From the Guidelines
When discussing early bladder cancer, you should apply bladder cancer risk stratification immediately upon diagnosis to guide treatment decisions and follow-up protocols. This approach is crucial in determining the most effective treatment plan and follow-up schedule for patients. According to the most recent guidelines, risk stratification should be based on tumor characteristics including stage, grade, size, number of tumors, presence of carcinoma in situ (CIS), and recurrence history 1.
Risk Stratification Categories
For non-muscle invasive bladder cancer (NMIBC), patients should be categorized as low, intermediate, or high risk.
- Low-risk patients typically have solitary, small (<3cm), low-grade Ta tumors;
- intermediate-risk patients have multiple or recurrent low-grade tumors;
- and high-risk patients have T1 tumors, high-grade disease, CIS, or rapidly recurring tumors.
Treatment Recommendations
This risk assessment directly impacts treatment recommendations, with low-risk patients often needing only a single immediate post-operative instillation of chemotherapy, intermediate-risk patients requiring adjuvant intravesical therapy (such as BCG or mitomycin C), and high-risk patients needing more intensive BCG immunotherapy or consideration for early cystectomy 1.
Importance of Risk Stratification
Risk stratification is essential because it helps predict both recurrence and progression risks, allowing for personalized surveillance schedules and optimal management strategies that balance cancer control with quality of life considerations. The NCCN guidelines emphasize the importance of risk stratification in the management of bladder cancer, highlighting the need for a tailored approach to treatment and follow-up 1.
Recent Guidelines
The most recent guidelines, published in 2024, reinforce the importance of risk stratification in the management of early bladder cancer, and provide updated recommendations for treatment and follow-up based on risk category 1. By applying bladder cancer risk stratification immediately upon diagnosis, healthcare providers can ensure that patients receive the most effective and personalized care possible, ultimately improving outcomes and quality of life.
From the Research
Bladder Cancer Risk Assessment
When discussing early bladder cancer, it is essential to consider the risk of progression to advanced disease. The risk assessment is crucial in determining the appropriate treatment approach.
- The risk of bladder cancer progression is influenced by various factors, including tumor stage, grade, and size, as well as the patient's overall health and medical history 2.
- Non-muscle-invasive bladder cancer (NMIBC) is typically treated with endoscopic resection and adjuvant intravesical therapy, depending on the risk classification 2.
- High-risk NMIBC patients who do not respond to adjuvant therapy with bacillus Calmette-Guérin (BCG) are at a higher risk of progression to advanced disease and may require alternative treatments, such as early radical cystectomy or immunotherapy 3, 4.
Treatment Options for High-Risk NMIBC
Several treatment options are available for high-risk NMIBC patients who do not respond to BCG therapy.
- Intravesical gemcitabine has been shown to be an effective alternative to BCG, with lower side effects and comparable efficacy in treating intermediate-risk NMIBC 5.
- Mitomycin C (MMC) instillations are also recommended for preventing recurrence in intermediate-risk NMIBC, with the optimal regimen and dose still being uncertain 6.
- Radical cystectomy is a treatment option for high-risk NMIBC patients who do not respond to BCG therapy, but it is associated with significant morbidity and mortality 3, 4.
Molecular Subtypes and Risk Stratification
Recent studies have identified molecular subtypes of NMIBC that can predict the response to BCG therapy and the risk of progression to advanced disease.
- The BCG response subtypes (BRS1, 2, and 3) have been identified, with BRS3 tumors having a reduced recurrence-free and progression-free survival compared to BRS1/2 3.
- The molecular subtypes have been validated in a second cohort of patients and have outperformed guideline-recommended risk stratification based on clinicopathological variables 3.