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Debate on low-risk BCa

The current EAU guidelines on non-muscle invasive bladder cancer (NMIBC) recommend cystoscopic follow-up for five years in patients with low- grade NMIBC but this is only a Grade C recommendation as there is little high quality evidence in this area.

Indeed the EAU guidelines themselves state that ‘tumour recurrence in the low-risk group is nearly always low stage and LG/G1. Small, Ta LG/G1 papillary recurrence does not present an immediate danger to the patient and early detection is not essential for successful therapy’ (LE:2b).

The UK National Institute for Health and Care Excellence (NICE) develops practice guidelines for the National Health Service (NHS) in England and the NICE Bladder Cancer Guidelines were developed by a panel of 15 experts and published in 2015. One of the most notable recommendations was that patients with low grade NMIBC could be discharged at one year as long as they had been free of recurrence at both their three and 12 month cystoscopies.

It is known that the outcome of cystoscopy at three months is a strong predictor for future recurrence and patients who are free at three months form a particularly low-risk group of patients with a recurrence rate between years one to five of only 12% none of which developed progression (Mariappan and Smith 2005). Given the lack of high quality evidence and costs and workload implications of cystoscopic surveillance in this group the NICE guidelines group developed a model to assess the clinical and economic impact of a reduced one-year follow-up in patients

with low-risk NMIBC compared with a standard five-year surveillance schedule. The results of this model showed that a reduced surveillance protocol
was associated in a reduction of nearly 50% or 4000 pounds per patient in costs with only a negligible reduction in clinical effectiveness.

Based on this, NICE recommended that in the UK patients with low risk/grade NMIBC with no recurrence at 12 months should be discharged back to primary care and importantly their primary care physician should not perform regular investigations such are urine cytology to monitor for recurrence. However patients were to report any visible haematuria immediately. The guidelines were published in February 2015 and in the two years since, the majority of urology departments in the UK have adopted this strategy. Although as yet no scientific literature has been published on outcomes following this change, the British Association of Urological Surgeons (BAUS) have been monitoring the situation closely and as yet no concerns have been raised by UK urologists.

Many departments report a significant easing of their cystoscopic workload following the change which has enabled them to focus on faster cystoscopic investigation of new haematuria referrals. Interestingly, there is anecdotal evidence that new low-risk NMIBC patients are happy to be discharged at one year, whereas patients with established LR NMIBC who are between years one to five seem more reluctant to be discharged, which suggests that what the patients are told at the outset about their disease follow-up has a strong influence in how acceptable reduced surveillance is for patients.

Reference

  1. A surveillance schedule for G1Ta bladder cancer allowing efficient use of check cystoscopy and safe discharge at 5 years based on a 25-year prospective database. Mariappan P, Smith G. J Urol. 2005 Apr;173(4):1108-11.

Author:
Mr. Hugh Mostafid, Consultant Urologist and Senior Lecturer Royal Surrey County Hospital
The University of Surrey, Guildford (GB)