Despite recommendations for low-intensity cystoscopic surveillance in low-risk non-muscle invasive bladder cancer patients, U.S. Department of Veterans Affairs (VA) providers overused cystoscopy in 75% of these patients, according to a study published in Urology (2019; 131:112-9).
About three-quarters of the more-than 80,000 new bladder cancer cases diagnosed annually are non-muscle invasive. Based on pathology, about 40% of non-muscle invasive bladder cancer cases are considered low risk and rarely progress to lethal disease, according to the paper.
“The guideline-recommended surveillance frequency for low-risk non-muscle invasive bladder cancer patients is to do a cystoscopy 3 months after transurethral resection, then 1 year after transurethral resection, and then yearly thereafter,” said senior author Florian R. Schroeck, MD, MS, of White River Junction VA Medical Center, VT, and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH.
There are some differences across guidelines for how long these patients should be followed. For example, the AUA recommends surveillance for 5 years versus the National Institute for Health and Care Excellence (NICE) in the United Kingdom, which recommends providers stop surveillance after 1 year, according to Dr. Schroeck.
The recommendations are based on a lack of proven benefit from more intense surveillance in patients with low-risk disease. Dr. Schroeck and colleagues reported in a paper recently published in Cancer (2019; 125:3147-54) that low-intensity surveillance for low-risk non-muscle invasive bladder cancer patients might be the better patient care option. In fact, they found in a study of 1,042 patients in the VA health system that frequent cystoscopy was linked to twice as many transurethral resections and did not decrease the risks for cancer progression death.
Their study in Urology reflected findings from 1,135 low-risk non-muscle invasive bladder cancer patients at 84 VA medical centers, who were diagnosed between 2005 and 2011. Providers overused cystoscopic surveillance in 852 of those patients, performing 4,516 cystoscopies in the entire patient cohort, when according to recommendations only 2,670 were necessary. That was an excess of 1,846 cystoscopies, according to the authors.
With further analysis, the authors found that even if they were to assume all patients were diagnosed with multifocal or intermediate-risk tumors, overuse would have still occurred in 45% of patients. The finding demonstrates that even if the authors substantially underestimated every single patient’s bladder cancer risk, almost half of them still had more surveillance cystoscopy procedures than recommended, according to Dr. Schroeck.