Bladder cancer’s high rate of recurrence makes it one of the most expensive cancers to treat over a patient’s lifetime and recommendations for follow-up regimens differ.
A recent review out of the United Kingdom compiles studies from nine countries and finds that follow-up regimens for non-muscle invasive bladder cancer (NMIBC) surveillance vary greatly across Europe and the U.S.
The two main questions when mapping a follow-up strategy, the authors write, are how often cystoscopies should be performed, and how long surveillance should continue. These are difficult to answer, however, because of a lack of consensus across various guidelines. Risk level, quality of life, cost effectiveness, and likelihood of diagnosis are some aspects to consider.
Approximately 75 percent of bladder cancer patients have NMIBC, and these patients mostly receive bladder-sparing treatments. These include transurethral resection of a bladder tumor (TURBT) followed by intravesical chemotherapy, and bacillus Calmette-Guerin (BCG) immunotherapy.
“Bladder preservation strategies, though attractive, necessitate regular surveillance because of a significant risk of recurrence requiring salvage treatment,” the study’s authors write.
The European Association of Urology (EAU), American Urological Association (AUA), and the National Institute for Health and Care Excellence (NICE) each offer endoscopic follow-up guidelines for patients following NMIBC treatment.
The EAU and AUA include risk stratification for NMIBC patients, and those with high-risk cancer require more extensive follow-up. Both associations agree that continuation of cystoscopy should end at five years in low-risk NMIBC patients who have remained cancer free.
But some of the studies identified low-risk patients with recurrence after five cancer-free years. In another study, half of clinicians surveyed say they would recommend cystoscopic surveillance continue for 10 years and 18 percent of them believe it should be life-long.
Several studies investigated the number of recurrences and the surveillance strategies by which they were detected. One study used cystoscopy every three months for two years and then annually up to five years. Recurrence diagnoses, researchers found, would have been delayed by following EAU or AUA guidelines. Another study utilized cystoscopy less frequently in the first two years and more often between years two and five.
Fourteen of more than 2,600 studies identified were deemed eligible for inclusion and each of those used cystoscopy at three months post-TURBT — a rare agreement across the differing guidelines.