NCCN Updates Guidelines for Bladder Cancer Management
The National Comprehensive Cancer Network (NCCN) released new additions to their guidelines for bladder cancer, including changes to systemic therapy, primary treatments, and adjuvant treatments.
As a general update to the entire guideline, “chemotherapy” has been replaced by “systemic therapy” where appropriate.
The second option for the primary treatment of cT2 disease has been revised to read, “Neoadjuvant cisplatin-based combination systemic therapy followed by partial cystectomy (highly selected patients with solitary lesion in a suitable location; no Tis).” In the adjuvant section of this algorithm, the recommendation for non-cystectomy candidates after no tumor has been detected now offers, “If prior BCG, maintenance BCG.”
In the section listing Principles of Surgical Management, endoscopic management of upper tract urothelial cancer was added.
As for the Principles of Systemic Therapy for perioperative chemotherapy and first-line systemic therapy for locally advanced or metastatic disease, the treatment regimens are now categorized under “Preferred regimens, “Other recommended regimens,” or “Useful under certain circumstances.” A similar categorization method is used in subsequent systemic therapy sections.
A statement was added to the Principles of Radiation Management of Invasive Disease page: “Unless otherwise stated, doses are 1.9-2.0 daily fractionation.” A sub-bullet for recurrent disease was also added: “Clinical target volume should include gross disease in any suspected areas of spread at 66-74 Gy (higher dose up to 74 Gy for larger tumor and non-urothelial histology) and consideration can be given to elective regional-nodal basins (45-50.4 Gy) as discussed above, if feasible based on normal tissue constraints.”
For Upper GU Tract Tumors, the primary treatment for non-metastatic disease was revised by adding “plus perioperative intravesical chemotherapy” to both low grade and high grade, large, or parenchymal invasion.
Chemoradiotherapy plus consolidative surgery was added for the primary treatment of T3, T4, and palpable inguinal lymph nodes in cN0 and cN1/cN2 Carcinoma of the Urethra.—Zachary Bessette