Welcome to the Non-Muscle Invasive Bladder Cancer Navigator adapted from AUA Guidelines.
Steps:
- Differentiate primary from recurrent tumor
- Risk stratify the patient
- Follow the most update AUA guidelines recommendations to generate a treatment plan
Step 1:
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Initial/reTURBT vs TURBT for Recurrent Tumor:
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Time to Recurrence:
Step 2: Risk Stratification
A Non-Muscle Invasive Bladder Cancer Recurrence > 1 year from previous resection is treated as a de novo primary tumor.
Use the highest risk tumor pathologic features to risk stratify the patient.
Step 3: Treatment Recommendations for Low Risk NMIBC
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Post Operative Chemotherapy:
Unless there is concern for systemic absorption, a single dose of intravesical chemotherapy should be administered within 24 hours of TURBT.
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Residual Tumor at 3 Month Surveillance Cystoscopy:
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Subsequent surveillance cystoscopy at 9-12 months and then annually for four more years. If there is no recurrence continuation of surveillance cystoscopy should be based on joint-decision making.
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Volume of Recurrence:
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Consider office fulguration if the recurrence is small (<1cm). Otherwise, repeat resection and risk stratification using the most aggressive pathological features.
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Repeat resection and risk stratification using most aggressive pathological features.
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Step 3: Treatment Recommendations for Intermediate Risk NMIBC
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Completeness of TURBT:
Remains Intermediate Risk:
Reassess patient based on higher risk tumor pathologic features.
Induction Intravesical Therapy with either BCG or chemotherapy (options: mitomycin C, gemcitabine, docetaxel, epirubicin, doxorubicin) to reduce recurrent disease.
Response to Initial Induction:
Initial Induction with BCG:
Induction BCG: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Response to Induction BCG:
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Perform repeat TURBT with optional postoperative intravesical therapy. Then reassess risk accordingly.
Induction Intravesical Therapy with either BCG or chemotherapy (options: mitomycin C, gemcitabine, docetaxel, epirubicin, doxorubicin) to reduce recurrent disease.
Response to Initial Induction:
Initial Induction with BCG:
Induction BCG: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Response to Induction BCG:
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
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T1 patients are at increased risk for upstaging
Perform repeat TURBT with optional postoperative intravesical therapy. Then reassess risk accordingly.
Remains Intermediate Risk:
Reassess patient based on higher risk tumor pathologic features.
Induction Intravesical Therapy with either BCG or chemotherapy (options: mitomycin C, gemcitabine, docetaxel, epirubicin, doxorubicin) to reduce recurrent disease.
Response to Initial Induction:
Initial Induction with BCG:
Induction BCG: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Response to Induction BCG:
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3, 6, and 12 months.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Step 3: Treatment Recommendations for High Risk NMIBC
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Perform repeat TURBT with optional postoperative intravesical therapy. Then reassess risk accordingly.
Remains High Risk:
Reassess patient based on higher risk tumor pathologic features.
Induction BCG: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Response to Induction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3 and 6 months, and then every 6 months for a total of 3 years.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3 and 6 months, and then every 6 months for a total of 3 years.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Induction BCG: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Response to Induction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3 and 6 months, and then every 6 months for a total of 3 years.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3 and 6 months, and then every 6 months for a total of 3 years.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
Reinduction BCG Therapy: Administer BCG weekly for six weeks to reduce recurrent disease and decrease progression of disease.
Complete Response to Reinduction BCG:
Consider Cystectomy: However, if a patient is unfit/unwilling to undergo surgery, treat with intravesical therapy or enroll patient in a clinical trial.
Maintenance BCG: Continue with maintenance BCG therapy (once a week for 3 weeks) at 3 and 6 months, and then every 6 months for a total of 3 years.Surveillance: Cystoscopy with cytology every three to four months for the first two years, then every six months for the next two years, and then annually thereafter.
This app was adapted by Dr. Jonathan Katz and Dr. Chad Ritch based on the AUA guidelines, “Diagnosis and Treatment of Non-muscle invasive bladder cancer: American Urological Association/Society of Urologic Oncology Joint Guideline (2016).” This app has not been approved or endorsed by the American Urological Association. Users should refer to the complete guideline at https://www.auanet.org/guidelines/bladder-cancer-non-muscle-invasive-guideline.
This app is meant to assist clinical providers in navigating through the guideline. All clinical decisions are the sole responsibility of the provider and should be made based on their expertise and discretion.
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