The impact of frequent cystoscopy on surgical care and cancer outcomes among patients with low-risk, non-muscle-invasive bladder cancer

Abstract

Background: Surveillance recommendations for patients with low-risk, non-muscle-invasive bladder cancer (NMIBC) are based on limited evidence. The objective of this study was to add to the evidence by assessing outcomes after frequent versus recommended cystoscopic surveillance.

Methods: This was a retrospective cohort study of patients diagnosed with low-risk (low-grade Ta (AJCC)) NMIBC from 2005 to 2011 with follow-up through 2014 from the Department of Veterans Affairs. Patients were classified as having undergone frequent versus recommended cystoscopic surveillance (>3 vs 1-3 cystoscopies in the first 2 years after diagnosis). By using propensity score-adjusted models, the authors estimated the impact of frequent cystoscopy on the number of transurethral resections, the number of resections without cancer in the specimen, and the risk of progression to muscle-invasive cancer or bladder cancer death.

Results: Among 1042 patients, 798 (77%) had more frequent cystoscopy than recommended. In adjusted analyses, the frequent cystoscopy group had twice as many transurethral resections (55 vs 26 per 100 person-years; P < .001) and more than 3 times as many resections without cancer in the specimen (5.7 vs 1.6 per 100 person-years; P < .001). Frequent cystoscopy was not associated with time to progression or bladder cancer death (3% at 5 years in both groups; P = .990).

Conclusions: Frequent cystoscopy among patients with low-risk NMIBC was associated with twice as many transurethral resections and did not decrease the risk for bladder cancer progression or death, supporting current guidelines.

Keywords: bladder cancer; cancer mortality; cancer progression; cancer surveillance; cystoscopy.

Conflict of interest statement

Conflicts of Interest: none

© 2019 American Cancer Society.

Figures

Figure 1.. Categorizing patients into those that received recommended versus frequent surveillance.

Patients were categorized based on consensus guideline recommendations and length of the surveillance window. At the top of the figure, the timeline of the surveillance window is depicted in months. X denotes the recommended time of cystoscopy. We allotted a 1.5-month grace period to allow for surveillance cystoscopies that were done slightly earlier than the 12- and 24-month time points. The lower half of the Figure depicts the number of patients that were categorized into recommended versus frequent surveillance, overall and stratified by the length of the surveillance window, along with the number of cystoscopies they underwent. ‡ Exact numbers not reported to protect confidentiality.

Figure 2.. Number of transurethral resections and of transurethral resections without cancer in the specimen among patients who underwent frequent versus recommended surveillance.

Patients who underwent frequent versus recommended surveillance underwent twice as many transurethral resections and more than 3 times as many transurethral resections without cancer in the specimen (p

Figure 3.. Cumulative incidence plots showing the probability of progression to muscle-invasive bladder cancer (MIBC) or bladder cancer death (panel A) and of bladder cancer death (panel B).

Data are from propensity score adjusted Fine and Gray competing risk models with death from other causes modeled as a competing risk. Median length of follow-up was 4.8 years. Blue line: recommended surveillance; red line: frequent surveillance. Note: In panel A, blue and red lines almost completely overlap.