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Bladder cancer

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Updated 2024 ESMO guidelines for the management of advanced urothelial carcinoma.

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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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 Society of Medical Oncology (ESMO 2024,2022,2014), the European Association of Urology (EAU 2023,2021), 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 2023 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 factors: as per EAU 2021 guidelines, recognize that there are several risk factors connected with the risk of BC, with tobacco smoking as the most important one.
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  • Staging

Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, use validated questionnaires to assess health-related QoL in patients with muscle-invasive BC, both at baseline and post-treatment.
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  • Urinary tract imaging

  • Imaging for staging

  • Laboratory tests

Diagnostic procedures

Cystoscopy and ureteroscopy
As per EAU 2023 guidelines:
Perform cystoscopy for the diagnosis of BC.
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Describe all macroscopic features of the tumor (site, size, number, and appearance) and mucosal abnormalities during cystoscopy. Use a bladder diagram.
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  • Cytology

  • Biopsy and histopathology

  • Molecular testing

Medical management

Management of non-muscle-invasive cancer, general principles: as per ESMO 2022 guidelines, follow a risk-stratified approach with transurethral resection of the bladder tumor and intravesical chemotherapy or BCG in intermediate- and high-risk patients with non-muscle-invasive BC.
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  • 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 (chemotherapy)

  • Management of muscle-invasive cancer (radiotherapy)

  • 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 2023 guidelines, counsel patients to stop active smoking and avoid passive smoking.
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Perioperative care

Perioperative care: as per EAU 2023 guidelines, do not offer preoperative bowel preparation.
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Surgical interventions

Transurethral resection of tumor, non-muscle invasive cancer: as per EAU 2021 guidelines, perform TURBT and pathology investigation of the obtained specimens as a diagnostic procedure and initial treatment step in patients with suspected BC.
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  • Transurethral resection of tumor (muscle invasive cancer)

  • Radical cystectomy (non-muscle-invasive cancer)

  • Radical cystectomy (muscle-invasive cancer)

  • Pelvic lymphadenectomy

  • Urinary diversion

  • TURP

  • Sexual-preserving surgery

Specific circumstances

Elderly patients: as per EAU 2023 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 2023 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 2023 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 2021 guidelines, use the 2006 EORTC scoring model to predict the risk of tumor recurrence in individual patients not treated with BCG.
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  • Surveillance (muscle-invasive cancer)

  • Surveillance (metastatic cancer)