Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The TNM classification for bladder cancer uses a combination of tumor, lymph node, and metastasis categories to determine the stage of cancer. This process involves three main inputs: tumor classification (T), lymph node classification (N), and distant metastasis (M).

For tumor classification (T), the options range from Tx to T4b, indicating the extent of tumor invasion, from unassessable (Tx) to invasion into pelvic or abdominal walls (T4b).

For lymph node classification (N), the options range from Nx to N3, describing the status of lymph nodes, from unassessable (Nx) to metastasis in common iliac lymph nodes (N3).

Lastly, distant metastasis classification (M) options assess the spread beyond the primary tumor, ranging from M0 (no metastasis) to M1b (metastasis to non-lymph node sites).

Here's how the calculator determines the stage:

- Stage 0a occurs if there is a non-invasive papillary carcinoma (Ta), no regional lymph node metastasis (N0), and no distant metastasis (M0).
- Stage 0is is specific to carcinoma in situ (Tis) with no regional lymph node metastasis (N0) and no distant metastasis (M0).
- Stage I is assigned when the tumor invades lamina propria (T1), with N0 and M0.
- Stage II is reached if the tumor invades muscularis propria (T2a or T2b), with N0 and M0.
- Stage IIIA is marked by further invasions (such as T3a, T3b, or T4a) with N0 and M0.
- Stage IIIB involves any tumor invasion from T1 to T4a, with single or multiple regional lymph node metastases (N1 or N2) and M0.
- Stage IVA results if the tumor invades the pelvic or abdominal walls (T4b) with N0 and M0, or meets the criteria of other invasions (such as N1 or N2) with metastasis beyond common iliacs (M1a).

Finally, Stage IVB represents non-lymph node distant metastasis (M1b) with any range of tumor or lymph node classification (from T1 to T4b and N1 to N3).

The arrangement of stages provides a structured view of how far the cancer has progressed, which aids in determining prognosis and treatment pathways.

The calculator in question is the TNM Classification for Bladder Cancer. TNM stands for Tumor, Node, Metastasis, and it is a globally recognized system used to stage different types of cancers, including bladder cancer. 

This classification system applies specifically to patients diagnosed with bladder cancer. It helps clinicians to determine the extent of the cancer's spread, which is crucial for planning appropriate treatment strategies and predicting patient prognosis. 

The TNM system for bladder cancer includes three components: T (Tumor), which describes the size of the primary tumor and whether it has invaded nearby tissue; N (Node), which indicates whether the cancer has spread to nearby (regional) lymph nodes; and M (Metastasis), which denotes whether the cancer has metastasized to other parts of the body.

There are no specific exclusion criteria for the use of the TNM Classification for Bladder Cancer. However, it may not be fully applicable or accurate in patients with rare forms of bladder cancer or those with multiple primary tumors.

TNM classification for bladder cancer

The European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator helps evaluate the risk associated with bladder cancer using inputs based on the 2004/2016 World Health Organization grading system. By considering several patient and tumor characteristics, it produces a score that determines the risk category.

The calculator requires answers to the following six questions:

- Age of the patient, with choices: "<= 70 years" or "> 70 years"
- Number of tumors present, with options: "Single" or "Multiple"
- Maximum diameter of the tumor, with choices: "< 3 cm" or ">= 3 cm"
- Stage of the cancer, with options: "Ta" or "T1"
- Presence of concomitant carcinoma in situ, with options: "No" or "Yes"
- The WHO grade according to the 2004/2016 classification, with options: "Low malignant potential-low grade" or "High-grade"

Each response is associated with a particular score:

| Factor                               | Option                             | Score |
|--------------------------------------|-------------------------------------|-------|
| Age                                  | <= 70 years                         | 0     |
|                                      | > 70 years                          | 55    |
| Number of tumors                     | Single                              | 0     |
|                                      | Multiple                            | 50    |
| Maximum diameter of the tumor        | < 3 cm                              | 0     |
|                                      | >= 3 cm                             | 65    |
| Stage of cancer                      | Ta                                  | 0     |
|                                      | T1                                  | 80    |
| Concomitant carcinoma in situ        | No                                  | 0     |
|                                      | Yes                                 | 100   |
| WHO 2004/2016 grade                  | Low malignant potential-low grade   | 0     |
|                                      | High-grade                          | 85    |

To determine the total score, sum the scores associated with each selected answer. This total score is then used to categorize the risk level as follows:

- A score of 80 or less indicates a Low risk.
- A score between 85 and 164 suggests an Intermediate risk.
- A score between 165 and 314 signifies a High risk.
- A score of 315 or more marks a Very high risk.

This risk assessment aids in guiding clinical decisions and shaping management strategies for patients diagnosed with non-muscle-invasive bladder cancer.

The European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator using the 2004/2016 World Health Organization grading system is a clinical tool used to predict the risk of recurrence and progression in patients with non-muscle invasive bladder cancer (NMIBC). This calculator is specifically designed for patients diagnosed with NMIBC and it helps clinicians to stratify patients into low, intermediate, and high-risk groups. The clinical utility of this calculator is to guide treatment decisions and follow-up strategies based on the individual patient's risk profile. It can also be used to inform patients about their prognosis and to facilitate shared decision-making. The EAU NMIBC risk calculator should not be used in patients with muscle-invasive bladder cancer or metastatic disease, as it is not designed to predict outcomes in these populations.

European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator using the 2004/2016 World Health Organization grading system

The Eastern Cooperative Oncology Group (ECOG) performance status calculator is designed to evaluate a patient's functional ability and categorize it into a specific score from 0 to 5. This quantitative measure helps clinicians make informed decisions about treatment based on the patient's capacity for daily activities and self-care. Here's how it operates:

The user provides input by selecting the description that best matches the patient's current condition from a list of predefined options. These options encapsulate various levels of activity and ability:

- A patient who is "Fully active, able to carry on all pre-disease performance without restriction" is assigned a score of ECOG PS 0. This indicates that the patient is not limited in any capacity by their disease.
- If a patient is "Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, such as light housework, office work," they receive an ECOG PS 1. This means the patient can perform some self-care and work activities but faces restrictions with strenuous tasks.
- "Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours" corresponds to an ECOG PS 2. This reflects moderate impairment, where the patient is active for the majority of the day but not capable of work activities.
- A patient who is "Capable of only limited self-care, confined to bed or chair more than 50% of waking hours" gets an ECOG PS 3. This score denotes significant limitation, as the patient is mobile for less than 50% of the time and requires assistance for most activities.
- With "Completely disabled, cannot carry on any self-care, totally confined to bed or chair," the patient is categorized as ECOG PS 4, indicating severe impairment and complete dependency.
- Finally, if the patient is "Dead," they are assigned an ECOG PS 5.

These score assignments help standardize assessments, providing an objective measure of a patient's status which can be pivotal in guiding medical decisions and evaluating treatment options.

The Eastern Cooperative Oncology Group (ECOG) performance status, also known as the ECOG score, is a widely used tool in oncology to assess a patient's level of functioning in terms of their ability to care for themselves, daily activity, and physical ability (walking, working, etc.). It is applicable to patients with cancer of any type and at any stage.

The ECOG score ranges from 0 to 5, with 0 indicating fully active and able to carry on all pre-disease activities without restriction, and 5 indicating death. The score is used to determine a patient's prognosis, assess how a disease is progressing, and to determine appropriate treatment strategies. It is also often used in clinical trials to assess eligibility and to monitor patient progress.

There are no specific exclusion criteria for the use of the ECOG score, but it is important to note that it is a subjective measure and may not fully capture a patient's functional status. It is also less useful in patients with fluctuating or rapidly changing conditions.

Eastern Cooperative Oncology Group performance status (ECOG score)

The Karnofsky Performance Scale (KPS) provides a practical method to evaluate a patient's functional ability and the extent of care required based on their health status. The scale ranges from 0% to 100%, where higher percentages signify better functional capacity and health.

This tool involves selecting a descriptive statement that best reflects a patient's current condition from a predefined list. Each statement is connected to a specific KPS percentage that indicates the patient’s ability to perform daily activities and their dependency levels. Here’s how the assessment works:

- When a patient is described as "Normal, no complaints, no evidence of disease," this is assessed as KPS 100%. At this level, the individual can engage in all regular activities, including work, without needing special care.

- If a patient can "carry on normal activity" but exhibits "minor signs or symptoms of disease," they are scored at KPS 90%, indicating the capability to maintain routine activities without requiring special care.

- A description of "Normal activity with effort, some signs or symptoms of disease" aligns with KPS 80%. This suggests the patient can still carry out normal activities but might require some extra effort.

- When the condition reflects "Cares for self, unable to carry on normal activity or to do active work," it corresponds to KPS 70%. The patient can handle most personal needs independently but may need occasional assistance.

- "Requires occasional assistance but is able to care for most personal needs" is rated as KPS 60%, implying increased dependency on assistance though the patient remains mostly self-sufficient.

- At KPS 50%, for conditions described as "Requires considerable assistance and frequent medical care," the patient can live at home but needs considerable help with personal care.

- As the need for care intensifies, with descriptions like "Disabled, requires special care and assistance," the KPS drops to 40%. This marks a significant deterioration in self-care ability.

- "Severely disabled, hospital admission is indicated, death not imminent" corresponds to KPS 30%, highlighting a need for hospitalization without immediate life-threatening conditions.

- For those "Very sick," necessitating hospital admission and "active supportive treatment," the KPS is 20%, indicating critical care requirements.

- At KPS 10%, "Moribund" denotes an inability to care for oneself, with urgent need for hospital-level care and a poor prognosis.

- Lastly, "Dead" is considered as KPS 0%.

This scale is instrumental in providing a quick overview of a patient's ability to function independently and their need for medical support, thereby facilitating better care planning and resource allocation.

The Karnofsky Performance Status Scale (KPSS) is a clinical calculator used primarily in patients with cancer. It is a simple, numerical scale that measures a patient's functional status, ability to perform daily activities, and overall quality of life. The KPSS ranges from 0 (indicating death) to 100 (indicating perfect health). 

The clinical utility of the KPSS is to assess a patient's prognosis, determine appropriate treatment strategies, and monitor changes in a patient's condition over time. It is particularly useful in oncology for determining eligibility for certain treatments, such as chemotherapy or surgery, and for predicting survival outcomes. 

There are no specific exclusion criteria for the use of the KPSS. However, it is less useful in patients with non-cancer illnesses or in those with cognitive impairment who may not be able to accurately self-report their functional status.

Karnofsky Performance Scale

The Charlson Comorbidity Index (CCI) is a tool used to predict a patient's 10-year survival by taking into account age and various medical conditions. Each component of the index is assigned a score based on the presence or absence of specific conditions and the patient's age. These scores are then summed to produce a total CCI score, which provides an estimate of long-term survival.

- Age is scored as:
  - Less than 50 years: 0 points
  - 50 to 59 years: 1 point
  - 60 to 69 years: 2 points
  - 70 to 79 years: 3 points
  - 80 years or older: 4 points

- Medical conditions are scored as follows:
  - Myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, connective tissue disease, and ulcer disease each contribute 1 point if present.
  - Liver disease scores 0 for none, 1 for mild chronic hepatitis or cirrhosis without portal hypertension, and 3 for moderate to severe cirrhosis with or without variceal bleeding.
  - Diabetes mellitus contributes 0 points if absent, 1 point for uncomplicated diabetes, and 2 points for diabetes with end-organ damage.
  - Hemiplegia and moderate to severe chronic kidney disease each add 2 points if present.
  - Solid tumors add 0 points if absent, 2 points if localized, and 6 points if metastatic.
  - Leukemia and lymphoma each contribute 2 points if present.
  - AIDS contributes 6 points if present.

The CCI score is the sum of these individual scores and can range from 0 to 37. The total score correlates with an estimated 10-year survival probability, which is interpreted as follows:

- A score of 0 suggests an estimated 10-year survival rate of 98%.
- A score of 1 corresponds to a 96% survival rate.
- A score of 2 indicates a 90% survival rate.
- With a score of 3, the survival rate is estimated at 77%.
- A score of 4 corresponds to a survival rate of 53%.
- A score of 5 suggests a survival rate of 21%.
- Scores of 6 or higher indicate a survival probability of less than 21%.

This scoring system helps healthcare providers assess long-term mortality risk in patients with multiple comorbidities based on their health conditions and age.

The Charlson Comorbidity Index (CCI) is a clinical calculator used to predict the ten-year mortality for a patient who may have a range of comorbid conditions. Each condition is assigned a score of 1, 2, 3, or 6, depending on the risk of dying associated with each one. Conditions include heart disease, AIDS, and cancer among others. The scores are summed to provide a total score to predict mortality. 

This calculator is applicable to a wide range of patients, particularly those with multiple comorbid conditions. It is often used in research settings to control for the confounding effect of comorbidities. 

The CCI is not recommended for use in patients without any comorbid conditions, as the score would be zero and not provide any additional prognostic information. It also may not be as accurate in populations with conditions not included in the original index, or in those with very high levels of comorbidity.

Charlson Comorbidity Index (CCI)

The EAU NMIBC risk calculator offers a systematic approach to evaluating the risk of non-muscle-invasive bladder cancer (NMIBC) progression based on several patient-specific characteristics. Here's how the process is structured:

First, the calculator collects information on six aspects of a patient's condition:

- Age: Assess whether the patient is <= 70 years or > 70 years. Scores assigned are 0 for <= 70 years and 32 for > 70 years.
- Number of tumors: Determine if there is a Single tumor or Multiple tumors. Single tumors contribute 0 to the score, while Multiple tumors add 50.
- Maximum diameter of the tumor: Compare the size to 3 cm. If the diameter is < 3 cm, the score is 0; if >= 3 cm, the score is 32.
- Tumor stage: Identify whether the tumor stage is Ta or T1. Ta has a score of 0, whereas T1 adds 52 points to the total.
- Concomitant carcinoma in situ: Check if there is a presence (Yes) or absence (No). No concomitant carcinoma scores 0, while Yes scores 58.
- 2004/2016 World Health Organization grade: Select from grades G1, G2, and G3. The scores are 0 for G1, 58 for G2, and 100 for G3.

Once all inputs are assigned their respective scores, these numbers are summed to create a total risk score. This total score correlates with specific risk levels:

- Low risk: A total score between 0 and 52.
- Intermediate risk: Scores ranging from 58 to 141.
- High risk: Scores from 142 up to 241.
- Very high risk: A score of 242 or more.

The outcome from the calculator includes both the numerical score and an interpretation that classifies the individual into one of these risk levels. This approach provides insight into the patient's prognosis, aiding in the planning of personalized treatment and follow-up.

The European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator is specifically designed for patients diagnosed with non-muscle-invasive bladder cancer. The calculator uses the 1973 World Health Organization grading system to stratify patients into risk groups based on various factors such as tumor size, number of tumors, prior recurrence rate, and presence of carcinoma in situ.

The clinical utility of the EAU NMIBC risk calculator is to predict the likelihood of recurrence and progression of non-muscle-invasive bladder cancer. This can help clinicians in making informed decisions about the management and treatment of the disease, including the need for more aggressive treatment or closer surveillance.

Exclusion criteria for the use of this calculator would include patients with muscle-invasive bladder cancer, those who have not had a confirmed diagnosis of bladder cancer, or those with insufficient data to complete the risk assessment.

European Association of Urology Non-Muscle-Invasive Bladder Cancer (EAU NMIBC) risk calculator using the 1973 World Health Organization grading system copy

The Modified Glasgow Prognostic Score (mGPS) is a key tool in predicting cancer outcomes, relying on the assessment of two biochemical markers: C-reactive protein (CRP) and albumin. This score helps to categorize the prognosis into three levels: good, intermediate, and poor.

To compute the mGPS:

- C-reactive protein is evaluated first. Two options are considered:  
  - If the CRP is less than or equal to 10 mg/L, it indicates lower systemic inflammation.
  - If the CRP is greater than 10 mg/L, it signifies higher inflammation levels.

- Albumin is the second marker, with two possibilities:  
  - An albumin level of less than 3.5 g/dL [35 g/L] suggests malnutrition or potential inflammatory conditions.
  - An albumin level equal to or greater than 3.5 g/dL [35 g/L] signifies a normal nutritional status and protein reserves.

The mGPS score is derived based on the following systematic interpretation:

- If CRP is <= 10 mg/L, regardless of the albumin level, the score is mGPS 0, corresponding to a good prognosis. This combination indicates a low level of inflammation, which is a favorable signal in cancer outcomes.
 
- If CRP is > 10 mg/L and albumin is >= 3.5 g/dL [35 g/L], the score is mGPS 1, associated with an intermediate prognosis. This combination suggests elevated inflammation yet with sufficient nutritional status, resulting in a moderate outlook.

- If CRP is > 10 mg/L and albumin is < 3.5 g/dL [35 g/L], the result is mGPS 2, indicating a poor prognosis. This reflects high inflammation levels coupled with low albumin, suggesting a more severe condition.

Here's a concise summary table for reference:

| C-reactive Protein | Albumin               | mGPS Score | Interpretation          |
|---------------------|-----------------------|-------------|-----------------------|
| <= 10 mg/L          | < 3.5 or >= 3.5 g/dL  | 0           | Good prognosis         |
| > 10 mg/L           | >= 3.5 g/dL           | 1           | Intermediate prognosis |
| > 10 mg/L           | < 3.5 g/dL            | 2           | Poor prognosis         |

This systematic approach enables healthcare providers to improve risk stratification in cancer patients, allowing for more tailored treatment planning.

The Modified Glasgow Prognostic Score (mGPS) is a clinical calculator used in the field of oncology to predict the prognosis of patients with cancer. It is applicable to a wide range of cancer types and stages, making it a versatile tool for clinicians. The mGPS is based on two simple, routinely measured inflammatory markers: C-reactive protein (CRP) and albumin levels. 

The clinical utility of the mGPS lies in its ability to stratify patients into different risk groups based on their inflammatory response to cancer. This can guide clinicians in making decisions about treatment strategies and follow-up plans. It can also provide valuable prognostic information to patients and their families.

There are no specific exclusion criteria for the use of the mGPS. However, it should be noted that the score may not be as accurate in patients with concurrent inflammatory or infectious conditions, as these can also affect CRP and albumin levels. Additionally, the mGPS may not be applicable to patients with rare types of cancer or those with very early or very advanced disease, as it has not been extensively validated in these groups.

Modified Glasgow Prognostic Score for cancer outcomes (mGPS)

Bladder cancer

Management of metastatic cancer

Staging

Smoking cessation

Management of muscle-invasive cancer

Management of muscle-invasive cancer, chemotherapy

Surveillance

Surveillance, non-muscle-invasive cancer

General counseling

As per ASCO/ASTRO/AUA/SUO 2017 guidelines, 

Management of non-muscle-invasive cancer

Management of non-muscle-invasive cancer, transurethral resection of tumor

Urinary tract imaging

Management of muscle-invasive cancer, radiotherapy

Avoidance of carcinogenic substances

Management of non-muscle-invasive cancer, radical cystectomy

Management of muscle-invasive cancer, palliative therapy

Biopsy and histopathology

Management of persistent/recurrent disease

Management of persistent/recurrent disease, non-muscle-invasive cancer

Indications for screening

Cytology

Imaging for staging

Management of muscle-invasive cancer, sexual-preserving surgery

Management of muscle-invasive cancer, general principles

History and physical examination

Management of non-muscle-invasive cancer, intravesical chemotherapy

Management of muscle-invasive cancer, bladder-preserving therapy

Cystoscopy and ureteroscopy

Management of non-muscle-invasive cancer, intravesical BCG immunotherapy

Management of non-muscle-invasive cancer (TURP)

Elderly patients

Management of persistent/recurrent disease (metastatic cancer)

Patients with upper urinary tract cancer

Molecular testing

Surveillance (metastatic cancer)

Surveillance, muscle-invasive cancer

Management of persistent/recurrent disease, muscle-invasive cancer

Management of non-muscle-invasive cancer (salvage therapy)

Management of muscle-invasive cancer (transurethral resection of tumor)

Management of non-muscle-invasive cancer, general principles

Management of persistent/recurrent disease (general principles)

Management of muscle-invasive cancer, radical cystectomy

Management of muscle-invasive cancer (urinary diversion)

Risk stratification

Laboratory tests

Management of non-muscle-invasive cancer (active surveillance)

Updated 2024 ESMO guidelines for the management of advanced urothelial carcinoma


Updated 2024 EAU guidelines for the diagnosis and management of bladder cancer


Bladder cancer

Background

Overview

Guidelines

Key sources