​2026 NCCN​ guideline update: Bladder cancer

By Litha Mfiki

What are the latest recommendations in bladder cancer care?

The 2026 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) provide updated guidance for the diagnosis, treatment, and follow‑up of bladder cancer, spanning non–muscle‑invasive, muscle‑invasive, and metastatic disease.¹ The guidance emphasizes structured diagnostic pathways, risk‑adapted treatment selection, and ongoing monitoring for recurrence and progression.

Integration of cystoscopy, imaging, and pathology in the diagnostic evaluation of bladder cancer

For patients presenting with hematuria or urinary symptoms, the NCCN Guidelines^® recommends an office cystoscopy to assess for the presence of a lesion.

If a lesion is identified, a transurethral resection of bladder tumor (TURBT) should be performed to confirm diagnosis, assess disease extent, and obtain tissue for histopathologic evaluation and staging.

Additional components of evaluation include:

• Urine cytology
• Assessment of risk factors, including smoking and family history
• Cross-sectional imaging (CT or MRI scan) of the abdomen and pelvis

The guidelines also discuss adjunctive imaging approaches, including blue light cystoscopy and narrow-band imaging, which improve detection of non–muscle-invasive lesions when used alongside white-light cystoscopy. These techniques may increase detection rates, particularly for carcinoma in situ, although limitations and availability should be considered.

Risk stratification guides treatment selection in non–muscle‑invasive bladder cancer

The NCCN Guidelines incorporate risk stratification aligned with the American Urological Association / Society of Urologic Oncology risk-based classification of non–muscle-invasive bladder cancer (NMIBC) to guide care management.

Risk groups are defined using tumor stage, grade, size, and multiplicity, and are categorized as low-, intermediate-, or high-risk disease.

Intravesical therapy remains central to NMIBC management

The NCCN Guidelines recommend single-dose intravesical chemotherapy within 24 hours of TURBT for selected patients with suspected NMIBC to reduce the risk of recurrence.

For intermediate- and high-risk disease, recommendations include:

• Induction intravesical therapy, including bacillus Calmette–Guérin (BCG) or chemotherapy
• Maintenance therapy, particularly with BCG in higher-risk disease

BCG therapy is associated with improved recurrence outcomes in higher-risk NMIBC and remains a key component of management.

Treatment pathways expanded for BCG-unresponsive NMIBC

For patients with BCG-unresponsive NMIBC, the NCCN Guidelines outline a range of treatment options, including:

• Cystectomy
• Intravesical therapies
• Systemic or device-based therapies in selected settings

Structured surveillance recommended across disease stages in NMIBC

The NCCN Guidelines emphasize regular surveillance to detect recurrence, particularly in NMIBC.

Surveillance typically includes:

• Cystoscopy at defined intervals
• Urine cytology
• Imaging in higher-risk disease

The frequency and duration of follow-up are adapted based on disease risk, prior treatments, and clinical course.

READ BLADDER CANCER CONGRESS HIGHLIGHTS

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