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Bladder cancer

About

What is covered

This interactive flowchart covers the investigation, diagnosis and treatment of adults (18 years and older) referred from primary care with suspected bladder cancer and those with newly diagnosed or recurrent bladder (urothelial carcinoma, adenocarcinoma, squamous-cell carcinoma or small-cell carcinoma) or urethral cancer. The interactive flowchart is divided into the management of three stages in bladder cancer:
  • non-muscle-invasive bladder cancer
  • organ-confined muscle-invasive bladder cancer
  • locally advanced or metastatic bladder cancer.

Updates

Updates to this interactive flowchart

16 December 2015 Bladder cancer (NICE quality standard 106) added to this interactive flowchart.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on bladder cancer in adults in an interactive flowchart

What is covered

This interactive flowchart covers the investigation, diagnosis and treatment of adults (18 years and older) referred from primary care with suspected bladder cancer and those with newly diagnosed or recurrent bladder (urothelial carcinoma, adenocarcinoma, squamous-cell carcinoma or small-cell carcinoma) or urethral cancer. The interactive flowchart is divided into the management of three stages in bladder cancer:
  • non-muscle-invasive bladder cancer
  • organ-confined muscle-invasive bladder cancer
  • locally advanced or metastatic bladder cancer.

Updates

Updates to this interactive flowchart

16 December 2015 Bladder cancer (NICE quality standard 106) added to this interactive flowchart.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Bladder cancer: diagnosis and management (2015) NICE guideline NG2
Improving outcomes in urological cancers (2002) NICE guideline CSG2
Laparoscopic cystectomy (2009) NICE interventional procedures guidance 287
Bladder cancer (2015) NICE quality standard 106

Quality standards

Quality statements

Obtaining detrusor muscle during transurethral resection of bladder tumour

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults who are having transurethral resection of bladder tumour (TURBT) have detrusor muscle obtained during the procedure.

Rationale

Obtaining detrusor muscle during TURBT is important for assessing the stage and type of bladder cancer, which can help to identify the most effective treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults having TURBT have detrusor muscle obtained during the procedure.
Data source: Local data collection.
Process
Proportion of TURBT procedures during which detrusor muscle was obtained.
Numerator – the number in the denominator in which detrusor muscle was taken at the time of performing the TURBT.
Denominator – the number of TURBT procedures performed.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults who are having TURBT to have detrusor muscle obtained during the procedure.
Healthcare professionals ensure that adults who are having TURBT have detrusor muscle obtained during the procedure.
Commissioners (clinical commissioning groups) ensure that they commission services that obtain detrusor muscle during TURBT procedures.

What the quality statement means for patients and carers

Adults who are having an operation to take tissue samples to check for bladder cancer (called transurethral resection of bladder tumour, or TURBT for short) have samples taken that include tissue from the muscle wall of their bladder. If cancer is found in their bladder, the type of treatment will depend on whether or not the cancer has grown into the muscle wall.

Source guidance

Chemotherapy during transurethral resection of bladder tumour

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults with suspected bladder cancer are offered a single dose of intravesical mitomycin C, given at the same time as the first transurethral resection of bladder tumour (TURBT).

Rationale

A single dose of intravesical mitomycin C given at the same time as the first TURBT has been found to reduce recurrence rates. Giving mitomycin C at the same time as the first TURBT is more convenient for the person having the TURBT and results in cost savings.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with suspected bladder cancer who are having a first TURBT are offered a single dose of intravesical mitomycin C, given at the same time as the TURBT.
Data source: Local data collection.
Process
Proportion of first TURBT procedures in which adults with suspected bladder cancer are given a single dose of intravesical mitomycin C.
Numerator – the number in the denominator in which a single dose of intravesical mitomycin C is given.
Denominator – the number of first TURBTs performed for adults with suspected bladder cancer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for example secondary care services) ensure that systems are in place for adults having a first TURBT for suspected bladder cancer to be offered a single dose of intravesical mitomycin C, given at the same time as the TURBT.
Healthcare professionals offer adults having a first TURBT for suspected bladder cancer a single dose of intravesical mitomycin C, given at the same time as the TURBT.
Commissioners (NHS England) ensure that they commission services that offer adults having a first TURBT for suspected bladder cancer a single dose of intravesical mitomycin C, given at the same time as the TURBT.

What the quality statement means for patients and carers

Adults who are having a first operation to take tissue samples to check for bladder cancer (called transurethral resection of bladder tumour, or TURBT for short) are offered a single dose of an anticancer drug called mitomycin C, which is given when they have the operation. If cancer is found in their bladder, mitomycin C can reduce the chance of it coming back again in the future.

Source guidance

Access to a clinical nurse specialist

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults with bladder cancer have access to a designated clinical nurse specialist.

Rationale

Adults with bladder cancer who are supported by a clinical nurse specialist have a better experience of bladder cancer services than those who are not. The clinical nurse specialist can be involved in discussing treatment options and act as the person’s key worker to address their information and care needs, including psychosocial support and referral to palliative care if needed. They can also discuss the effects of treatment on the person’s body image and sexual health, and help them find relevant information.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that designated clinical nurse specialists are accessible to adults with bladder cancer.
Data source: Local data collection.
Process
Proportion of adults with bladder cancer who have a designated clinical nurse specialist.
Numerator – the number in the denominator who have a designated clinical nurse specialist.
Denominator – the number of adults with bladder cancer in secondary care.
Data source: Local data collection.
Outcome
Satisfaction with support received from a clinical nurse specialist, reported by adults with bladder cancer.
Data source: Local data collection. The National cancer patient experience survey collects data on support from a clinical nurse specialist for adults with urological cancers.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults with bladder cancer to have access to a designated clinical nurse specialist.
Healthcare professionals offer adults with bladder cancer access to a designated clinical nurse specialist.
Commissioners (clinical commissioning groups) ensure that they commission services that offer adults with bladder cancer access to a designated clinical nurse specialist.

What the quality statement means for patients and carers

Adults with bladder cancer are offered support from a clinical nurse specialist who has experience in caring for people with bladder cancer. The clinical nurse specialist can provide information about bladder cancer and the treatment options, and help them find information and other support they might need.

Source guidance

  • Bladder cancer (2015) NICE guideline NG2, recommendations 1.1.2 and 1.1.3

Risk classification

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults with newly diagnosed non-muscle-invasive bladder cancer have a risk classification of their cancer completed.

Rationale

Risk classification of non-muscle-invasive bladder cancer is used in multidisciplinary team discussions and in discussions with the person to help consider prognosis and decide treatment options.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with newly diagnosed non-muscle-invasive bladder cancer have a risk classification of their cancer completed.
Data source: Local data collection.
Process
Proportion of adults with newly diagnosed non-muscle-invasive bladder cancer who have a risk classification of their cancer completed.
Numerator – the number in the denominator who have a risk classification of their cancer completed.
Denominator – the number of adults with a new diagnosis of non-muscle-invasive bladder cancer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults with newly diagnosed non-muscle-invasive bladder cancer to have a risk classification completed.
Healthcare professionals complete a risk classification for adults with newly diagnosed non-muscle-invasive bladder cancer.
Commissioners (clinical commissioning groups) ensure that they commission services that complete a risk classification for adults with newly diagnosed non-muscle-invasive bladder cancer.

What the quality statement means for patients, service users and carers

Adults with bladder cancer that has not grown into the muscle wall of the bladder have information about the likely future risk from their cancer, including the risk of it growing into the muscle wall, written in their notes when the cancer is first diagnosed. This information helps them and their doctors to decide the best treatment options.

Source guidance

Definitions of terms used in this quality statement

Risk classification of non-muscle-invasive bladder cancer
Low risk
Urothelial cancer with any of:
  • solitary pTaG1 with a diameter of less than 3 cm
  • solitary pTaG2 (low grade) with a diameter of less than 3 cm
  • any papillary urothelial neoplasm of low malignant potential.
Intermediate risk
Urothelial cancer that is not low risk or high risk, including:
  • solitary pTaG1 with a diameter of more than 3 cm
  • multifocal pTaG1
  • solitary pTaG2 (low grade) with a diameter of more than 3 cm
  • multifocal pTaG2 (low grade)
  • pTaG2 (high grade)
  • any pTaG2 (grade not further specified)
  • any low-risk non-muscle-invasive bladder cancer recurring within 12 months of last tumour occurrence.
High risk
Urothelial cancer with any of:
  • pTaG3
  • pT1G2
  • pT1G3
  • pTis (Cis).
[Bladder cancer (NICE guideline NG2) section 1.3]

Discussing treatment options for high-risk non-muscle-invasive bladder cancer

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults with high-risk non-muscle-invasive bladder cancer discuss intravesical Bacille Calmette-Guérin (BCG) and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist.

Rationale

Discussing the benefits and risks of intravesical BCG and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist helps adults to make an informed choice about which treatment would best suit them. It ensures that they are aware of the possible outcomes and implications of both treatments, including likely effects on their quality of life, body image, and sexual and urinary functions.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with high-risk non-muscle-invasive bladder cancer discuss intravesical BCG and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist before a treatment option is agreed.
Data source: Local data collection.
Process
The proportion of adults with high-risk non-muscle-invasive bladder cancer who discuss intravesical BCG and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist before agreeing a treatment option.
Numerator – the number in the denominator who have a discussion about intravesical BCG and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist before agreeing a treatment option.
Denominator – the number of adults with newly diagnosed high-risk non-muscle-invasive bladder cancer.
Data source: Local data collection.
Outcome
Satisfaction with explanation of treatment options reported by adults with high-risk non-muscle-invasive bladder cancer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults with high-risk non-muscle-invasive bladder cancer to discuss intravesical BCG and radical cystectomy with a urologist who performs both treatments and a clinical nurse specialist before agreeing a treatment option.
Healthcare professionals (urologists who perform both intravesical BCG and radical cystectomy, and clinical nurse specialists) discuss both procedures with adults who have high-risk non-muscle-invasive bladder cancer before agreeing a treatment option.
Commissioners (clinical commissioning groups) ensure that they commission services in which a clinical nurse specialist and a urologist who performs both intravesical BCG and radical cystectomy discuss both of these procedures with adults who have high-risk non-muscle-invasive bladder before agreeing a treatment option.

What the quality statement means for patients and carers

Adults with bladder cancer that has not grown into the muscle wall of the bladder, but has a high-risk of doing so, have a discussion with a clinical nurse specialist and a specialist bladder cancer doctor about having treatment either with a vaccine called BCG, which can stop the cancer growing, or by having their bladder removed in an operation called cystectomy. Knowing the benefits and risks of these treatment options, including the likely effects on their future quality of life, will help them to choose the option that is best for them.

Source guidance

Definitions of terms used in this quality statement

Discussion
Discussion should include:
  • the type, stage and grade of the cancer, the presence of carcinoma in situ, the presence of variant pathology, prostatic urethral or bladder neck status and the number of tumours
  • risk of progression to muscle invasion, metastases and death
  • risk of understaging
  • benefits of both treatments, including survival rates and the likelihood of further treatment
  • risks of both treatments
  • factors that affect outcomes (for example, comorbidities and life expectancy)
  • impact on quality of life, body image, and sexual and urinary functions.
[Bladder cancer (NICE guideline NG2) recommendation 1.3.6]

Equality and diversity considerations

Radical cystectomy may not be suitable for people who have problems with manual dexterity or cognitive function, or people who have visual impairment.

Discussing treatment options for muscle-invasive urothelial bladder cancer

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults with muscle-invasive urothelial bladder cancer discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist.

Rationale

Discussing the benefits and risks of neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist helps adults to make an informed choice about the treatments that would best suit them. It ensures that they are aware of the possible outcomes and implications of the treatments, including likely effects on their quality of life, body image, and sexual and urinary functions.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with muscle-invasive urothelial bladder cancer discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist.
Data source: Local data collection.
Process
The proportion of adults with muscle-invasive urothelial bladder cancer who discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist before agreeing a treatment option.
Numerator – the number in the denominator who have a discussion about neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist before agreeing a treatment option.
Denominator – the number of adults with muscle-invasive urothelial bladder cancer.
Data source: Local data collection.
Outcome
Satisfaction with explanation of treatment options reported by adults with muscle-invasive urothelial bladder cancer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults with muscle-invasive urothelial bladder cancer to discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist before agreeing a treatment option.
Healthcare professionals (urologists who perform radical cystectomy, clinical oncologists and clinical nurse specialists) discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with adults who have muscle-invasive urothelial bladder cancer before agreeing a treatment option.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission services in which a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist discuss neoadjuvant chemotherapy, radical cystectomy and radiotherapy using a radiosensitiser with adults who have muscle-invasive urothelial bladder cancer before agreeing a treatment option.

What the quality statement means for patients, service users and carers

Adults with bladder cancer that has grown into the muscle wall of the bladder have a discussion with a clinical nurse specialist and specialist bladder cancer doctors about either having their bladder removed (cystectomy) or having radiotherapy (high-energy rays that destroy cancer cells). They also discuss having chemotherapy (treatment with anticancer drugs) before having either of these treatments. Knowing the benefits and risks of these treatment options, including the likely effects on their future quality of life, will help them to choose the option that is best for them.

Source guidance

  • Bladder cancer (2015) NICE guideline NG2, recommendations 1.5.2 and 1.5.3

Definitions of terms used in this quality statement

Discussion
Adults with newly diagnosed muscle-invasive urothelial bladder cancer for whom cisplatin-based chemotherapy is suitable should be offered neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy or radical radiotherapy. They should have an opportunity to discuss the risks and benefits with an oncologist who treats bladder cancer.
[Bladder cancer (NICE guideline NG2) recommendation 1.5.2]
Adults with muscle-invasive urothelial bladder cancer for whom radical therapy is suitable should be offered a choice of radical cystectomy or radiotherapy with a radiosensitiser, and have their choice of treatment based on a discussion with a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist.
The discussion includes:
  • the prognosis with or without treatment
  • the limited evidence about whether surgery or radiotherapy with a radiosensitiser is the most effective cancer treatment
  • the benefits and risks of surgery and radiotherapy with a radiosensitiser, including the impact on sexual and bowel functions and the risk of death as a result of the treatment.
[Bladder cancer (NICE guideline NG2) recommendation 1.5.3]

Equality and diversity considerations

Radical cystectomy may not be suitable for people who have problems with manual dexterity or cognitive function, or people who have visual impairment.

Discharge to primary care

This quality statement is taken from the bladder cancer quality standard. The quality standard defines clinical best practice in bladder cancer and should be read in full.

Quality statement

Adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial transurethral resection of bladder tumour (TURBT) are discharged to primary care.

Rationale

Discharging adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months to primary care reduces the need for follow-up cystoscopies in secondary care. It is important that the discharge is discussed with the patient beforehand, and that written information about the patient’s care is sent to the GP who will be taking over their care when they are discharged.

Quality measures

Structure
Evidence of local arrangements for adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial TURBT to be discharged to primary care.
Data source: Local data collection.
Process
Proportion of adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial TURBT who are discharged to primary care.
Numerator – the number in the denominator who are discharged to primary care.
Denominator – the number of adults who have had low-risk non-muscle-invasive bladder cancer who have no recurrence of the bladder cancer within 12 months of their initial TURBT.
Data source: Local data collection.
Outcome
Satisfaction with discharge to primary care reported by adults who have had low-risk non-muscle-invasive bladder cancer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that systems are in place for adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial TURBT to be discharged to primary care.
Healthcare professionals discharge to primary care adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial TURBT.
Commissioners (clinical commissioning groups) ensure that they commission services that discharge to primary care adults who have had low-risk non-muscle-invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months of their initial TURBT. Commissioners work with providers in primary and secondary care to ensure that there is good communication between primary care, secondary care and the person who is being discharged.

What the quality statement means for patients and carers

Adults who have had bladder cancer removed in an operation called transurethral resection of bladder tumour, or TURBT for short, are discharged back to their GP after 1 year if there are no further signs of cancer, the cancer had not spread into the muscle wall of the bladder, and it was a type of cancer with a low-risk of spreading or coming back in the future.

Source guidance

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Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Offer white-light-guided TURBT with one of photodynamic diagnosis, narrow-band imaging, cytology or a urinary biomarker test (such as UroVysion using FISH, ImmunoCyt or a NMP22 test) to people with suspected bladder cancer. This should be carried out or supervised by a urologist experienced in TURBT.
Obtain detrusor muscle during TURBT.
Do not take random biopsies of normal-looking urothelium during TURBT unless there is a specific clinical indication (for example, investigation of positive cytology not otherwise explained).
Record the size and number of tumours during TURBT.
Offer people with suspected bladder cancer a single dose of intravesical mitomycin C given at the same time as the first TURBT.
Consider further TURBT within 6 weeks if the first specimen does not include detrusor muscle.
Offer people who have chosen radical cystectomy a urinary stoma, or a continent urinary diversion (bladder substitution or a catheterisable reservoir) if there are no strong contraindications to continent urinary diversion such as cognitive impairment, impaired renal function or significant bowel disease.
Members of the specialist urology multidisciplinary team (including the bladder cancer specialist urological surgeon, stoma care nurse and clinical nurse specialist) should discuss with the person whether to have a urinary stoma or continent urinary diversion, and provide opportunities for the person to talk to people who have had these procedures.
Offer people with bladder cancer and, if they wish, their partners, families or carers, opportunities to have discussions with a stoma care nurse before and after radical cystectomy as needed.

Risk categories for non-muscle-invasive bladder cancer1

Low risk
Intermediate risk
High risk
Urothelial cancer with any of:
  • solitary pTaG1 with a diameter less than 3 cm
  • solitary pTaG2 low grade with a diameter less than 3 cm
  • any papillary urothelial neoplasm of low malignant potential
Urothelial cancer that is not low risk or high risk, including:
  • solitary pTaG1 with a diameter more than 3 cm
  • multifocal pTaG1
  • solitary pTaG2 low grade with a diameter more than 3 cm
  • multifocal pTaG2 low grade
  • pTaG2 high grade
  • any pTaG2 grade not further specified
  • any low-risk non-muscle-invasive bladder cancer recurring within 12 months of last tumour occurrence
Urothelial cancer with any of:
  • pTaG3
  • pT1G2
  • pT1G3
  • pTis (Cis)
  • aggressive variants of urothelial carcinoma, for example micropapillary or nested variants
1 There is no widely accepted classification of risk in non-muscle-invasive bladder cancer. To make clear recommendations for management, the Guideline Development Group developed this consensus classification based on evidence reviewed and clinical opinion.
See what NICE says on the use of urinary biomarkers for follow-up after treatment for bladder cancer.
Refer people urgently to urological services if they have haematuria or other urinary symptoms and a history of non-muscle-invasive bladder cancer.
Offer follow-up after radical cystectomy or radical radiotherapy.
After radical cystectomy consider using a follow-up protocol that consists of:
  • monitoring of the upper tracts for hydronephrosis, stones and cancer using imaging and glomerular filtration rate (GFR) estimation at least annually and
  • monitoring for local and distant recurrence using CT of the abdomen, pelvis and chest, carried out together with other planned CT imaging if possible, 6, 12 and 24 months after radical cystectomy and
  • monitoring for metabolic acidosis and B12 and folate deficiency at least annually and
  • for men with a defunctioned urethra, urethral washing for cytology and/or urethroscopy annually for 5 years to detect urethral recurrence.

Glossary

magnetic resonance imaging
transurethral resection of bladder tumour
fluorescence in situ hybridization
fluorodeoxyglucose positron emission tomography
Bacille Calmette-Guérin
glomerular filtration rate
nuclear matrix protein 22
methotrexate, vinblastine, doxorubicin and cisplatin

Paths in this pathway

Pathway created: December 2015 Last updated: May 2017

© NICE 2017

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