Management of non-muscle-invasive bladder cancer: quality of clinical practice guidelines and variations in recommendations

BACKGROUND: Bladder cancer (BC) has become a major worldwide public health issue, especially non-muscle-invasive bladder cancer (NMIBC). A flood of related clinical practice guidelines (CPGs) have emerged; however, the quality and recommendations of the guidelines are controversial. We aimed to appraise the quality of the CPGs for NMIBC within the past 5 years and compare the similarities and differences between recommendations for therapies. METHODS: A systematic search to identify CPGs for NMIBC was performed using electronic databases (including PubMed, Embase, Web of Science), guideline development organizations, and professional societies from January 12, 2014 to January 12, 2019. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Intraclass correlation coefficient (ICC) analysis was performed to assess the overall agreement among reviewers. RESULTS: Nine CPGs were included. The overall agreement among reviewers was excellent. The interquartile range (IQR) of scores for each domain were as follows: scope and purpose 69.44% (35.42, 85.42%); stakeholder involvement 41.67% (30.56, 75.00%); rigour of development 48.96% (27.08, 65.63%); clarity and presentation 80.56% (75.00, 86.11%); applicability 34.38% (22.92, 40.63%) and editorial independence 70.83% (35.42, 85.42%). The NICE, AUA, EAU and CRHA/CPAM clinical practice guidelines consistently scored well in most domains. It was generally accepted that the transurethral resection of bladder tumour (TURBT) and intravesical chemotherapy should be performed in the management of bladder cancer. The application of chemotherapy was highly controversial in high risk NMIBC. The courses of BCG maintenance were similar and included 3 years of therapy at full maintenance doses. CONCLUSIONS: The quality of NMIBC guidelines within the past 5 years varied, especially regarding stakeholders, rigour and applicability. Despite many similarities, the recommendations had some inconsistencies in the details.