Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Lifestyle Issues
Smoking
B - Smoking should be discouraged.
Diet
B - People should be encouraged to:
- Eat more fruit and vegetables
- Reduce the amount of animal fat in their diet
Other Risks
B - Clinicians should be aware that previous treatments with radiotherapy and certain chemotherapy may predispose patients to transitional cell carcinoma of the bladder.
Referral
Timing of Treatment
C - For optimum survival benefit, cystectomy for patients with muscle invasive bladder cancer should be performed within three months of diagnosis.
Involving the Patient in the Decision Making Process
D - Healthcare professionals should involve patients in making decisions about their treatment, if the patient expresses a wish to do so.
Management of Superficial Bladder Cancer
Imaging During Follow Up
B - Only patients with high grade tumours (including carcinoma in situ [CIS]) at time of diagnosis should have regular upper tract surveillance.
Photodynamic Aided Resection
B - Fluorescence cystoscopy under blue/violet light (wavelength 400 nm) which causes tumours to fluoresce red should be used to improve the completeness of resection of superficial bladder tumours.
Follow Up
C - Patients with a single pTa G1/G2 tumour at the time of diagnosis and who are recurrence free at three months after the original resection should have annual cystoscopy.
Intravesical Therapy
A - A single instillation of intravesical chemotherapy should be used to reduce the risk of recurrent disease following resection in all patients considered to be at high risk of recurrence.
Random Biopsy of Normal Mucosa
C - Normal looking areas of the bladder need not be routinely biopsied at the time of diagnosis or follow up.
Management Strategies
C - Patients with CIS of the bladder should be treated with bacille Calmette-Guerin (BCG).
B - Maintenance therapy with BCG should be considered in patients with CIS to improve local control and reduce the incidence of progression.
Progression to Muscle Invasive Disease (pT2-4)
C - Routine pathological reporting should include microstaging of pT1 disease, where possible.
Surgical Treatment
Imaging for Staging of Invasive Disease
C - Patients with muscle invasive bladder cancer should have cross-sectional imaging prior to treatment.
C - Magnetic resonance imaging (MRI) is the best staging modality to assess invasion into or through bladder muscle.
Indications for Removal of the Urethra
C - Urethrectomy should be performed in high-risk patients having cystectomy and urinary diversion.
C - If frozen section biopsies of the urethral margin are negative the urethra can be preserved for orthotopic reconstruction.
Indications for Removal of the Lymph Nodes
C - All patients having curative radical cystectomy should have bilateral pelvic lymph node dissection.
C - A meticulous lymph node dissection should be performed for retrieval of the maximum number of nodes.
Bladder Reconstruction
C - Where appropriate, patients should be given the option of bladder reconstruction after radical cystectomy.
Non-Surgical Treatment
Radiotherapy
B - Radiotherapy using 21Gy in three fractions in one week should be considered for palliation of patients with bladder cancer.
Chemotherapy
A - Neoadjuvant chemotherapy should be offered to suitable patients prior to definitive radical therapy for patients with T2-T4 transitional cell carcinoma of the bladder.
A - A combination chemotherapy regimen containing cisplatin should be used.
Information for Discussion with Patients and Carers
Support Needs of Patients, Families and Carers
C - Patients should be offered verbal and written information throughout their journey of care and should be made aware of the support mechanisms that are in place and how to access them.
C - Structured emotional support should be available to all patients and carers.
Methods and Sources of Communication
B - Healthcare professionals in cancer care should be trained in listening and communication skills.
B - Healthcare professionals in cancer care should consider giving either written summaries or audiotapes of consultations to people who have expressed a preference for them.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group