Listen to evidence-based treatment protocols: TURBT is the gold standard for nonmuscle invasive bladder cancer

Listen to evidence-based treatment protocols: TURBT is the gold standard for nonmuscle invasive bladder cancer
'Our Rock' – Fight Bladder Cancer UK, by Craig Kemp Used with permission of a Creative Commons License.

In my online support group, a list serve managed by Inspire for the Bladder Cancer Advocacy Network, there has been lots of chatter about whether removing a tumor in the bladder can “seed” cancer cells.

Those who argue that it can and does stir up fear about a very safe and successful procedure that has saved thousands of lives. I’m at a loss as to the alternative that these fear mongerers suggest. Leave the tumor alone? Choose herbs and nutrition to treat the tumor on the basis of no evidence whatsoever? Remove the bladder entirely?

I have two concerns.

First, fear is such a dominant part of the experience of cancer that I deeply resent when folks stir up more. From conspiracy theories about “big pharma” being in league with scientists and physicians to keep “real cures” away from us in the interest of making money to the idle, armchair critics who claim to have “surveyed all the literature” on the topic, I’m furious at people who pour gasoline on a fire.

Second, there actually are good answers to these questions. I cannot abide folks who recommend that the newly diagnosed shouldn’t follow evidence-based protocols. I don’t care if you’ve been a surgical nurse for 20 years, if you recommend against the NCCN guidelines (they are here) and evidence-based research, then you should keep your advice to yourself.

So, here’s the lowdown on whether or not TURBT “seeds” cancer cells. Evidence argues that it does not. I base my opinion on a piece of research in the Journal of Urology, written by Gary Steinberg and colleagues at the University of Chicago. Steinberg is one of the most respected bladder cancer experts in the country.

He, Kyle A. Richards and Norm D. Smith conducted a “systematic review” of the published research on TURBT. This means that they really did survey all the literature out there on the topic and put it through a statistical analysis. You can find the article, available free, here.

Their results reaffirm what the NCCN guidelines recommend, TURBT is the gold standard for nonmusical invasive bladder cancer. This should be repeated in four weeks when the pathology results indicate T1 or high grade cells without muscle tissue.

With a high-quality TURBT, Steinberg et al report that “the mortality rate from low risk disease is nil vs 30% at 10 years for high risk disease.” The two most important points: TURBT works amazingly well and you need to know what constitutes a “high quality” procedure.

Their research offers the following recommendations for a high-quality procedure:

  • Choose a senior surgeon. There is a learning curve with TURBT and practice makes perfect.
  • Surgical technique should closely follow recommendations, including the type of equipment your surgeon uses.
  • Blue light diagnosis is most likely a better option than White Light, but more research needs to be done.
  • Post-op intravesical chemotherapy should be a part of TURBT except in particular cases, such as a very large tumor and a plan for aggressive therapy.

In addition, the paper reports very low complication rates for TURBT, with bladder perforation being the most concerning but uncommon.

Steinberg and colleagues make clear that treatment plans need to be individualized for patients by clinicians.

Bottom line:
Go to NCCN and print off the guidelines for treatment of bladder cancer (if your clinician hasn’t already given them to you) If your clinician doesn’t follow the guidelines, get a second opinion from a physician at an NCI-designated cancer center. You can find the list of centers here.

And, yes, TURBT is the gold standard.

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