Transcript Related Guidelines

How Are Patients Risk Stratified Once NMIBC Is Confirmed By TURBT?

Sam S. Chang, MD, MBA · Vanderbilt University   

Disclosures

May 14, 2020

This transcript has been edited for clarity.

Risk stratification is a key point of guidelines, both within the AUA and the EAU, because it really attempts to individualize care for each of these patients. There are some patients where we should really be minimizing therapy and minimizing our surveillance. And that would include what we consider low-risk patients, such as patients who have solitary tumors, low-grade tumors, smaller tumors, or something called PUNLMP (papillary urothelial neoplasia of low malignant potential). So for those patients, we should be doing less—less therapy, less surveillance. And that’s an important part of risk stratification. 

Then you have the high-risk patients, who are essentially those we worry about not only recurrence, but importantly and dangerously, progression. And the AUA high-risk stratification would include those patients with high-grade T1 lesions or CIS or any variant histology or who have evidence of lymphovascular invasion—or who, importantly, have had therapy and continue to show evidence of disease that is quite concerning, such as recurrent high-grade TA, T1, or CIS disease.[1] So those are patients who are at high risk. 

And importantly, what the AUA risk stratification table does is it takes into account how patients do in terms of therapy. In other words, if you have a recurrence, even with a lower-risk tumor, you automatically are put into what’s called an intermediate risk category. And an intermediate risk category would include those patients with smaller high-grade TA tumors, those patients who have low-grade TA tumors but are multifocal.[1] 

So we worry here about recurrence, probably less so with progression. But each one of these different stratification tables or algorithms are important, because it helps direct care. Especially with our BCG shortage for patients who are high risk, we really should be saving and rationing our BCG for those patients who receive induction BCG.

For our intermediate-risk patients, we should be considering actually using chemotherapy as opposed to intravesical BCG. And I think probably just as importantly, we should avoid over-treating our patients, especially our low-risk patients. Those patients should not be getting BCG. 

[Risk stratification] is important in terms of treatment and therapy. It’s also important in terms of prognosis when you look whether or not a patient has a higher chance of recurrence. I think also importantly, in terms of progression. Importantly, the guidelines—both from the AUA and the EAU—look at risk stratification.

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