Bladder cancer: diagnosis andmanagementNICE guidelinePublished: 25 February 2015nice.org.uk/guidance/ng2 NICE 2015. All rights reserved.
Bladder cancer: diagnosis and management (NG2)ContentsIntroduction . 4Medicines . 5Patient-centred care. 6Key priorities for implementation . 7Information and support for people with bladder cancer . 7Diagnosing and staging bladder cancer . 7Treating non-muscle-invasive bladder cancer. 8Follow-up after treatment for non-muscle-invasive bladder cancer . 9Treating muscle-invasive bladder cancer . 91 Recommendations .101.1 Information and support for people with bladder cancer . 101.2 Diagnosing and staging bladder cancer . 121.3 Treating non-muscle-invasive bladder cancer . 131.4 Follow-up after treatment for non-muscle-invasive bladder cancer. 171.5 Treating muscle-invasive bladder cancer. 181.6 Follow-up after treatment for muscle-invasive bladder cancer . 201.7 Managing locally advanced or metastatic muscle-invasive bladder cancer . 211.8 Specialist palliative care for people with incurable bladder cancer . 242 Research recommendations .262.1 Patient satisfaction . 262.2 BCG or primary cystectomy in high-risk non-muscle-invasive bladder cancer. 262.3 Follow-up of high-risk non-muscle-invasive bladder cancer. 272.4 Biomarkers for treatment selection. 282.5 Follow-up after radical treatment for organ-confined muscle-invasive bladder cancer . 283 Other information .293.1 Scope and how this guideline was developed. 293.2 Related NICE guidance. 29 NICE 2015. All rights reserved.Page 2 of 55
Bladder cancer: diagnosis and management (NG2)4 The Guideline Development Group, National Collaborating Centre and NICE project team, anddeclarations of interests.314.1 Guideline Development Group . 314.2 National Collaborating Centre for Cancer . 324.3 NICE project team. 334.4 Declarations of interests . 34About this guideline .53Strength of recommendations. 53Other versions of this guideline . 54Implementation . 54Your responsibility. 54Copyright. 55 NICE 2015. All rights reserved.Page 3 of 55
Bladder cancer: diagnosis and management (NG2)This guideline is the basis of QS106.IntroductionBladder cancer is the seventh most common cancer in the UK. It is 3–4 times more common in menthan in women. In the UK in 2011, it was the fourth most common cancer in men and the thirteenthmost common in women. There were 10,399 people diagnosed with bladder cancer and5081 deaths from bladder cancer in 2011. The majority of cases occur in people aged over 60. Themain risk factor for bladder cancer is increasing age, but smoking and exposure to some industrialchemicals also increase risk.Bladder cancer is usually identified on the basis of visible blood in the urine or blood found on urinetesting, but emergency admission is a common way for bladder cancer to present, and is oftenassociated with a poor prognosis.Most bladder cancers (75–80%) do not involve the muscle wall of the bladder and are usuallytreated by telescopic removal of the cancer (transurethral resection of bladder tumour [TURBT]).This is often followed by instillation of chemotherapy or vaccine-based therapy into the bladder,with prolonged telescopic checking of the bladder (cystoscopy) as follow-up. Some people in thisgroup who are at higher risk are treated with major surgery to remove the bladder (cystectomy).People with cancer in or through the bladder muscle wall may be treated with intent to cure usingchemotherapy, cystectomy or radiotherapy, and those who have cancer too advanced to cure mayhave radiotherapy and chemotherapy.The involvement of the urogenital tract and the nature of the treatments give this cancer a strongpsychological impact, in addition to the physical impact of the disease and its treatments, which isoften profound. The prevalence of the condition and the nature of its management make bladdercancer one of the most expensive cancers for the NHS.There is thought to be considerable variation across the NHS in the diagnosis and management ofbladder cancer and the provision of care to people who have it. There is evidence that the patientexperience for people with bladder cancer is worse than that for people with other cancers.This guideline covers adults (18 years and older) referred from primary care with suspectedbladder cancer and those with newly diagnosed or recurrent bladder (urothelial carcinoma,adenocarcinoma, squamous-cell carcinoma or small-cell carcinoma) or urethral cancer. There was NICE 2015. All rights reserved.Page 4 of 55
Bladder cancer: diagnosis and management (NG2)insufficient high-quality evidence on which to make specific recommendations for non-urothelialbladder cancer (adenocarcinoma, squamous-cell carcinoma or small-cell carcinoma).It does not cover people aged under 18 or adults with bladder sarcoma, urothelial cancer of theupper urinary tract, or secondary bladder or urethral cancer (for example, bowel or cervix cancerspreading into the bladder).MedicinesThe guideline assumes that prescribers will use a medicine's summary of product characteristics toinform decisions made with individual patients.This guideline recommends some medicines for indications for which they do not have a UKmarketing authorisation at the date of publication, if there is good evidence to support that use.The prescriber should follow relevant professional guidance, taking full responsibility for thedecision. The patient (or those with authority to give consent on their behalf) should provideinformed consent, which should be documented. See the General Medical Council's Prescribingguidance: prescribing unlicensed medicines for further information. Where recommendations havebeen made for the use of medicines outside their licensed indications ('off-label use'), thesemedicines are marked with a footnote in the recommendations. NICE 2015. All rights reserved.Page 5 of 55
Bladder cancer: diagnosis and management (NG2)Patient-centred careThis guideline offers best practice advice on the care of adults with bladder cancer.Patients and healthcare professionals have rights and responsibilities as set out in the NHSConstitution for England – all NICE guidance is written to reflect these. Treatment and care shouldtake into account individual needs and preferences. Patients should have the opportunity to makeinformed decisions about their care and treatment, in partnership with their healthcareprofessionals. Healthcare professionals should follow the Department of Health's advice onconsent. If someone does not have capacity to make decisions, healthcare professionals shouldfollow the code of practice that accompanies the Mental Capacity Act and the supplementary codeof practice on deprivation of liberty safeguards.NICE has produced guidance on the components of good patient experience in adult NHS services.All healthcare professionals should follow the recommendations in patient experience in adult NHSservices. NICE 2015. All rights reserved.Page 6 of 55
Bladder cancer: diagnosis and management (NG2)Key priorities for implementationThe following recommendations have been identified as priorities for implementation. The full listof recommendations is in section 1.Information and support for people with bladder cancerUse a holistic needs assessment to identify an individualised package of information andsupport for people with bladder cancer and, if they wish, their partners, families or carers, atkey points in their care such as:when they are first diagnosedafter they have had their first treatmentif their bladder cancer recurs or progressesif their treatment is changedif palliative or end of life care is being discussed.Diagnosing and staging bladder cancerDiagnosisConsider CT or MRI staging before transurethral resection of bladder tumour (TURBT) ifmuscle-invasive bladder cancer is suspected at cystoscopy.Offer white-light-guided TURBT with one of photodynamic diagnosis, narrow-band imaging,cytology or a urinary biomarker test (such as UroVysion using fluorescence in-situhybridization [FISH], ImmunoCyt or a nuclear matrix protein 22 [NMP22] test) to people withsuspected bladder cancer. This should be carried out or supervised by a urologist experiencedin TURBT.Offer people with suspected bladder cancer a single dose of intravesical mitomycin C given atthe same time as the first TURBT. NICE 2015. All rights reserved.Page 7 of 55
Bladder cancer: diagnosis and management (NG2)Treating non-muscle-invasive bladder cancerPrognostic markmarkersers and risk classificationEnsure that for people with non-muscle-invasive bladder cancer all of the following arerecorded and used to guide discussions, both within multidisciplinary team meetings and withthe person, about prognosis and treatment options:recurrence historysize and number of cancershistological type, grade, stage and presence (or absence) of flat urothelium, detrusormuscle (muscularis propria), and carcinoma in situthe risk category of the person's cancerpredicted risk of recurrence and progression, estimated using a risk prediction tool.High-risk non-muscle-innon-muscle-invasivvasivee bladder cancerOffer the choice of intravesical BCG (Bacille Calmette-Guérin) or radical cystectomy to peoplewith high-risk non-muscle-invasive bladder cancer, and base the choice on a full discussionwith the person, the clinical nurse specialist and a urologist who performs both intravesicalBCG and radical cystectomy. Include in your discussion:the type, stage and grade of the cancer, the presence of carcinoma in situ, the presenceof variant pathology, prostatic urethral or bladder neck status and the number oftumoursrisk of progression to muscle invasion, metastases and deathrisk of understagingbenefits of both treatments, including survival rates and the likelihood of furthertreatmentrisks of both treatmentsfactors that affect outcomes (for example, comorbidities and life expectancy)impact on quality of life, body image, and sexual and urinary function. NICE 2015. All rights reserved.Page 8 of 55
Bladder cancer: diagnosis and management (NG2)Follow-up after treatment for non-muscle-invasive bladder cancerLow-risk non-muscle-innon-muscle-invasivvasivee bladder cancerDischarge to primary care people who have had low-risk non-muscle-invasive bladder cancerand who have no recurrence of the bladder cancer within 12 months.Intermediate-risk non-muscle-innon-muscle-invasivvasivee bladder cancerOffer people with intermediate-risk non-muscle-invasive bladder cancer cystoscopic follow-upat 3, 9 and 18 months, and once a year thereafter.Treating muscle-invasive bladder cancerNeoadjuvant chemotherchemotherapapyy for newly diagnosed muscle-inmuscle-invasivvasivee urothelial bladdercancerOffer neoadjuvant chemotherapy using a cisplatin combination regimen before radicalcystectomy or radical radiotherapy to people with newly diagnosed muscle-invasive urothelialbladder cancer for whom cisplatin-based chemotherapy is suitable. Ensure that they have anopportunity to discuss the risks and benefits with an oncologist who treats bladder cancer.Radical thertherapapyy for muscle-inmuscle-invasivvasivee urothelial bladder cancerOffer a choice of radical cystectomy or radiotherapy with a radiosensitiser to people withmuscle-invasive urothelial bladder cancer for whom radical therapy is suitable. Ensure that thechoice is based on a full discussion between the person and a urologist who performs radicalcystectomy, a clinical oncologist and a clinical nurse specialist. Include in the discussion:the prognosis with or without treatmentthe limited evidence about whether surgery or radiotherapy with a radiosensitiser is themost effective cancer treatmentthe benefits and risks of surgery and radiotherapy with a radiosensitiser, including theimpact on sexual and bowel function and the risk of death as a result of the treatment. NICE 2015. All rights reserved.Page 9 of 55
Bladder cancer: diagnosis and management (NG2)Recommendations1The following guidance is based on the best available evidence. The full guideline gives details ofthe methods and the evidence used to develop the guidance.The wording used in the recommendations in this guideline (for example, words such as 'offer'and 'consider') denotes the certainty with which the recommendation is made (the strength ofthe recommendation). See about this guideline for details.1.1Information and support for people with bladder cancer1.1.1Follow the recommendations on communication and patient-centred care inNICE's guideline on patient experience in adult NHS services and the advice inNICE's guidelines on improving outcomes in urological cancers and improvingsupportive and palliative care for adults with cancer throughout the person'scare.1.1.2Offer clinical nurse specialist support to people with bladder cancer and givethem the clinical nurse specialist's contact details.1.1.3Ensure that the clinical nurse specialist:acts as the key worker to address the person's information and care needshas experience and training in bladder cancer care.1.1.4Use a holistic needs assessment to identify an individualised package ofinformation and support for people with bladder cancer and, if they wish, theirpartners, families or carers, at key points in their care such as:when they are first diagnosedafter they have had their first treatmentif their bladder cancer recurs or progressesif their treatment is changedif palliative or end of life care is being discussed. NICE 2015. All rights reserved.Page 10 of 55
Bladder cancer: diagnosis and management (NG2)1.1.5When carrying out a holistic needs assessment, recognise that many of thesymptoms, investigations and treatments for bladder cancer affect theurogenital organs and may be distressing and intrusive. Discuss with the person:the type, stage and grade of their cancer and likely prognosistreatment and follow-up optionsthe potential complications of intrusive procedures, including urinary retention,urinary infection, pain, bleeding or need for a catheterthe impact of treatment on their sexual health and body image, including how to findsupport and information relevant to their genderdiet and lifestyle, including physical activitysmoking cessation for people who smokehow to find information about bladder cancer, for example through informationprescriptions, sources of written information, websites or DVDshow to find support groups and survivorship programmeshow to find information about returning to work after treatment for cancerhow to find information about financial support (such as free prescriptions andindustrial compensation schemes).1.1.6Offer smoking cessation support to all people with bladder cancer who smoke,in line with NICE's guidelines on smoking cessation services and briefinterventions and referral for smoking cessation.1.1.7Offer people with bladder cancer and, if they wish, their partners, families orcarers, opportunities to have discussions at any stage during their treatmentand care with:a range of specialist healthcare professionals, including those who can providepsychological supportother people with bladder cancer who have had similar treatments. NICE 2015. All rights reserved.Page 11 of 55
Bladder cancer: diagnosis and management (NG2)1.1.8Clinic
Follow-up after treatment for non-muscle-invasive bladder cancer Low-risk non-muscle-invasive bladder cancer Discharge to primary care people who have hadlow-risknon-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12months. Intermediate-risk non-muscle-invasive bladder cancer
538 Applications of Nanotechnology in Bladder Cancer Therapy Figure 1. The staging of bladder cancer and therapeutic treatments. The staging of bladder cancer is based on the location and spread of bladder cancer cells. Ta: Non-invasive papillary carcinoma; T1: The tumor has grown from
Uncontrolled urination or inability to empty your bladder can have a negative effect on your quality of life and cause bladder and kidney infections and other problems. Appropriate bladder management can help keep your bladder and kidneys healthy. Each type of bladder management option has pros and cons.
muscle Tis: Carcinoma in situ—A high-grade cancer . It looks like a reddish, velvety patch on the bladder lining T1: Tumor goes through the bladder lining but does not reach the muscle layer T2: Tumor grows into the muscle layer of the bladder T3: Tumor goes past the muscle layer into tissues surrounding the bladder
Recurrence and routine surveillance/treatment make bladder cancer most expensive malignancy to treat from diagnosis to death ( 187,241/patient in 2001) M:F 3:1 (survival better in men) Peak incidence ages 60-70 Majority ( 93%) are urothelial cancer (transitional cell carcinoma) Siegel et al. CA Cancer J Clin 2014.
As the Chair and Co-Chair of the Kansas Cancer Partnership (KCP), we are pleased to provide . you with the 2017-2021 Kansas Cancer Prevention and Control Plan. This plan is the result of . Breast Biopsies Breast Cancer Cervical Cancer Colorectal Cancer Lung Cancer Prostate Cancer. Post-Diagnosis & Quality of Life throughout the Cancer Journey.
Ovarian cancer is the seventh most common cancer among women. There are three types of ovarian cancer: epithelial ovarian cancer, germ cell cancer, and stromal cell cancer. Equally rare, stromal cell cancer starts in the cells that produce female hormones and hold the ovarian tissues together. Familial breast-ovarian cancer
Alcohol before breast cancer diagnosis and breast cancer mortality . 81 Alcohol less than 12 months after diagnosis and breast cancer mortality . 86 Alcohol intake 12 months or more after primary breast cancer diagnosis and breast . Before diagnosis BMI and cardiovascular disease mortality . 317 BMI less than 12 months after .
functional elements in human DNA. This includes: protein-coding genes non-protein-coding genes regulatory elements involved in the control of gene transcription DNA sequences that mediate chromosomal structure and dynamics. The ENCODE Project catalog of functional elements ENCODE has catalogued functional elements in human, mouse, Drosophila, and a nematode. Conclusions of the ENCODE project .