Managing High-Risk NMIBC
Transcript: Diagnosis - Navigating multiple guidelines
Morgan Rouprêt, MD, PhD, and Ashish Kamat, MD, MBBS, FACS
Podcast recorded July 2025. All transcripts are created from interview footage and directly reflect the content of the interview at the time. The content is that of the speaker and is not adjusted by Medthority.
- [Ashish] Welcome back to Expert Voices: Navigating non-muscle invasive bladder cancer. I'm Ashish Kamat. I'm joined once again by Professor Morgan Roupret. Morgan, thank you for taking the time again and joining us today. You were part of the first episode of the series when we talked about diagnosis. This one here is gonna be a little bit more confusing for both of us. Controversial, but hopefully, at the end of it, both you and I will leave with key messages to our audience because what we're gonna talk about now is making sense of multiple guidelines. You and I, again, we sit on multiple guidelines. You've written guidelines, I've written guidelines, we've been involved with different organisations, and they don't often see eye to eye for different reasons, right? So let me ask you this and feel free to be provocative, but when you are seeing a patient, I know you're in Europe, I know you're part of the EAU, and I know you follow the EAU guidelines, but do you always just follow one set of guidelines or do you pick and choose from different sets of guidelines? What do you do?
- [Morgan] I have to be honest, Ashish, and with the experience, and that this is fascinating because bladder cancer is a field of medicine where we have a lot of evidence. So the guidelines are quite strong, and the level of recommendation is quite high. And usually, you do not really follow the guidelines where the level of evidence is high. And you will go, for instance, for testicular cancer, where the level of evidence is very low. But you don't know many things, so you look at the guidelines, and this is typically the opposite. We should stick to the guidelines where the level of evidence is very strong, such as prostate cancer, bladder cancer, and so on. And it is true that any scientific association is displaying its own guidelines. But ultimately, I believe that the sense and the bullet points and the take home messages are more or less the same. For instance, in non-muscle invasive bladder cancer, I'm European, I'm French, I participate a lot, and I worked with Richard Sylvester. But I have to tell you that the stratification, which is promoted by the EAU is by far too complicated if you're not an academic to follow. And I like the IBCG classification, I like the a AUA and the way it is at the moment. I understand that you can have low risk, intermediate, high risk, very high risk, but thereafter, you have subgroups and so on and so on. So when you start to lose the clinicians, when you start to lose the urologists who are supposed to use the guidelines, and when you feel that the guidelines are not going to be converting into pocket guidelines, that is going to be impossible, then at the end of the day, it's complicated. So it is true, to answer your question, that from time to time, I jump from a text to another to make it pragmatic and to make it simple, because there are people surrounding us, residents, fellow young colleagues that are going to try to understand and they want to have a clear pathway. So I pick the best of each group. This is the philosophy, yeah.
- [Ashish] Yeah, but Morgan, I'll challenge you a little bit because again, you are an expert, right? So you can sit in your chair when you're seeing a patient and all these guidelines are happening at the back of your head. And then like before you can blink, you know, which guideline is appropriate for a particular patient. But say a young trainee comes to you and says, you know, Professor Roupret, I'm just starting out working in this hospital, would you recommend that they follow what their institution recommends? Should they follow what, for example, the insurance companies asking them to? What is some practical advice that you would give to a new person or a junior faculty that's just starting off in that aspect?
- [Morgan] Yeah, yeah, in our hospital, we, even in our department, we have created the pocketbook for the resident and the young fellows that are following us to let them know that for this area of urology, you should stick to this. This is the philosophy of the department there. This is where we go, because we don't want to have one urologist saying, I'm doing three years of BCG, the other one, one year and the other one 18 months. So the thing is that we try to stick to one document, but some colleagues, they're coming with me to the clinics, for instance, and they see that each time I start a discussion with the patient, you know, it's like what we call personalised medicine. So I'm not thinking about guidelines. We are feeding the guidelines, but if we want also to change the guidelines, we need to produce new data, enrol patient in trials and so on. So yeah, it has to be a virtual circle. And this virtual circle is probably sometimes difficult. It is true that we understood from a young guy who is stepping in. And so, for these people, I tell them as much as they are concerned that they should go to the pocket guidelines, for instance, for any summary that is very brief and sending the good messages.
- [Ashish] Yeah, no, I think that's very important, right? Because again, full disclosure, you know, I am in North America, I used to follow the EAU guidelines much more than the a AUA guidelines until 2020. And that's because in 2020, it's when the guidelines in the European recommendation became so complicated with all the age and 70 and et cetera, and all of those. And that's why now, really, what I recommend, and you mentioned it as well, is the simple IBCG definition. If it's high grade, it's high risk. If it's low grade, first time, small, solitary, it's low risk. Everything else is intermediate risk. And that helps us counsel patients, right? Because the risk stratification when a patient is standing in front of us, if he's 70 years old today, and then tomorrow he becomes 71, he shouldn't have jumped in the classification just because the calculator says that. So I liked what you said about it being the pocket version of a practical definition that we need for our patients. But there are grey zones, right? Now, so for example, that grey zone is something like if you have a patient with variant histology, say Micropapillary disease. That really doesn't fit into any of these guidelines. So how do you approach these grey zones? Are you now thinking guidelines? Are you thinking your knowledge of what is available to you, the literature? How do you factor all of that in?
- [Morgan] No, I think what is really important is that the way which treat cancer has changed also because it's not my own decision in my office, it's a team decision. Any cases of cancer have to be discussed on a tumour board. And in a tumour board, you seek around the guidelines, but you seek also around the experience of the older urologists of people who are coming from different institutions. So we have a very large tumour board. And it is true that sometimes the decision that we're making, I would say from case to cases are sometimes a bit irrational or I would say subjective, but it is the way medicine has to be. We are balanced and we communicate around evidence-based medicine. We are feeding evidence-based medicine but you know, it is true. There are many things that are not covered by the guidelines and grey zones. Particularly, I would've said the surveillance regimen of non-muscle invasive bladder cancer is much more eminence-based than evidence-based. And it is true also that for the histological variants, I mean, when you have someone like Eva Comperat, who is sitting in your tumour board, and she's not just a pathologist, she's a pathologist with a clinical, I would say, who has a clinical influence. So it is good to be surrounded not only by urologists who knows the pathology, and it's not about mastering a technique and being the best at doing TURBT, you don't want to learn a technique, you want to learn the disease. And it is true that it is a fair balance at this moment between your experience, the experience of the institution, to be open-minded with the colleague and to be really lucid on the fact that the guidelines are not covering everything. And it is absolutely important.
On top of that, you mentioned with your group that some guidelines, your open guidelines, for instance, based on database are sometimes overestimating the risk of progression. So when you reevaluate the guidelines according to geographic catchment areas, you can see that there are discrepancies and so on. So it's nothing perfect, I consider it as a frame, which is very important, gives you the good direction, I would say. But if you want the cherry on the cake, then you need to have also the experience and the clinical experience. - [Ashish] Yeah, I mean, I think the same way you do, I think the guidelines are more a frame of reference. They're to let people know what is the average recommendation for a particular disease state, et cetera. But they're not prescriptive. And I like the fact that you said that it's personalised, right? So you have to take what's in the guidelines and apply it to an individual patient and give personalised recommendations. And that brings me to an interesting, you know, stage, place that we are currently in 2025. When we are seeing AI and machine learning trickling its way into everything, molecular tools, et cetera. How are you looking at AI? Whether it's commercially available platforms such as ChatGPT or something that people are developing that is not ready for prime time. But in general, where do you look at the future of AI in helping people look at guidelines and implement those?
- [Morgan] In fact, when you look back at the ability to predict the evolution of the disease, and in terms of bladder cancer, it's always the two key words, which are recurrence and progression. For many, many years in the literature, what was very popular, with the use of nomogram or predictive tools. And I think those nomograms are totally outdated today, especially in prostate cancer. I'm sorry for my friend, Alberto Briganti. But today, the next generation of nomogram is clearly, I would say or the predictive system that we will use. It will be with the help as the support of artificial intelligence. And nothing is better than these machines to help us to see the future of the disease of a particular patient. So we are at the moment in time when we use general tools, ChatGPT can be used. I mean, I don't know to play the lottery to understand the victory of Napoleon in Austerlitz, but we need to be aware of the tools that are going to be allocated only to the field of medicine. And I think that we have huge database, we have a lot of knowledge, but the ability of these tools to yes, the data and to help us at the moment to support, I would say our decision is going to be massive. We are going to be quick. It is going to influence, I would say, massively the way we are going to treat the patient. So I'm totally committed and I believe 100% that it will be a huge change in our practise. But I feel that at the moment, the general tools of artificial intelligence are not well, I would say, or designed enough to fit with the objectives of medicine. So I'm looking at all the startups, as we have discussed for the markers. There are many, many startups, small companies coming around us, interested in the way they could support medicine and especially bladder cancer. But the EORTC or the CUETO risk calculator and so on will be soon totally outdated by these tools.
- [Ashish] Yeah, and I agree with you. I mean, I think the EORTC and CUETO did an excellent job coming up with those nomograms when that's all you had, but they're cumbersome and it's hard for people to pull out a calculator or go online and look at things. And ultimately, at one point, hopefully there'll be an app AI driven or other where you put in the patient information and it pulls in all the knowledge of Morgan Roupret, the guidelines from across the world. Everything puts together and then spits out the best recommendation. But we're not there yet. And I think we have to be careful about using, you know, these commercial things such as ChatGPT or Gemini or whatever's out there to make medical decisions. So I'm glad you raised that, that word of caution. Morgan, you know, you and I are international citizens. You travel around and teach, and I do the same. And we often will face this issue, right? We recommend the guidelines that the EAU, IBCG, AUA put out. But you go to, for example, when I was in Ethiopia, or when you've travelled to a smaller place, Nairobi, for example.
They can't use these guidelines, right? So when you are talking to people that are resource constrained, they don't have the same ability to follow the best level of medicine because it's just not feasible. And our listeners are listening from all over the world. How would you explain to them, like these are the other guidelines, but again, you should have... Would you recommend having specific guidelines to a specific country or would you say still follow the EAU guidelines but only select these? Like how do you approach these situations?
- [Morgan] No, I'm not so sure that in these areas or countries, there are, I would say dedicated guidelines that are produced locally. So the thing is probably to teach and to share with them the ability to read between the lines of the guidelines and to go into the art or the core of the guidelines. And when we go back to bladder cancer, if I remember correctly, the first episode of this podcast, we had together, is talking about being very pragmatic, delivering a good TURBT, be sure that I'm surrounded by a pathologist who is going to let me know whether or not it's muscle invasive or non-muscle invasive. There is a limitation of resources, of course, but it goes mainly in the treatment of very advanced and metastatic diseases. And I think that for early bladder cancer, for locally or locally advanced, we can still do a good job because the vast majority of the treatment of this patient relies on surgery. And even if it's not a very sophisticated surgery, if they're not going to deliver robotic cystectomy, but they can still do a good open surgery. The problem is the epidemiology of the disease in these countries. It's totally the opposite of what we see in our daily practise because most of the people I travel sometimes to North Africa and so on, they have, I would say 80% of the cases are advanced bladder cancer. And is the availability of all the access to the doctors, that is a key question. But I think from the big text of the guidelines, you can go back and switch back to the pocket guidelines and once again, enhance what are the bullet points. We are surgeons, we are surgeons who are interested in academic, I would say evidence. We are manipulating drugs from time to time, but we cure bladder cancer most of the time with surgery. And surgery can be done in an old fashioned way, it's still good surgery. So I think they have to go back to basics and be sure that they are delivering a good medical service to the population because each step of the way, we just need to guarantee that the tumour has been extracted correctly and it has nothing to do just with technology or the surgical approach. It can be done in several ways. There is no reason why we should stick only to the technology.
- [Ashish] Yeah, no, I agree 100% because when you're taking these technologies and moving them to different places, it is not the same, right? We don't have the robot, for example, in poor countries. And if you're trying to use the robot to do robotic cystectomies and then you're depriving patients of having a diagnosis with regular cystoscopy, that's hard. In fact, we did this in Chile. The IBCG went to Chile and we were working with their bladder cancer guidelines because it was completely top heavy. There were so much emphasis on robotic cystectomy. Robotic cystectomy, but the patients were not getting cytologies, were not getting basic diagnosis. So it's a very important point that you made that we have to focus on doing what is readily available, but still high quality, which can be basic surgery. Morgan, again, I want to thank you for your time. You really provided a lot of insights to our audience. Let's wrap up this episode of Expert Voices. And our listeners, stay tuned for the next episode. Thank you.
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