NCCN Releases Updates for Bladder Cancer Staging, Treatment


The National Comprehensive Cancer Network (NCCN) has released updated guidelines for the staging, primary evaluation, and surgical management of bladder cancer.

Muscle invasive staging has been updated or clarified throughout the guidelines to reflect the AJCC 8th edition. Among the additions are cT2 now listed as “Stage II (cT2, N0),” cT3 and cT4 now listed as “Stage IIIA (cT3, N0; cT4, N0; cT1-T4a, N1),” cT4b now listed as “Stage IVA (cT4b, Any N, M0; Any T, Any N, M1a),” “Stage IIIB (cT1-T4a, N2,3),” and metastatic now clarified as “Metastatic (Stage IVB Any T, Any N, M1b).”

In the section for primary evaluation and surgical treatment, the third bullet was revised: “Single-dose intravesical chemotherapy within 24 hours of TURBT: Gemcitabine (Category 1) or Mitomycin (Category 1).” For evaluation after TURBT, the same recommendation was added.

In the section for stage II (cT2, N0), the option for negative nodes and cN1-3 was removed from the page after workup. The primary treatment, third option was clarified by removing “Bladder preservation following maximal TURBT” from “concurrent chemotherapy.” The same clarification was made for stage IIIA disease. In stage II adjuvant treatment after concurrent chemoradiotherapy, “completion of definitive RT” was removed for no present tumor and “cystectomy (preferred)” was replaced with “If Tis, Ta, or T1, consider intravesical BCG or Surgical consolidation or Treat as metastatic disease” for present tumor.

For stage IIIA (cT3, N0; cT4, N0; cT1-T4a, N1) disease, the option of negative nodes and cN1-3 was removed from the page after workup. “TURBT alone” was removed as a primary treatment for non-cystectomy candidates. Additionally, “Concurrent chemoradiotherapy (if no prior RT)” was removed as an adjuvant treatment for non-cystectomy candidates.


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For stage IVA (cT4b, Any N, M0; Any T, Any N, M1a) bladder cancer, “negative nodes,” “cN1-3 nodes,” and “Consider biopsy of nodes” were removed after additional workup and replaced with “M0 disease” and “M1a disease.”

In the section for metastatic (Stage IVB Any T, Any N, M1b) disease, “consider biopsy of nodes” was moved from after node only to additional workup. “Metastatic” was removed from the page.—Zachary Bessette