Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Information and support for people with bladder cancer

  • Use a holistic needs assessment to identify an individualised package of information and support for people with bladder cancer and, if they wish, their partners, families or carers, at key points in their care such as:

    • when they are first diagnosed

    • after they have had their first treatment

    • if their bladder cancer recurs or progresses

    • if their treatment is changed

    • if palliative or end of life care is being discussed.

Diagnosing and staging bladder cancer

Diagnosis

  • Consider CT or MRI staging before transurethral resection of bladder tumour (TURBT) if muscle‑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‑situ hybridization [FISH], ImmunoCyt or a nuclear matrix protein 22 [NMP22] test) to people with suspected bladder cancer. This should be carried out or supervised by a urologist experienced in TURBT.

  • Offer people with suspected bladder cancer a single dose of intravesical mitomycin C given at the same time as the first TURBT.

Treating non-muscle-invasive bladder cancer

Prognostic markers and risk classification

  • Ensure that for people with non‑muscle‑invasive bladder cancer all of the following are recorded and used to guide discussions, both within multidisciplinary team meetings and with the person, about prognosis and treatment options:

    • recurrence history

    • size and number of cancers

    • histological type, grade, stage and presence (or absence) of flat urothelium, detrusor muscle (muscularis propria), and carcinoma in situ

    • the risk category of the person's cancer

    • predicted risk of recurrence and progression, estimated using a risk prediction tool.

High-risk non-muscle-invasive bladder cancer

  • Offer the choice of intravesical BCG (Bacille Calmette‑Guérin) or radical cystectomy to people with high-risk non‑muscle‑invasive bladder cancer, and base the choice on a full discussion with the person, the clinical nurse specialist and a urologist who performs both intravesical BCG and radical cystectomy. Include in your discussion:

    • the type, stage and grade of the cancer, the presence of carcinoma in situ, the presence of variant pathology, prostatic urethral or bladder neck status and the number of tumours

    • risk of progression to muscle invasion, metastases and death

    • risk of understaging

    • benefits of both treatments, including survival rates and the likelihood of further treatment

    • risks of both treatments

    • factors that affect outcomes (for example, comorbidities and life expectancy)

    • impact on quality of life, body image, and sexual and urinary function.

Follow-up after treatment for non-muscle-invasive bladder cancer

Low-risk non-muscle-invasive bladder cancer

  • Discharge to primary care people who have had low-risk non‑muscle‑invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months.

Intermediate-risk non-muscle-invasive bladder cancer

  • Offer people with intermediate-risk non‑muscle‑invasive bladder cancer cystoscopic follow‑up at 3, 9 and 18 months, and once a year thereafter.

Treating muscle-invasive bladder cancer

Neoadjuvant chemotherapy for newly diagnosed muscle-invasive urothelial bladder cancer

  • Offer neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy or radical radiotherapy to people with newly diagnosed muscle‑invasive urothelial bladder cancer for whom cisplatin‑based chemotherapy is suitable. Ensure that they have an opportunity to discuss the risks and benefits with an oncologist who treats bladder cancer.

Radical therapy for muscle-invasive urothelial bladder cancer

  • Offer a choice of radical cystectomy or radiotherapy with a radiosensitiser to people with muscle‑invasive urothelial bladder cancer for whom radical therapy is suitable. Ensure that the choice is based on a full discussion between the person and a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist. Include in the discussion:

    • the prognosis with or without treatment

    • the limited evidence about whether surgery or radiotherapy with a radiosensitiser is the most effective cancer treatment

    • the benefits and risks of surgery and radiotherapy with a radiosensitiser, including the impact on sexual and bowel function and the risk of death as a result of the treatment.

  • National Institute for Health and Care Excellence (NICE)