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Bladder cancer

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Updated 2024 EAU guidelines for the diagnosis and management of bladder cancer.

Background

Overview

Definition
BC is a malignancy that originates in the epithelial lining of the bladder.
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Pathophysiology
The pathophysiology of BC involves abnormal and uncontrolled growth of cells in the bladder lining leading to the formation of a tumor, which can be noninvasive or invasive.
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Epidemiology
The prevalence of BC worldwide is estimated at 35.05 per 100,000 population.
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Risk factors
Risk factors for BC include tobacco smoking )the most prevalent risk factor), occupational exposure to carcinogenic substances. advanced age, male gender, and a history of chronic bladder inflammation.
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Disease course
Clinically, BC often presents with gross or microscopic hematuria, urinary urgency, and pelvic pain. Diagnosis is typically made through cystoscopy and upper tract imaging.
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Prognosis and risk of recurrence
The prognosis of BC is influenced by several factors. The stage of the cancer at diagnosis is a key determinant, with each successive stage carrying a worse prognosis.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of bladder cancer are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the European Society of Medical Oncology (ESMO 2024,2022), the American Urological Association (AUA/SUO/ASTRO/ASCO 2017), the American Urological Association (AUA/SUO 2016), and the U.S. Preventive Services Task Force (USPSTF 2011).
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Screening and diagnosis

Indications for screening: as per EAU 2024 guidelines, take into account the increased risk of developing BC in patients undergoing external-beam radiation therapy, brachytherapy, or a combination of those, during follow-up. Follow-up closely patients treated with radiation at a young age, as they are at the greatest risk and BC requires time to develop.
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Classification and risk stratification

Risk stratification: as per EAU 2024 guidelines, consider using the 2021 EAU risk group calculator to stratify patients into the following four risk groups to predict progression
Situation
Guidance
Low risk
A primary, single, TaT1 LG/G1 tumor < 3 cm in diameter without carcinoma in situ in patients aged ≤ 70 years
A primary Ta LG/G1 tumor without carcinoma in situ with at most one of the additional clinical risk factors
Intermediate risk
Patients without carcinoma in situ not included in either the low-, high-, or very high-risk groups
High risk
All T1 high-grade/grade 3 without carcinoma in situ, except those included in the very high-risk group
All carcinoma in situ patients, except those included in the very high-risk group
Ta low-grade/grade 2 or T1 grade 1, no carcinoma in situ with all 3 risk factors
Ta high-grade/grade 3 or T1 low-grade, no carcinoma in situ with at least 2 risk factors
T1 grade 2 no carcinoma in situ with at least 1 risk factor
Very high risk
Ta high-grade/grade 3 and carcinoma in situ with all 3 risk factors
T1 grade 2 and carcinoma in situ with at least 2 risk factors
T1 high-grade/grade 3 and carcinoma in situ with at least 1 risk factor
T1 high-grade/grade 3 no carcinoma in situ with all 3 risk factors
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European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator using the 2004/2016 World Health Organization grading system
Age
≤ 70 years
> 70 years
Number of tumors
Single
Multiple
Maximum diameter
< 3 cm
≥ 3 cm
Stage
Ta
T1
Concomitant carcinoma in situ
No
Yes
2004/2016 WHO grade
Low malignant potential-low grade
High-grade
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  • Staging

Diagnostic investigations

History and physical examination: as per EAU 2024 guidelines, elicit a patient history, focusing on urinary tract symptoms and hematuria.
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  • Urinary tract imaging

  • Imaging for staging

  • Laboratory tests

Diagnostic procedures

Cystoscopy and ureteroscopy: as per EAU 2024 guidelines, perform cystoscopy for the diagnosis of BC.
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  • Cytology

  • Biopsy and histopathology

  • Molecular testing

Medical management

Management of non-muscle-invasive cancer, general principles: as per EAU 2024 guidelines, discuss high-risk and very high-risk patients within a multidisciplinary board, when possible.
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  • Management of non-muscle-invasive cancer (active surveillance)

  • Management of non-muscle-invasive cancer (transurethral resection of tumor)

  • Management of non-muscle-invasive cancer (TURP)

  • Management of non-muscle-invasive cancer (radical cystectomy)

  • Management of non-muscle-invasive cancer (intravesical chemotherapy)

  • Management of non-muscle-invasive cancer (intravesical BCG immunotherapy)

  • Management of non-muscle-invasive cancer (salvage therapy)

  • Management of muscle-invasive cancer (general principles)

  • Management of muscle-invasive cancer (bladder-preserving therapy)

  • Management of muscle-invasive cancer (sexual-preserving surgery)

  • Management of muscle-invasive cancer (transurethral resection of tumor)

  • Management of muscle-invasive cancer (urinary diversion)

  • Management of muscle-invasive cancer (chemotherapy)

  • Management of muscle-invasive cancer (radiotherapy)

  • Management of muscle-invasive cancer (radical cystectomy)

  • Management of muscle-invasive cancer (palliative therapy)

  • Management of metastatic cancer

  • Management of persistent/recurrent disease (general principles)

  • Management of persistent/recurrent disease (non-muscle-invasive cancer)

  • Management of persistent/recurrent disease (muscle-invasive cancer)

  • Management of persistent/recurrent disease (metastatic cancer)

Nonpharmacologic interventions

Smoking cessation: as per EAU 2024 guidelines, counsel patients to stop active smoking and avoid passive smoking.
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Perioperative care

Perioperative care: as per EAU 2024 guidelines, do not offer preoperative bowel preparation.
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Specific circumstances

Elderly patients: as per EAU 2024 guidelines, screen for frailty and cognitive impairment and provide a Comprehensive Geriatric Assessment where optimization is needed.
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  • Patients with upper urinary tract cancer

Patient education

General counseling: as per EAU 2024 guidelines, inform patients of the advantages and disadvantages of open radical cystectomy and robot-assisted radical cystectomy to allow selection of the proper procedure.
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Preventative measures

Avoidance of carcinogenic substances
As per EAU 2024 guidelines:
Inform workers in potentially hazardous workplaces of the potential carcinogenic effects of a number of recognized substances, including duration of exposure and latency periods. Advise protective measures.
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Do not prescribe pioglitazone in patients with active BC or a history of BC.
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Follow-up and surveillance

Surveillance, non-muscle-invasive cancer: as per EAU 2024 guidelines, base follow-up of TaT1 tumors and carcinoma in situ on regular cystoscopy. (Strong)
perform cystoscopy at 3 months in patients with low-risk Ta tumor. Perform subsequent cystoscopy 9 months later and annually for 5 years, if the initial cystoscopy is negative.
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  • Surveillance (muscle-invasive cancer)

  • Surveillance (metastatic cancer)