Published in UAB Insight, Winter 2008
Enhanced Risk Stratification, Targeted Therapy Improve Outcomes
As urologists learn more about the relationship between urothelial carcinoma stage and grade and risks for recurrence and progression, management paradigms are shifting to provide patients at higher risk for aggressive disease with earlier, more definitive treatment.
Improving recognition of risk factors at the primary care level can lead to earlier detection and enhanced outcomes, says UAB urologic surgeon J. Erik Busby, MD. “All patients with evidence of microscopic hematuria [≥5 red blood cells per high-power microscopic field] on two of three urinalyses should be referred to a urologist for evaluation,” he says. “It is not uncommon to diagnose advanced bladder cancer in patients previously treated for extended periods for suspected urinary tract infections, when symptoms are actually caused by progressive growth of a bladder tumor. This situation is especially common in women 60 years and older,” he says.
Gross or microscopic hematuria among patients taking aspirin, warfarin, clopidogrel, and other blood thinners is sometimes attributed to anticoagulation, Busby says. “In fact, these patients are more likely to have a tumor or other abnormal findings than individuals not taking such drugs.”
Staging and Treatment
“Accurate staging is crucial to optimal management of bladder cancer,” Busby says. “Transurethral resection [TUR] establishes pathological stage, but specimens often are inadequate. Biopsies must include muscularis propria to establish whether disease involves muscle invasion.”
Repeat TUR is now standard for patients with superficial disease. “The rationale is that on re-resection, about 75% of patients have residual tumor, and up to 25% have previously undiagnosed muscle involvement,” he says. “Re-resections may remove residual disease, clarify treatment decisions, and improve intravesical treatment.”
Bacille Calmette-Guérin (BCG) is the most effective intravesical therapy for bladder cancer. “Although patients with low-grade tumors often can be treated with TUR and a single postoperative instillation of mitomycin C, those with high-grade superficial disease — Ta, T1, or carcinoma in situ — should be considered for maintenance BCG,” Busby says.
Maintenance BCG can reduce recurrence and progression, but most people do not complete the 3-year maintenance course [6 weekly instillations followed by interval instillations every 3-6 months]. “Reducing BCG dose or adding interferon, however, produces similar efficacy with fewer side effects,” he says.
Patients with recurrent high-grade Ta, T1, multifocal, or muscle-invasive disease typically require radical cystectomy. “With greater understanding of risks for progression and recurrence, many urologists are advocating cystectomy at earlier stages to avoid missing the window for possible prevention of metastatic progression,” Busby says.
In high-risk patients, multimodal approaches, including neoadjuvant or adjuvant chemotherapy, are becoming more common, as research shows such strategies improve survival. Other methods for enhancing bladder cancer prevention, detection, and treatment are under study.
“UAB scientists are on the research forefront, seeking chemopreventive agents as well as biomarkers that can indicate disease development or recurrence,” he says.
For more information:
Dr. Erik Busby
1.800.UAB.MIST
mist@uabmc.edu