrow-band imaging (NBI) is an optical technology that employs filtering of white light into 2 narrow bands (440–460 nm and 540–560 nm) that are absorbed by hemoglobin, resulting in visual detection of increased vascularity with tumors. NBI cystoscopy increases detection of tumors resulting in decreased rates of recurrence of superficial bladder tumors.⁵² Unlike other forms of fluorescent-based imaging, NBI does not require instillation of a precursor reagent and only requires a special filter

Summary

As more is learned about the biology and natural history of bladder cancer, office-based management is becoming more widely used for low-grade and -stage lesions. Clinical decision making should be based on risk stratification. Low-risk patients can be safely followed on a semiannual or even yearly basis. Patients with high-risk tumors require more stringent cystoscopic surveillance, cytology, and yearly upper tract imaging. Smoking cessation is an invaluable tool to decrease rates of