What factors affect bladder cancer treatment options? Bladder cancer specialist Dr. Piyush Agarwal defines bladder cancer risk categories and lays out how these classifications can help guide treatment recommendations.
Dr. Piyush K. Agarwal is the Director of the Bladder Cancer Program at the University of Chicago Medicine Comprehensive Cancer Center (UCCCC), where he also serves as Professor of Surgery, Vice Chief of Urology, and Fellowship Director of Urologic Oncology. Learn more about Dr. Agarwal.
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Transcript
Katherine Banwell:
Could you walk us through the key factors considered when deciding on a bladder cancer therapy?
Dr. Piyush Agarwal:
Yeah, so we will typically place patients based on their pathologic features into a low-risk category, an intermediate-risk category, or a high-risk category. And fortunately, in bladder cancer, a lot of us have come up with treatment algorithms for these different risk groups. For low risk, usually using a one-time chemotherapy treatment at the time of a tumor resection with surveillance. It works very well in most patients.
Those patients who are intermediate risk, which are typically low-grade tumors, but that either recur frequently or are very large, those patients in the intermediate-risk category, which could also include some high-grade tumors that are very tiny, there are some new novel agents that were recently approved that can be used in lieu of actually resecting and surgically operating on patients. What we’ve been doing for a while, which still continues to work, is we can also resect the tumor surgically and give them sort of adjuvant bladder installation.
That’s an area that a lot of companies are doing clinical trials in, to see if they can offer a product that’s more effective than what we have currently. That’s an active area of trial investigation. And then for the high-risk patients, then that will guide treatments like BCG and those other novel agents. Yeah, the grade is very important, and the stage, because then that determines the risk group, and then the risk group really determines very algorithmic treatments.
And so, that’s what I like about bladder cancer opposed to other urologic cancers we treat, that it is sort of – we as a community have done, I think, a good job at sort of specifying how these tumors should be treated. And I feel that most patients can get really good care with most providers, because we’re all sort of adhering to these treatment algorithms.
Katherine Banwell:
Can you define the risk groups? Low, intermediate, and high?
Dr. Piyush Agarwal:
Yeah, so low-risk tumors are low-grade tumors. Essentially, low-grade tumors, less than 3 centimeters. Solitary low-grade tumors, these are tumors that fall into the low-risk category, those that take more than a year to recur, so a low recurrence risk, small size, and solitary tumors. The intermediate risk category is mostly made up of low-grade tumors, but low-grade tumors that are larger, so 3 centimeters or greater; low-grade tumors that are multifocal, or low-grade tumors that recur more often than beyond a year. You’ll have some of these patients who have tumors every three to six months.
When you look in their bladder, they recur and then they’ve got to go back to the OR, or they want some sort of intervention done. That’s the intermediate risk category. Now, some of us will also add high-grade tumors that are very small, less than 3 centimeters, and solitary to that group. There are others of us that feel that all high grade tumors should be in the high-risk category. That’s a little bit of an asterisk, whether or not that that select high-grade tumor should be incorporated in the intermediate risk group.
Everyone agrees that high risk includes any high-grade tumor greater than 3 centimeters, any high-grade tumor that’s multifocal; any CIS, which is the flat tumor. Any tumor that is in the Lamina propria, which is stage T1, is also considered high grade. Because of the risk group definitions, it gives us a good way to treat our patients, because based on the risk, we have treatments that they’re eligible for.