AUA Guidelines for Invasive Bladder Cancer: What’s New?”

MichaelS.Cookson,MD,MMHCProfessorandChairman

DepartmentofUrology,UniversityofOklahoma

History• 1999:AUAguidelinesPanelNon-muscleinvasivebladdercancer(AUA)–Smithetal

• 2009:UpdateAUAguidelinesPanelNon-muscleinvasivebladdercancer(AUA)– Halletal

• 2016:UpdateAUAguidelinesPanelNon-muscleinvasivebladdercancer(AUA/SUO)– Changetal

• 2017:TreatmentofNon-MetastaticMuscle-Invasive BladderCancer:AUA/ASCO/ASTRO/SUOGuideline

GuidelineReview

AHRQSYSTEMATICREVIEW• January1990- October2014

Twoinvestigatorsindependentlyassessedtheriskofbiasforallrandomizedtrialsandobservationalstudiesandassignedratingsof“high,” “medium,” or“low” riskofbias.

Methodology

• GradingofGuidelines:

A• WellconductedRCT’s• Exceptionalobservationalstudies

B• RCT’sand/orobservationalstudieswithsomeweaknesses

C• Observationalstudiesthatareinconsistent-difficulttointerpret

MethodologyStrongRecommendation

(Netbenefitorharmsubstantial)

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)issubstantial

• Appliestomostpatientsinmostcircumstancesandfutureresearchisunlikelytochangeconfidence

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)issubstantial

• Appliestomostpatientsinmostcircumstancesbutbetterevidencecouldchangeconfidence

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)appearssubstantial

• Appliestomostpatientsinmostcircumstancesbutbetterevidenceislikelytochangeconfidence

• (rarelyusedtosupportaStrongRecommendation)

ModerateRecommendation

(Netbenefitorharmmoderate)

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)ismoderate

• Appliestomostpatientsinmostcircumstancesandfutureresearchisunlikelytochangeconfidence

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)ismoderate

• Appliestomostpatientsinmostcircumstancesbutbetterevidencecouldchangeconfidence

• Benefits>Risks/Burdens(orviceversa)

• Netbenefit(ornetharm)appearsmoderate

• Appliestomostpatientsinmostcircumstancesbutbetterevidenceislikelytochangeconfidence

ConditionalRecommendation

(Noapparentnetbenefitorharm)

• Benefits=Risks/Burdens• Bestactiondependsonindividual

patientcircumstances• Futureresearchunlikelyto

changeconfidence

• Benefits=Risks/Burdens• Bestactionappearstodependon

individualpatientcircumstances• Betterevidencecouldchange

confidence

• BalancebetweenBenefits&Risks/Burdensunclear

• Alternativestrategiesmaybeequallyreasonable

• Betterevidencelikelytochangeconfidence

Principlevs.ExpertOpinionCLINICALPRINCIPLE

• Astatementaboutacomponentofclinicalcarethatisverywidelyagreeduponbyurologistsorothercliniciansforwhichtheremayormaynotbeevidenceinthemedicalliterature.

EXPERTOPINION• Astatement,achievedbyconsensusofthePanel,

thatisbasedonmembers’ clinicaltraining,experience,knowledge,andjudgmentforwhichthereisnopublishedevidence.

Epidemiology

• 79,000newcasesin2017• 16,870deathsin2017

• 25%ofnewlydiagnosedpatientspresentwithmuscleinvasivedisease

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

INITIALPATIENTEVALUATION&COUNSELING

1.Priortotreatmentconsideration,afullhistoryandphysicalexamshouldbeperformed,includinganexamunderanesthesia,atthetimeoftransurethralresectionofbladdertumorforasuspectedinvasivecancer.(ClinicalPrinciple)

• H&P,PE,examunderanesthesiaatTURBT

2.Priortomuscle-invasivebladdercancermanagement,cliniciansshouldperformacompletestagingevaluation,includingimagingofthechestandcrosssectionalimagingoftheabdomenandpelviswithintravenouscontrastifnotcontraindicated.LaboratoryevaluationshouldincludeaCMPandCBC.(ClinicalPrinciple)

• Imaging:chest,crosssectionalabd/pelviswcontrast(ifnotcontraindicated)• Labs:CBC,CMP

INITIALPATIENTEVALUATION&COUNSELING

3.Anexperiencedgenitourinarypathologistshouldreviewthepathologyofapatientwhenvarianthistologyissuspectedorifmuscleinvasionisequivocal(e.g.,micropapillary,nested,plasmacytoid,neuroendocrine,sarcomatoid,extensivesquamousorglandulardifferentiation).(ClinicalPrinciple)

• VariantHistologyshouldbere-viewedbyGUtrainedpathologist• Upto1/3treatmentstrategieschangedafterreviewbyGUPathologist• VariantHistologiesàMorelocallyadvancedcomparedtoUCbladder

INITIALPATIENTEVALUATION&COUNSELING

Selectedurothelialcarcinomavariantsandtheirtreatment

Squamous Higherriskofupstaging,localrecurrence canbehigh

Smallcell SystemicChemotherapyà observation,RC,XRT

Plasmacytoid Aggressivecancerà immediateRC, haspredilectionforcarinomatosis

Micropapillary Aggressivecancerà immediateRC+/- neoadjuvant chemo**

Sarcomatoid Aggressivecancerà immediateRC

Nested/largenested Aggressivecancerà immediateRC

Adenocarcinoma -- Canconsiderpartialcystectomyifurachal/dome-- evaluate forGIadenocarcinoma

INITIALPATIENTEVALUATION&COUNSELING

4. Forpatientswithnewlydiagnosedmuscle-invasivebladdercancer,curativetreatmentoptionsshouldbediscussedbeforedeterminingaplanoftherapythatisbasedonbothpatientcomorbidityandtumorcharacteristics.Patientevaluationshouldbecompletedusingamultidisciplinaryapproach.(ClinicalPrinciple)

• Multi-disciplinarydiscussion:• Cysectomy +/- Neoadj Chemotherapy

• Trimodal Therapy:TURBT+Chemotherapy+Radiotherapy

INITIALPATIENTEVALUATION&COUNSELING

5.Priortotreatment,cliniciansshouldcounselpatientsregardingcomplicationsandtheimplicationsoftreatmentonqualityoflife(e.g.,impactoncontinence,sexualfunction,fertility,boweldysfunction,metabolicproblems).(ClinicalPrinciple)

• ComplicationimpactonQOLdiscussion• Both:sexualandurinary• Cystectomy:• Complication:60%Grade2-5Clavien complicationrate(RecentRCT)• ReadmissionRC:10-30%• DiversionrelatedQOL:continence,metabolic

• Trimodal Therapy• EarlyandlateGU/GItoxicity• Longtermfollow-upwithcystoscopy

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

TREATMENT:CHEMOTHERAPY(NAC/AC)

6.Utilizingamultidisciplinaryapproach,cliniciansshouldoffercisplatin-basedneoadjuvant chemotherapytoeligibleradicalcystectomypatientspriortocystectomy.(StrongRecommendation;EvidenceLevel:GradeB)

InternationalCollaborationofTrialists 2011

• Neoadjuvant Cisplatinbasedchemoshouldbeoffered

TREATMENT:CHEMOTHERAPY(NAC/AC)

InternationalCollaborationofTrialists 2011

• N=976,RCorRTvs.CMV+RCorRT• 16%reductionincancerspecific

mortality• Increase3-yearcancer-specific

survivalfrom50to56%

TREATMENT:CHEMOTHERAPY(NAC/AC)

Grossmanetal2003

• N=317,RCvs.MVAC+RC

• cT2-cT4N0

• MedianOS:77versus46months,p=0.05• HigherpT0rate:38%vs15%

TREATMENT:CHEMOTHERAPY(NAC/AC)

Zaidetal2014

• Utilizationlagsbehindthedata

• 7.6%à 20.9%utilizationfrom2006-2010

• Reasons:• Overtreatment• Delayintreatmentifnoresponse• Toxicity• ModestSurvivalbenefit

TREATMENT:CHEMOTHERAPY(NAC/AC)

Culpetal2013

• MDAndersonriskadaptedapproach• Retrospective• Notvalidated

TREATMENT:CHEMOTHERAPY(NAC/AC)

• Therearenovalidatedpredictivefactorsorclinicalcharacteristics(includingage)associatedwithanincreasedordecreasedprobabilityofresponseandbenefit

• Thebestregimenanddurationforcisplatin-basedNACremainsundefined

• Thedecisionregardingeligibility forcisplatin-basedNACshouldbebasedoncomorbiditiesandperformancestatus,includingcardiacstatusandpresenceofperipheralneuropathy,hearingloss,andrenaldysfunction

TREATMENT:CHEMOTHERAPY(NAC/AC)

7.Cliniciansshouldnotprescribecarboplatin-basedneoadjuvantchemotherapyforclinicallyresectable stagecT2-T4aN0bladdercancer.Patientsineligibleforcisplatin-basedneoadjuvantchemotherapyshouldproceedtodefinitivelocoregional therapy.(ExpertOpinion)

• NoCarboplatin(patientswhoarecisplatinineligible)• Proceedtodefinitivetreatment

TREATMENT:CHEMOTHERAPY(NAC/AC)

8.Cliniciansshouldperformradicalcystectomyassoonaspossiblefollowingapatient’scompletionofandrecoveryfromneoadjuvantchemotherapy.(ExpertOpinion)

• TimelyCystectomyafterNeoadj chemo• ~4weeks(dependingonpatient’sfunctionalstatus,CBC)

TREATMENT:CHEMOTHERAPY(NAC/AC)

9.Eligiblepatientswhohavenotreceivedcisplatin-basedneoadjuvantchemotherapyandhavenon-organconfined(pT3/T4and/orN+)diseaseatcystectomyshouldbeofferedadjuvantcisplatin- basedchemotherapy.(ModerateRecommendation;EvidenceLevel:GradeC)

• AdjuvantCisplatinbasedchemoshouldbeoffered pT3/pT4/andorN+• Alladj chemotrialsunderpowered,terminatedearly• Meta-analyseshavedemonstratedpossiblebenefit(qualityofdatavariable)

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

TREATMENT:RADICALCYSTECTOMY10.Cliniciansshouldofferradicalcystectomywithbilateralpelviclymphadenectomyforsurgicallyeligiblepatientswithresectable non-metastatic(M0)muscle-invasivebladdercancer.(StrongRecommendation;EvidenceLevel:GradeB)

• RC+BilateralPLNDshouldbeperformed11.Whenperformingastandardradicalcystectomy,cliniciansshouldremovethebladder,prostate,

andseminalvesiclesinmalesandshouldremovethebladder,uterus,fallopiantubes,ovaries,andanteriorvaginalwallinfemales.(ClinicalPrinciple)

• Removeadjacentorgansathighestriskofharboringdisease• Male:Prostate,SVs• Female:Uterus,fallopiantubes,ovaries,anteriorvaginalwall

TREATMENT:RADICALCYSTECTOMY

12. Cliniciansshoulddiscussandconsidersexualfunctionpreservingproceduresforpatientswithorgan-confineddiseaseandabsenceofbladderneck,urethra,andprostate(male)involvement.(ModerateRecommendation;EvidenceLevel:GradeC)

• Considersexualpreservation• Vaginalsparing,ovariansparing

• Periprostatic nervesparing

TREATMENT:RADICALCYSTECTOMY

13.Inpatientsundergoingradicalcystectomy,ileal conduit,continentcutaneous,andorthotopicneobladder urinarydiversionsshouldallbediscussed.(ClinicalPrinciple)

• ConsiderQOLwithdiversionchoice

TREATMENT:RADICALCYSTECTOMY

14.Inpatientsreceivinganorthotopic urinarydiversion,cliniciansmustverifyanegativeurethralmargin.(ClinicalPrinciple)

• Verifynegativeurethralmargin• Riskofcancerinretainedurethracanbebetween1%-17%• Reportedriskfactors:• tumormultifocality• papillarypattern• CIS/tumoratthebladderneck• prostaticurethralinvolvementandprostaticstromalinvasion**(shouldnotprecludeneobladderàfrozen section)

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

Perioperative Management

15.Cliniciansshouldattempttooptimizepatientperformancestatusintheperioperativesetting.(ExpertOpinion)

• Optimizationofpatientperformancestatus• Nutritionalcounseling• Smokingcessation• PhysicalConditioning

Perioperative ManagementPre-Op

•Counseling•Nomechanicalbowelpreparation

•Carbohydrateloading•Avoidance ofprolonged NPO

•AdequateVTEprophylaxis

•Appropriateanti-microbialprophylaxis

Operative

•Analgesicprotocolwithepiduralanalgesia

•Conservativefluidmanagement

•Preventionofhypothermia

Post-Op

•RemovalofNGtubebeforePACU

•Avoidanceopioids

•Aggressivecontrolofnausea/vomiting

• Earlyambulation

•EarlyFeeding

Discharge

•Enterostomaltherapy

•Patienteducation

•Caretakereducation

• Survivorship

Perioperative Management

• N=110patients,• MedianLOS4days• 82%BMonPOD2• 30dayreadmissionrate:21%

PerioperativeManagement

16.Perioperativepharmacologicthromboembolicprophylaxisshouldbegiventopatientsundergoingradicalcystectomy.(StrongRecommendation;EvidenceLevel:GradeB)• VTEprophylaxis• OptimalPerioperativetiminganddurationstillundetermined• ConsiderextendedDVTproph for30dayspost-op(upto15%mayexperiencepost-opDVT)• >50%VTEoccurafterdischarge

PerioperativeManagement

17.Inpatientsundergoingradicalcystectomyµ-opioidantagonisttherapyshouldbeusedtoaccelerategastrointestinalrecovery,unlesscontraindicated.(StrongRecommendation;EvidenceLevel:GradeB)

• Entereg (Alvimopan)post-op:

Lee2014

PerioperativeManagement

• Entereg (Alvimopan)post-op:• Timebowelfunction:(5.5versus6.8days,p<0.001)• ShorterLOS(7.4versus10.1days;p=0.005).• Firstdoseisgivenjustpriortosurgeryandthencontinueduntildietistoleratedorforamaximumof15doses(7days)

• Noopioids7daysprior

Lee2014

PerioperativeManagement

18.Patientsshouldreceivedetailedteachingregardingcareofurinarydiversionpriortodischargefromthehospital.(ClinicalPrinciple)

• UrinaryDiversionPatientEducationisParamount• Ostomyteaching

• Continentdiversionteaching

• Homehealthassistancepost-op

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

Treatment:PelvicLymphadenectomy

19.Cliniciansmustperformabilateralpelviclymphadenectomyatthetimeofanysurgerywithcurativeintent.(StrongRecommendation;EvidenceLevel:GradeB)

• PLNDwithanysurgerywithcurativeintent• RadicalCystectomy• PartialCystectomy

Treatment:PelvicLymphadenectomy

20.Whenperformingbilateralpelviclymphadenectomy,cliniciansshouldremove,ataminimum,theexternalandinternaliliacandobturatorlymphnodes(standardlymphadenectomy).(ClinicalPrinciple)

• Atminimumremove:• Obturatornodes• External/internaliliacnodes

ADDRCTtrialLERNER

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

BLADDERPRESERVATION:PATIENTSELECTION

21.Forpatientswithnewlydiagnosednon-metastaticmuscle-invasivebladdercancerwhodesiretoretaintheirbladder,andforthosewithsignificantcomorbiditiesforwhomradicalcystectomyisnotatreatmentoption,cliniciansshouldofferbladderpreservingtherapywhenclinicallyappropriate.(Clinicalprinciple)

• Selection:unfitforcystectomyordesirebladderpreservation• Panelpreferredapproach:à TURBT,systemicchemotherapy,radiationtherapy,andongoingcystoscopytoevaluateresponse

BLADDERPRESERVATION:PATIENTSELECTION

22.Inpatientsunderconsiderationforbladderpreservingtherapy,maximaldebulking transurethralresectionofbladdertumorandassessmentofmultifocaldisease/carcinomainsitushouldbeperformed.(StrongRecommendation;EvidenceStrength:GradeC)

• TURBTconsiderationforbladderpreservationtherapy:• MaximalResection• AssessmentofMultifocaldisease• CISassessment• Tumorsize

BLADDERPRESERVATION:MAXIMALTURBTANDPARTIALCYSTECTOMY

23.Patientswithmuscle-invasivebladdercancerwhoaremedicallyfitandconsenttoradicalcystectomyshouldnotundergopartialcystectomyormaximaltransurethralresectionofbladdertumorasprimarycurativetherapy.(ModerateRecommendation;EvidenceLevel:GradeC)

• Theidealpatientsforpartialcystectomyhavea,nohydronephrosis,solitary,initialtumorwithoutconcomitantCISinthebladderorprostaticurethrathatisamenabletoresectionwitha2cmsurgicalmargin.

• Literaturereviewindicatesthatonly5%ofpatientswithinvasivebladdercancermeetthesecriteria

BLADDERPRESERVATION:PRIMARYRADIOTHERAPY

24.Forpatientswithmuscle-invasivebladdercancer,cliniciansshouldnotofferradiationtherapyaloneasacurativetreatment.(StrongRecommendation;EvidenceLevel:GradeC)

• Donotofferradiationtherapyalone:• Highratesofpelvicfailure• Fiveyearlocalcontrolratesof31-50%• Likelyanunderestimateasthosewhodevelopmetastaticdiseasearelesslikelytoundergocontinuedbladdersurveillance

MULTIMODALBLADDERPRESERVATIONTHERAPY

25.Forpatientswithmuscle-invasivebladdercancerwhohaveelectedmulti-modalbladderpreservingtherapy,cliniciansshouldoffermaximaltransurethralresectionofbladdertumor,chemotherapycombinedwithexternalbeamradiationtherapy,andplannedcystoscopic re-evaluation.(StrongRecommendation;EvidenceLevel:GradeB)

• MaximalTURBT+chemo+radiation• Chemoàsensitizes tumorcellstoradiationandcontrolofoccultmetastases

• ConsiderCystoscopic re-evaluationwithbiopsy(advocatedduringmiddleofRT)

MULTIMODALBLADDERPRESERVATIONTHERAPY

• MaximalTURBT+chemo+radiation

• Idealcandidate• 1)unifocal tumor<3cm• 2)nocarcinomainsitu(CIS),• 3)noevidenceofhydronephrosis,and• 4)atumorthatcanbecompletelytransurethrally resected

MULTIMODALBLADDERPRESERVATIONTHERAPY

Mak2014

MULTIMODALBLADDERPRESERVATIONTHERAPY

• Itisunclearwhatproportionofpatientswho,havinginitiallychosenbladderpreservation,ultimatelyrequirecystectomyinanon-studysetting.

• Thereportedbladderpreservationratesmaybedependentuponthedegreeofinitialpatientevaluationandselection

Mak2014

MULTIMODALBLADDERPRESERVATIONTHERAPY

26. Radiationsensitizingchemotherapyregimensshouldincludecisplatinor5-fluorouracilandmitomycin C.(StrongRecommendation;EvidenceLevel:GradeB)

• Radiationsenistizers:• 5FU+MMC• Cisplatin

MULTIMODALBLADDERPRESERVATIONTHERAPY

27.Followingcompletionofbladderpreservingtherapy,cliniciansshouldperformregularsurveillancewithCTscans,cystoscopy,andurinecytology.(StrongRecommendation;EvidenceLevel:GradeC)

• SurveillanceStrategy:• Publishedprotocolsrecommendevery3monthcystoscopyduringthefirstyear,every4-6monthsinthesecond,andevery6-12monthsthereafter.• Cross-sectionalimagingoftheabdomenandpelvisandchestimagingeverysixmonthsforthefirsttwoyears

MULTIMODALBLADDERPRESERVATIONTHERAPY

28.Inpatientswhoaremedicallyfitandhaveresidualorrecurrentmuscle-invasivediseasefollowingbladderpreservingtherapy,cliniciansshouldofferradicalcystectomywithbilateralpelviclymphadenectomy.(StrongRecommendation;EvidenceLevel:GradeC)

• Ifmultimodaltherapyfailsà Radicalcystectomy:• Upto30%ofpatientswillhaveaninvasiverecurrence

MULTIMODALBLADDERPRESERVATIONTHERAPY

29.Inpatientswhohaveanon-muscleinvasiverecurrenceafterbladderpreservingtherapy,cliniciansmayoffereitherlocalmeasures,suchastransurethralresectionofbladdertumorwithintravesical therapy,orradicalcystectomywithbilateralpelviclymphadenectomy.(ModerateRecommendation;EvidenceLevel:GradeC)

• Non-muscleinvasiverecurrenceà TURBT,intravesical therapy,orRC:• CaseseriesshowthatNMIBCrecurrencesfollowingbladdersparingtherapymaystillbemanagedbystandardlocalmeasuressimilartodenovo NMIBC

Guidelines

• 35statementstotal:

• InitialPatientEvaluationandCounseling:#1-5• Treatment(Chemotherapy):#6-9• Treatment(RadicalCystectomy):#10-14• PerioperativeConsiderations:#15-18• Treatment(PelvicLymphadenopathy):#19-20• BladderPreservation:#21-29• Surveillance:#30-35

PATIENTSURVEILLANCE

30.CliniciansshouldobtainchestimagingandcrosssectionalimagingoftheabdomenandpelviswithCTorMRIat6-12monthintervalsfor2-3yearsandthenmaycontinueannually.(ExpertOpinion)

• Radiographicevaluationoftheabdomenandpelvis:• Detectionofuppertractcancer• Diseasedetectioninthemostcommonsitesofrecurrence,progression,andmetastasis

• Urinarydiversionconcerns

PATIENTSURVEILLANCE

31.Followingtherapyformuscle-invasivebladdercancer,patientsshouldundergolaboratoryassessmentatthreetosixmonthintervalsfortwotothreeyearsandthenannuallythereafter.(ExpertOpinion)

• Labevaluation:Electrolyteimbalances,B12deficiency,acidosis

31.Followingradicalcystectomyinpatientswitharetainedurethra,cliniciansshouldmonitortheurethralremnantforrecurrence.(ExpertOpinion)

• Monitorurethraforrecurrence:• 4-14%riskofrecurrenceinurethra• UrethralCytologycanbelowyield(nospecificrecommendation)• Considerinhigherriskpatients(painorurethralbleedingattimeofdx)

PATIENTSURVEILLANCE33.Cliniciansshoulddiscusswithpatientshowtheyarecopingwiththeirbladdercancerdiagnosisandtreatmentandshouldrecommendthatpatientsconsiderparticipatinginacancersupportgrouporconsiderreceivingindividualcounseling.(ExpertOpinion)

34.Cliniciansshouldencouragebladdercancerpatientstoadopthealthylifestylehabits,includingsmokingcessation,exercise,andahealthydiet,toimprovelong-termhealthandqualityoflife.(ExpertOpinion)• Survivorship:

bcan.orgcancersupportcommunity.orgcancercare.org

bladdercancersupport.orgcancer.orgurologyhealth.org

PATIENTSURVEILLANCE

35.Inpatientsdiagnosedwithvarianthistology,cliniciansshouldconsideruniqueclinicalcharacteristicsthatmayrequiredivergencefromstandardevaluationandmanagementforurothelial carcinoma.(ExpertOpinion)

• Modifystandardevaluationforvarianthistology:

Summary