Real-world Adherence to European Association of Urology-recommended Non-muscle-invasive Bladder Cancer Management: From Evidence-based Practice to Oncological Outcomes.

BACKGROUND AND

OBJECTIVE

Adherence to European Association of Urology (EAU) guideline-recommended management of non-muscle-invasive bladder cancer (NMIBC) is essential for optimal outcomes. We quantified real-world adherence to early instillation (EI), second-look transurethral resection of bladder tumor (re-TURBT), and risk-adapted intravesical therapy, and assessed their impact on oncological outcomes.

METHODS

We retrospectively analyzed 2194 consecutive NMIBC patients treated with TURBT at six European tertiary centers (2014-2021). Eligibility for EI, re-TURBT, and intravesical instillations was defined using the EAU criteria. Adherence was evaluated through Sankey plots. Recurrence-free survival (RFS) and progression-free survival (PFS) were assessed using Kaplan-Meier analyses with inverse probability of treatment weighting and compared by adherence status. Cox regression models were also fitted.

KEY FINDINGS AND LIMITATIONS: Tumor stage distribution was as follows: 63% Ta, 32% T1, and 5.4% Tis stage; 60% were of high grade. Risk distribution was as follows: 22% low, 27% intermediate, 38% high, and 13% very high. EI was recommended in 1333 patients and performed in 290 (22%) patients. Re-TURBT was indicated in 1006 patients and performed in 445 (44%) patients. Intravesical instillations were recommended in 1713 patients and initiated in 497 (29%) patients. Adherence to EI (79% vs 61%; hazard ratio [HR] 0.60), re-TURBT (70% vs 54%; HR 0.53), and instillations (72% vs 53%; HR 0.49) was associated with superior RFS; re-TURBT (94% vs 87%; HR 0.41) and instillations (95% vs 89%; HR 0.47) also improved PFS (all p < 0.001). Nonadherence reasons were not reported.

CONCLUSIONS AND CLINICAL IMPLICATIONS: In real-world practice, adherence to EAU-recommended NMIBC management remains low; yet, it is associated with more favorable outcomes. Improving delivery of guideline-based care through standardized pathways should be a priority in NMIBC management.