An estimated 84,000 patients will be diagnosed with bladder cancer in the United States in 2021 according to the American Cancer Society. The vast majority of these cases (70% to 80%) will be nonmuscle invasive bladder cancers (NMIBC) requiring endoscopic resection and subsequent surveillance cystoscopy. Per joint AUA and SUO (Society of Urologic Oncology) guidelines, NMIBC patients should be assigned to low, intermediate and high risk groups based on their individual risk of disease recurrence and progression after initial resection.¹ These groupings can then be used to determine appropriate timing and use of cystoscopy, urine cytology and upper tract imaging during followup (fig. 1).¹ Delivering care according to these guidelines ensures that patients receive “risk aligned” bladder cancer surveillance.²

Figure 1. NMIBC cancer risk stratification by AUA/SUO surveillance guidelines.

Adherence to AUA/SUO Guidelines

Adherence to AUA/SUO guidelines for NMIBC surveillance has historically been poor.³ Problems with adherence generally come in 2 flavors: overuse of surveillance among low risk patients and underuse of surveillance in high risk patients. We examined cystoscopic surveillance among 1,135 veterans diagnosed with low risk NMIBC between 2005 and 2011. In this cohort, overuse of surveillance cystoscopy occurred in 75% of patients, equating to more than 1,800 more cystoscopies than recommended by guidelines.⁴ Similarly, among 2,115 veterans with high risk NMIBC, we found that patients underwent an average of 5.4 surveillance cystoscopies over 2 years, a frequency well short of the 6 to 8 recommended by AUA/SUO guidelines.⁵ Issues with adherence are not unique to the veteran population, however. Widely differing surveillance practices have also been observed among Medicare patients, suggesting that this is a prevalent and systemic issue.⁶

Overuse of Surveillance in Low Risk NMIBC and Outcomes

Patients with low risk NMIBC are recommended to undergo surveillance cystoscopy at 3 months, 6 to 9 months later, and then annually after initial tumor resection (assuming no disease recurrence).¹ Given the extent of overuse in this population, it is important for urologists to understand the implications of overuse.

Patients with low risk NMIBC who experienced overuse of cystoscopy underwent double the number of transurethral resections (55 vs 26 per 100 person-years, p <0.001) and triple the number of resections without cancer in the specimen (5.7 vs 1.6 per 100 person-years, p <0.001) compared to those who received recommended surveillance (fig. 2).⁷ Most importantly, there were no differences in time to disease progression or bladder cancer death between the surveillance groups, both of which were quite rare (3% at 5 years for both groups).⁷ These results were based on a retrospective cohort study examining the relationship between overuse of surveillance cystoscopy and surgical and bladder cancer outcomes in 1,042 veterans with low risk NMIBC. Overuse was defined as more than 3 surveillance cystoscopies over a 2-year period since initial tumor resection.

Figure 2. Numbers of transurethral resections and transurethral resections without cancer in the specimen are illustrated among patients with low risk NMIBC who underwent frequent vs recommended surveillance. Patients who underwent frequent vs recommended surveillance underwent twice as many transurethral resections and more than 3 times as many transurethral resections without cancer in the specimen (p <0.001 for both). Published with permission from Cancer.⁷

We can learn 2 very important points about overuse of surveillance cystoscopy in low risk NMIBC patients from this study. First, when we perform more frequent surveillance than recommended, this results in more trips to the operating room for transurethral resections and commonly for resections that are ultimately negative with no cancer in the specimen. Second, more frequent surveillance cystoscopy has no impact on key bladder cancer outcomes, including progression of disease and bladder cancer death. Therefore, more frequent cystoscopy among low risk NMIBC patients is largely unwarranted and subjects many patients to unnecessary morbidity from repeat resections in the operating room.

Underuse of Surveillance in High Risk NMIBC and Outcomes

Patients with high risk NMIBC are recommended to undergo approximately twice as many surveillance cystoscopies than patients with low risk disease—a cystoscopy every 3 to 4 months for the first 2 years after diagnosis.¹ However, as explicitly stated in the AUA/SUO guideline, the evidence supporting this recommendation is based on “panel consensus and historic precedence,” and an “urgent need” was identified “for studies to determine if less stringent followup regimens can be employed without significantly affecting oncologic outcomes.”¹

Figure 3. Bladder cancer death rates for patients with high risk NMIBC did not differ significantly between those undergoing low vs high intensity surveillance. This was true for both those with high grade Ta and those with high grade T1 disease as shown in cumulative incidence plots. Shared per the Creative Commons Attribution (CC BY) license of PLoS ONE.⁸

In this vein, we examined outcomes among veterans with high risk NMIBC who underwent the recommended high intensity cystoscopic surveillance vs those with fewer cystoscopies than recommended. We found that patients who underwent fewer cystoscopies had 3 times fewer transurethral resections (37 vs 99 per 100 person-years, p <0.001).⁸ Despite fewer resections, no difference was observed in the risk of bladder cancer death between the surveillance intensity groups (fig. 3).⁸

These findings suggest that less frequent surveillance may not be unreasonable for patients with high risk NMIBC. They are in line with prior studies demonstrating no survival benefit of high intensity surveillance using institutional⁹ or SEER-Medicare data.¹⁰

Future Directions

In conclusion, overuse of surveillance cystoscopy in low risk NMIBC is likely resulting in a substantial number of patients undergoing unwarranted transurethral resections and no benefit toward disease progression and bladder cancer death. However, less intensive surveillance cystoscopy in high risk NMIBC (ie underuse) may be reasonable for some patients. Overall, we are likely subjecting many patients to unnecessary and uncomfortable office cystoscopies, operating room procedures, anesthesia events, postoperative recoveries and costs with little benefit to their overall bladder cancer outcome. However, our findings on outcomes after underuse of cystoscopic surveillance among patients with high risk NMIBC are limited by the retrospective study design with potential for unobserved confounding. As such, we do not advocate for changing surveillance recommendations. Rather, future prospective work is needed not only to improve adherence to AUA/SUO guidelines, but also to develop better evidence to support surveillance recommendations, particularly for patients diagnosed with high risk NMIBC.