Recommandations du Comité de cancérologie de l’Association Française d’Urologie (CC-AFU) pour la bonne pratique des instillations intravésicales de mitomycine C, d’épirubicine et de BCG pour le traitement des tumeurs de la vessie n’infiltrant pas le muscle (TVNIM)

French AFU Cancer Committee Guidelines - Update 2024-2026: Non-muscle invasive bladder cancer (NMIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of non-muscle invasive bladder cancer (NMIBC).

METHODS

A systematic review (Medline) of the literature from 20222024 was performed, taking into account the elements of diagnosis, treatment options and monitoring of NMIBC and evaluating references with their level of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, or CIS) is made after complete and deep tumour resection. The use of bladder photodynamic diagnosis and the indication for a second TURBT (4 to 6weeks later) help to improve the initial diagnosis. The risk of recurrence and/or tumour progression is assessed via the EORTC score. By stratifying patients into low-, intermediate- and high-risk groups, adjuvant treatment can be proposed, including endovesical instillations of chemotherapy (immediate postoperative regimen), BCG (induction and maintenance regimen), or even the indication of cystectomy for unresponsive patients.

CONCLUSION

Updating the CCAFU's recommendations should help improve patient management, as well as the diagnosis and treatment of NMIBC.

Incidence, initial management and survival of high-risk non-muscle invasive bladder cancer in Northern France

OBJECTIVE

Information on bladder cancer (BC) according to the risk scoring for recurrence or progression in a general population is scarce despite its clinical relevance. The objective was to describe the characteristics of incident BC in a general population, with a focus on the initial management of high-risk non-muscle invasive BC (HR-NMIBC).

MATERIALS

BC incident in 2011-2012 recorded in a population-based cancer registry were studied. Data was extracted from medical files. NMIBC were classified according to potential risk for recurrence/progression. Individual and tumor characteristics of incident BC were described. Incidence, initial management and survival (12/31/2021) of HR-NMIBC were assessed.

RESULTS

Among 538 BC cases, 380 were NMIBC [119 low (22.1%), 163 intermediate (30.3%), 98 high (18.2%) risk] and 147 (27.3%) were MIBC. HR-NMIBC diagnostic and therapeutic management [imaging, re-TUR, multidisciplinary team meetings (MDT) assessment, specific treatment] revealed discrepancies with guidelines recommendations. Seventy-two out of 98 cases were assessed in an MDT with a median time from diagnosis of 18days [first quartile: 12-third quartile: 32]. Globally, treatment agreed with MDT decisions. Intravesical instillation was the most common treatment (n=56) but 27 HR-NMIBC did not receive specific treatment after TUR. Five and 10years overall survival was 52% [42-63] and 41% [31-51], respectively. Five years net survival was 63% [47-75].

CONCLUSIONS

Despite National cancer plans aiming to improve care giving and despite the severity of HR-NMIBC, guideline-recommended patterns of care were underused in this region. This may deserve attention to identify obstacles to guideline adoption to try to improve BC patient care and survival.

LEVEL OF EVIDENCE: 3

Antibiotic therapy impact on intravesical BCG therapy efficacy for high-risk localized bladder cancer treatment

Intravesical Bacillus Calmettes-Guerin (BCG) instillations is the gold standard adjuvant treatment for high and very high-risk non-muscle-invasive bladder cancer (NMIBC). Antibiotics may be required to treat asymptomatic bacteriuria before instillations or to prevent side effects. By modifying the bladder microbiota and through its bactericidal action, it could modify the efficacy of BCG. This study evaluates the impact of antibiotics received during BCG-induction treatment on the oncological outcomes for high and very high risk NMIBC. We retrospectively included all patients who received a full induction regimen of BCG therapy between January 2017 and June 2022. Clinical and tumor characteristics as well as tolerability were collected. Recurrence-free survival (RFS) and progression-free survival (PFS) were compared according to the prescription of antibiotics, its type and duration. A total of 126 patients were included, 86.5% of the tumors were high risk and 13.5% very high risk. The median follow-up was 31 months (7-60). 36% of the patients received antibiotics during BCG-induction treatment (among which 44% received fluoroquinolones). 21.4% of patients had tumor recurrence. There was no difference in RFS (p=0.902) or PFS (p=0.88) according to the duration or the type of antibiotics received. The use of a prolonged antibiotic treatment (> 7 days) significantly increased the duration of the BCG-induction treatment from 35 to 41,5 days (p=0,049) and the median number of delayed treatments by 1,5 [0-4]. Neither the use of antibiotics nor their duration modified the risk of recurrence or the intensity of side effects in multivariate analysis. Antibiotics received during BCG-induction immunotherapy did not influence oncological short-term outcomes or intensity of side effects.

French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

OBJECTIVE

To update the ccAFU recommendations for the management of bladder tumours that do not infiltrate the bladder muscle (NBMIC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed, taking account of the diagnosis, treatment options and surveillance of NMIBC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, CIS) is made after complete full-thickness tumour resection. The use of bladder fluorescence and the indication of a second look (4-6 weeks) help to improve the initial diagnosis. The EORTC score is used to assess the risk of recurrence and/or tumour progression. Through the stratification of patients in low, intermediate and high-risk categories, adjuvant treatment can be proposed: intravesical chemotherapy (immediate postoperative, initiation regimen) or BCG (initiation and maintenance regimen) instillations, or even the indication of cystectomy for BCG-resistant patients.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and treatment of NMIBC.