The American Urological Association (AUA)/Society of Urologic Oncology (SUO) has just released a guideline amendment for nonmuscle invasive bladder cancer (NMIBC).
Updates were made to sections on variant histologies, urine markers after diagnosis, intravesical therapy, bacillus Calmette-Guérin (BCG) maintenance, chemotherapy/BCG combinations, and enhanced cystoscopy, according to Jeffrey M. Holzbeierlein, MD, of the University of Kansas Cancer Center in Kansas City, and colleagues, who provided a summary in The Journal of Urology.
Based on grade B evidence, a clinician should use blue light cystoscopy during transurethral resection of bladder tumor (TURBT) to increase detection and decrease recurrence. Grade C evidence also allows use of narrow-band imaging.
With respect to managing bladder cancer with a variant histology, based on expert opinion, the guideline suggests performing a restaging TURBT within 4-6 weeks of the initial TURBT if considering a bladder-sparing approach.
Based on expert option, urine biomarkers can be used to gauge response to intravesical BCG and aid cases of equivocal cytology. Studies indicate that a persistently positive UroVysion® FISH following completion of induction BCG predicts a poor response.
Based on grade B evidence, in a patient with low- or intermediate-risk bladder cancer, a clinician should consider instilling a single dose of intravesical chemotherapy such as gemcitabine or mitomycin C within 24 hours of TURBT unless the patient has a perforation or extensive resection.
Grade C evidence recommends treating high-risk patient with BCG failure with radical cystectomy. Based on grade C evidence, a patient with high-grade NMIBC within 12 months of adequate BCG therapy who forgoes cystectomy can be offered clinical trial enrollment, intravesical nadofaragene firadenovec-vncg or gemcitabine/docetaxel. A patient with carcinoma in situ (CIS) can be offered systemic pembrolizumab.
As for future directions, the CX Bladder platform and urinary cell free DNA hold promise for detection and risk stratification. Novel therapies are being explored to increase BCG response or manage BCG failure. In the Quilt -3.0-32 trial, BCG plus nogapendekin alfa inbakicept, an IL-15 superagonist, achieved a 1-year disease free survival rate of 45% in BCG-unresponsive CIS and papillary bladder cancer.
For MIBC detection in patients with high-risk NMIBC, mpMRI with use of the vesical imaging reporting and data system (VI-RADS) and 3 Tesla MR systems shows promise.
Access the full updated guideline at auanet.org/NMIBCGuideline.