ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of invasive bladder cancer
L. Sengeløv
Department of Oncology, Herlev University Hospital, Herlev, Denmark
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Incidence
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- The crude incidence of bladder cancer in the European Union is 23 cases/100 000 per year, and the mortality is 10 cases/ 100 000 per year. Seventy per cent of patients with bladder cancer are >65 years of age.
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Diagnosis
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- Pathological diagnosis should be made according to the WHO classification from a biopsy obtained by transurethral resection (TUR) of primary tumor; 90% of bladder carcinomas are transitional cell carcinomas.
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Staging and risk assessment
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- Staging and risk assessment should be by complete history and physical examination, blood counts, creatinine, chest X-ray and computed tomography (CT) scan of the abdomen if invasive tumor is diagnosed and cystoscopic examination and TUR with a biopsy and determination of size and the presence of extravesical extension or invasion of adjacent organs.
Patients with bladder cancer should be staged according to the TNM-97 system and be grouped into the following risk categories (Table 1):
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Treatment of stage I disease
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- TUR and fulguration are the treatment of choice but careful surveillance is important. Intravesical therapy with BCG or chemotherapy may be used in patients with recurrent superficial tumors [I, A]. Radical cystectomy or curative radiotherapy in patients with high-risk tumors (recurrent, large, multifocal, poorly differentiated or with carcinoma in situ).
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Treatment of stage II and III disease
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- Radical cystectomy with or without pelvic lymph node dissection is considered standard treatment. Patients unfit for surgery should receive full-dose external-beam radiotherapy. TUR with fulguration in selected cases. Neoadjuvant chemotherapy or chemo-radiotheraphy is under investigation to provide organ-sparing treatment.
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Treatment of stage IV disease
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- Platinum-based combination chemotherapy (methotrexate, vinblastine, doxorubicin, cisplatin or gemcitabine, cisplatin) prolongs survival [I, A]. Patients with T4b and/or N1 may be candidates for cystectomy and lymph node dissection or radiotherapy in selected cases.
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Response evaluation
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- Response evaluation is mandatory after radiotherapy by repetition of cystoscopy after 3 months. Response evaluation during chemotherapy with the initial radiographic tests are recommended.
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Follow-up
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- For patients treated with full-dose external-beam radiotherapy, cystoscopy and urinary cytology should be performed every 3 months during the first 2 years, and every 6 months thereafter. After cystectomy, clinical control should be performed every 3 months during the first 2 years and subsequently every 6 months for 5 years.
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Note
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Levels of Evidence [IV] and Grades of Recommendation [AD] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.
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Literature
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Coordinating author for the ESMO Guidelines Task Force: L. Sengeløv, Department of Oncology, Herlev University Hospital, Herlev, Denmark.
Approved by the ESMO Guidelines Task Force: August 2002.
Correspondence to:
ESMO Guidelines Task Force
ESMO Head Office
Via La Santa 7
CH-6962 Viganello-Lugano
Switzerland
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References
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1. Herr HW, Schwalb DM, Zhang ZF et al. Intravesical bacillus CalmetteGuerin therapy prevents tumor progression and death from superficial bladder cancer: ten-year follow-up of a prospective randomized trial. J Clin Oncol 1995; 13: 14041408.[Abstract]
2. International Collaboration of Trialists. Neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: a randomised controlled trial. Lancet 1999; 354: 533540.[CrossRef][ISI][Medline]
3. Coppin C, Cospodarowicz M. The NCI-Canada trial of concurrent cisplatin and radiotherapy for muscle invasive bladder cancer. Prog Clin Biol Res 1990; 353: 7583.[Medline]
4. Loehrer PJ, Einhorn LH, Elson PJ et al. A randomized comparison of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma. J Clin Oncol 1992; 10: 10661073.[Abstract]
5. Mead G, Russel M, Clark P et al. A randomized trial comparing methotrexate and vinblastine (MV) with cisplatin, methotrexate and vinblastine (CMV) in advanced transitional cell carcinoma: results and a report on prognostic factors in a Medical Research Council study. Br J Cancer 1998; 78: 10671075.[ISI][Medline]
6. von der Maase H, Hansen SW, Roberts JT et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000; 18: 30683077.[Abstract/Free Full Text]