NCCN Guidelines B Ca v3 – 2020
The most recent NCCN Clinical Practice Guideline on B Ca (v3 – 2020) has been published in JNCCN in March 2020.
https://jnccn.org/view/journals/jnccn/18/3/article-p329.xml (PDF available)
NCCN Guidelines differ from EAU and EAU guidelines by its frequent updated publications. The latest aspects that have evolved in the field are given consideration on their merit.
Bladder Cancer has arisen from its Orphaned state, which existed for around 25 years, to a condition where considerable progresses have occurred during the past few years. Research wise, probably, B Ca has probably overtaken P Ca but still many lacunae are present.
There is still confusion regarding grading classification. In 2004, ISUP introduced the two tier grading system as against the 1973, three tier grading system. The 2016 WHO book on Grading and Staging of GU cancers has retained the 2004 system essentially with some modifications. Many eminent Pathologists have begun questioning the validity of grading systems. Both the 1973 WHO and the 2004 WHO Classifications are effective in predicting tumor progression in Non-muscle invasive bladder cancer, while the 1973 WHO Classification is more suitable for predicting tumor recurrence.
Judith Bosschieter* et al (2018) summed up this ambiguity by concluding ‘Reproducibility of the WHO 2004 and WHO 1973 classification for grade are poor. Scoring of individual criteria is poorly reproducible, suggesting that descriptions of these criteria for grade are not specific. The prognostic value of both the WHO 1973 and the WHO 2004 differ per pathologist’.
Number of markers is on the anvil in various stages of development. But many like Cxbladder have become commercialized but they have not made its entry into clinical Guidelines yet. The future appears to be in the introduction of new Classification systems for both NMIBC and MIBC. This will be essentially based on the understanding of Luminal and Basal Genetic Subtypes. In a nutshell it can be said that the molecular subtyping system mainly uses cluster analysis to examine the genome and the expression levels of genes and their involved biological processes. Compared with the traditional classification system, molecular subtyping reflects the intrinsic characteristics of the tumours, and it not only predicts the prognosis and treatment response of NMIBCs but also MIBCs.
This NCCN Guideline has given importance in many talked about areas of B Ca. BCG shortage, a much talked about area in the west, has been discussed. More importantly the role of Checkpoint inhibitors for both MIBC and NMIBC are discussed at length.
With warm Regards,