Cystoscopy overuse common in surveillance of low-risk bladder Ca

September 9, 2019

Despite recommendations for low-intensity cystoscopic surveillance in low-risk non-muscle invasive bladder cancer patients, U.S. Department of Veterans Affairs providers overused cystoscopy in 75% of these patients, according to a study published in Urology (2019; 131:112-9). 

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.

Continue to the next page for more.Surveillance overuse was more likely in Caucasian patients, patients with a number of comorbidities, and those diagnosed in earlier years, according to Dr. Schroeck.

“Unfortunately, none of these are modifiable nor targets for improvement interventions. Our long-term goal is to improve care for patients with non-muscle invasive bladder cancer. That will include closer adherence to guideline concordant surveillance cystoscopies. As a first step, we wanted to see whether there are any factors associated with overuse of cystoscopy that could be targets for improvement efforts,” said Dr. Schroeck.

Dr. Schroeck thinks there could be even more overuse among patients on Medicare and private insurance because in a fee-for-service environment, urologists get paid for “doing more,” but there are no data to support that yet.

Part of the problem also could be that urologists were historically trained to perform surveillance cystoscopy every 3 to 4 months, according to Dr. Schroeck.

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“And that practice likely still persists,” he said.

Dr. Schroeck recommends that urologists become familiar with guideline recommendations and take each patient’s risk into account when recommending when the patient should return for the next cystoscopy.

“That may be easier said than done because there are likely many factors influencing what actually happens, which may or may not be in the control of the practicing urologists-such as how easily risk is accessible in the records, issues related to scheduling, productivity incentives, etc.,” he said. “The take home in my mind for the practicing urologist: For low-risk (low-grade) non-invasive urothelial carcinoma, less frequent surveillance cystoscopy is more.”

Dr. Schroeck is a site principal investigator, without compensation, for a clinical trial sponsored by Eleven Biotherapeutics.