<p><strong> </strong><strong>For low-risk patients whose first surveillance cystoscopy is negative for a tumor, clinicians should perform subsequent surveillance cystoscopy six to nine months later, and then annually thereafter; surveillance after five years in the absence of recurrence should be based on shared decision-making between the patient and clinician. (<em>Moderate Recommendation; Evidence Level: Grade C</em>)</strong></p>
Discussion
Discussion
<p>The data comparing different surveillance regimens for NMIBC and associated oncologic outcomes are very limited. One study by Olsen and Genster randomized 97 patients with papillary Grade 1-2 tumors that remained tumor-free 3 months after the first TURBT between 2 follow-up regimens.<sup>320</sup><sup> </sup>A more frequent follow-up regimen (every three months for two years, every six months in year three, then annually thereafter) was compared to a less frequent regimen (every six months for year one, then annually thereafter). While the study is small and likely underpowered, there was no difference in the risk of recurrence (RR: 1.2; 95% CI: 0.87 to 1.8) or progression (RR: 3.5; 95% CI: 0.37 to 32.0) with a median follow-up of 27-31 months. This suggests that those who are low-risk can be surveyed at a less stringent interval while maintaining a similar risk of recurrence and/or progression. Less stringent endoscopic surveillance may reduce a patient’s exposure to the anxiety, discomfort, and modest infection risks associated with cystoscopy without unduly compromising a patient’s risk.</p>
<p>There is relatively little data on the ongoing rates of recurrence for patients with NMIBC who remain disease-free for a prolonged period of time. Two retrospective studies reported a recurrence rate of 10-15% in patients who had been free of disease for 5 or more years, with about 3% of patients having muscle invasive disease.<sup>321, 322</sup><sup> </sup>The initial stage and grade of tumor did not appear to determine the risk of recurrence<sup>321</sup> and it is unclear if routine annual cystoscopy as opposed to symptom-based evaluation would have resulted in a significant change in clinical outcome. Life-long surveillance in the absence of documented recurrence subjects a patient to repeated anxiety, discomfort, and a small risk of infection or bleeding associated with cystoscopic surveillance of the bladder. Given these competing risks and a relative paucity of data to drive decision-making, the Panel feels that ongoing surveillance after five years in the absence of recurrence should be based on shared decision-making between the patient and their clinician.</p>