Swedish National Guidelines on Urothelial Carcinoma: 2021 update on non-muscle invasive bladder cancer and upper tract urothelial carcinoma

Figures & data

Figure 1. The age-standardized incidence bladder cancer per 100,000 inhabitants in Sweden stratified by gender (men: dark yellow;  women: yellow).

Table 1. The EAU 2021 prognostic risk groups based on WHO 1973 and/or WHO 2016 grading system.

Risk group
Low risk	A primary, single, Ta/T1 LG/G1 tumour < 3 cm in diameter without CIS in a patient < 70 years
	A primary Ta LG/G1 tumour without CIS with at most ONE of the additional clinical risk factors (see below*)
Intermediate risk	Patients without CIS who are not included in either the low, high or very high risk groups
High risk	All T1 HG/G3 without CIS, EXCEPT those included in the very high risk group
	All CIS patients, EXCEPT those included in the very high risk group
	Stage, grade with additional clinical risk factors:
	Ta LG/G2 or T1 G1, no CIS with all 3 risk factors
	Ta HG/G3 or T1 LG, no CIS with at least 2 risk factors
	T1 G2 no CIS with at least 1 risk factor
Very high risk	Stage, grade with additional clinical risk factors:
	Ta HG/G3 and CIS with all 3 risk factors
	T1 G2 and CIS with at least 2 risk factors
	T1 HG/G3 and CIS with at least 1 risk factor
	T1 HG/G3 no CIS with all 3 risk factors

The scoring system does not consider patients with primary carcinoma in situ (CIS) or with recurrent tumours. Similarly, some pathologic features such as variant histologies, lymphovascular invasion and CIS in the prostatic urethra are not included in the model, although based on data in the literature, if any of these factors are present the patient should be included in the very high risk group.

*Additional clinical risk factors are: age > 70; multiple tumours; tumour diameter 3 cm and above.

Table 2. Probabilities of disease progression to muscle invasion or distant metastases at 1, 5 and 10 years according to the EAU 2021 prognostic risk groups.

Risk group	Probability of progression and 95% confidence interval (CI)
	1 Year	5 Years	10 Years
Risk groups with WHO 2004/2016
Low	0.06% (0.01–0.43%)	0.93% (0.49–1.7%)	3.7% (2.3–5.9%)
Intermediate	1.0% (0.50–2.0%)	4.9% (3.4–7.0%)	8.5% (5.6–13%)
High	3.5% (2.4–5.2%)	9.6% (7.4–12%)	14% (11–18%)
Very high	16% (10–26%)	40% (29–54%)	53% (36–73%)
Risk groups with WHO 1973
Low	0.12% (0.02–0.82%)	0.57% (0.21–1.5%)	3.0% (1.5–6.3%)
Intermediate	0.65% (0.36–1.2%)	3.6% (2.7–4.9%)	7.4% (5.5–10%)
High	3.8% (2.6–5.7%)	11% (8.1–14%)	14% (10–19%)
Very high	20% (12–32%)	44% (30–61%)	59% (39–79%)

Figure 2. Annual proportion (%) of patients with bladder cancer stage T1–T4 or upper tract urothelial carcinoma discussed at a multidisciplinary tumor board (MDT) between 2016 and 2020 in Sweden stratified by health care region (Uppsala-Örebro (

), Northern (

), Southern (

), Stockholm-Gotland (

), Southeastern (

) and Western (

) health care regions) as well as visualizing the compiled national proportion (

).

Figure 3. Proportion (%) of patients with bladder cancer stage T1–T4 or upper tract urothelial carcinoma discussed at a multidisciplinary tumor board (MDT) between 2016 and 2020 in Sweden stratified by region. Each blue bar represents a region and the yellow bar the whole Swedish population, where the colours delineate p-values compared to the national proportions with the following colour-codes

p <0.01,

p < 0.05.

Figure 4. Proportion of patients with non-muscle invasive bladder cancer with the presence of detrusor muscle in the resected specimen between 2018 and 2020 stratified by treating hospital. Each blue bar represents a hospital and the yellow bar the whole Swedish population, where the colours delineate p-values compared to the national proportions with the following colour-codes

p < 0.01,

p < 0.05 .

Figure 5. Annual proportion (%) of patients with bladder cancer stage T1–T4 or upper tract urothelial carcinoma receiving a patient navigator at diagnosis in Sweden stratified by health care region (Uppsala-Örebro (

), Northern (

), Southern (

), Stockholm-Gotland (

), Southeastern (

) and Western (

) health care regions) as well as visualizing the compiled national proportion (

).

Table 3. Main differences between the new Swedish national guidelines and the current EAU guidelines from 2021.

	Swedish national guidelines 2021	EAU guidelines 2021
Grading system for urothelial carcinomas	WHO 1999 and 2016	WHO 1973 and 2016
MMR-screening with IHC in upper tract urothelial carcinoma specimens	Recommended	Not recommended
Stratified follow-up of low risk non-muscle invasive bladder cancer PUNLMP	Yes	No