Haematuria is a highly concerning symptom for urological malignancy, with 26% of patients with visible haematuria and 6% of patients with non-visible haematuria having cancer identified – most being bladder cancers.
The absence of risk factors for bladder cancer should not deter or delay full and prompt investigation – 8% of under 45-year-olds, 18% of non-smokers, and 20% of females with visible haematuria have an underlying malignancy. Women, unfortunately, suffer worse outcomes from bladder cancer once diagnosed, partly due to under-investigation and delayed referral.
Investigations for haematuria should include an MSU, upper tract imaging (CTIVU or renal ultrasound) and cystoscopy (most sensitive investigation for bladder cancer). Once identified, transurethral resection of the bladder tumour informs the urologist of the grade and T-stage of the cancer. Over 90% of bladder cancers are urothelial cancers (transitional cell carcinomas), however, rarer variant pathologies do occur.
Non-muscle-invasive bladder cancer
Patients with non-muscle-invasive bladder cancer (NMIBC) require close cystoscopic surveillance after initial resection because bladder cancer has a high risk of recurrence (return of non-muscle-invasive disease) and progression (subsequent increase in grade or stage).
Patients with higher risk disease may also undergo intravesical drug instillations to reduce these risks, with either chemotherapeutic agents or Bacillus Calmette-Guérin (BCG). BCG consists of live attenuated mycobacterium bovis, which stimulates an antigen-mediated immune response that is very effective in destroying bladder cancer cells.
Treatment protocols vary, but one published example is the ‘Fremantle protocol’ that consists of an induction phase (weekly instillations for six weeks) followed by a maintenance phase (monthly instillations for 10 months).
Advances in the management of NMIBC that have been incorporated into current clinical practice in Western Australia to varying degrees include improved modalities for bladder tumour detection (narrow-band imaging, blue light cystoscopy), utilisation of immediate post-operative intravesical chemotherapy, and combination intravesical chemotherapy regimens for BCG-refractory disease (e.g. gemcitabine-docetaxel).
Treatment options for NMIBC are likely to expand significantly over the coming years with the outcomes from trials examining combination treatments, vaccine therapies, novel agents, and alternative modalities for delivery of treatment eagerly awaited.
Muscle-invasive bladder cancer
Patients with muscle-invasive bladder cancer (MIBC) usually undergo further staging with either CT or FDG PET. Their treatment options include radical cystectomy (+/- neo-adjuvant or adjuvant chemotherapy), chemoradiation, or radiotherapy. Radical cystectomy preceded by neo-adjuvant chemotherapy is generally considered to offer the best chance of cure, however, various patient and disease factors may affect individual suitability or fitness for this.
If undergoing radical cystectomy, then a concurrent bilateral pelvic lymph node dissection is commonly performed, as well as urinary diversion usually with either an ileal conduit or neo-bladder.
Constructing a neo-bladder involves fashioning approximately 60cm of ileum into a bladder-shaped reservoir, with re-implantation of the ureters and anastomosis of the urethra onto this. While a neo-bladder avoids the need for a stoma, it does not function like a normal bladder and may not be suitable for most patients.
Robotic cystectomy appears to deliver equivalent oncologic and perioperative outcomes to open cystectomy, with the robotic approach conferring advantages regarding blood loss, recovery, and potentially wound complications and venous thromboembolism.
Robotic cystectomy is now being offered in WA, through both the public and private sector, although some patients may not be considered suitable for this approach.
Another recent advance in the management of patients with MIBC in Australia is the ability for high-risk patients to access adjuvant immunotherapy funded through the PBS following neo-adjuvant chemotherapy and radical cystectomy. Future directions for the treatment of MIBC may include combination systemic treatments, use of antibody-drug conjugates, and the use of novel investigations such as circulating tumour DNA to help identify patients suitable for bladder preservation.
Patients with metastatic bladder cancer have historically had limited treatment options, however, some patients are now able to access several lines of therapy including chemotherapy, immunotherapy, antibody-drug conjugates, and combinations thereof, resulting in improved survival.
Key messages
- Patients with visible haematuria have a high risk of underlying urological malignancy. Even if they do not have risk factors for bladder cancer, further investigation is generally warranted with an MSU, upper tract imaging, and cystoscopy
- Non-muscle-invasive bladder cancer is usually managed with cystoscopic surveillance and intravesical BCG or chemotherapy for higher risk tumours, while options for muscle-invasive bladder cancer include radical cystectomy (+/- neo-adjuvant or adjuvant chemotherapy), chemoradiation, or radiotherapy
- Recent treatment advances include combination intravesical chemotherapy for BCG-refractory disease, robotic cystectomy, and adjuvant immunotherapy for high-risk patients.
Author competing interests – nil
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