Can patients with low-grade papillary bladder tumors be followed up with a cystoscopy interval of 6 months?

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Abstract

BACKGROUND

Over half of patients diagnosed with bladder cancer have low-grade, noninvasive papillary bladder tumors that are unlikely to become life-threatening; however, patients are often treated with transurethral resection (TUR) and followed up with frequent cystoscopic examinations, which are expensive and uncomfortable procedures.

OBJECTIVE

To evaluate a management strategy with a 6-month cystoscopy interval for patients with low-grade papillary bladder tumors.

DESIGN AND INTERVENTION

This study included consecutive patients who were newly diagnosed with low-grade, noninvasive, papillary bladder tumors between 1995 and 2000. Flexible digital cystoscopy was performed at the first clinic visit; if tumor was visible or suspected, TUR was performed within 2 weeks. All patients underwent cystoscopy 3 months after the initial clinic visit, and then were followed up with cystoscopy and voided urine cytology every 6 months thereafter. Patients who remained tumor free at 5 years received annual cystoscopy. CT was performed yearly to assess upper urinary tract disease. Recurrent tumors were treated with cystoscopic fulguration whenever possible, particularly patients with 5 or fewer tumors, each <0.5 cm in size; all other patients underwent TUR. Patient data were entered into a prospective database and were analyzed retrospectively.

OUTCOME MEASURES

The outcome measures were tumor status at first follow-up cystoscopy, frequency, time and number of tumor recurrences, number of TURs or fulgurations, tumor progression, and overall survival.

RESULTS

The study included 215 patients, of whom 172 had low-grade papillary carcinoma (TaLG), 27 had papillary urothelial neoplasm of low malignant potential, and 16 had papilloma. The median patient age was 62 years and the median follow-up period was 8 years. In total, 143 patients had tumor recurrence, with a median time to recurrence of 13 months. At the first follow-up visit, 39 and 176 patients did and did not have visible tumor, respectively, of whom 92% and 59%, respectively, went on to have tumor recurrence. Of the 143 patients with at least one recurrence, the average number of tumors was 6.2 per year, requiring 0.8 TURs and 0.61 fulgurations per year; recurrence was managed by fulgurations alone in 22% of cases. On univariate analysis, the factors associated with tumor recurrence were TaLG tumor type, visible tumor on first follow-up cystoscopy, and single TUR if no residual tumor was found; on multivariate analysis, TaLG tumor type, visible tumor on first follow-up cystoscopy, large tumors and multiple tumors were associated with recurrence. Restaging TUR was not a significant variable for recurrence, but revealed residual disease in 52% of patients. Grade progression was observed in 17 patients, upper urinary tract tumors developed in 18 patients, and 1 patient died of their bladder cancer.

CONCLUSIONS

A cystoscopy follow-up interval of 6 months allows most recurrences to be fulgurated at the time of cystoscopy, thereby reducing the number of TURs in patients with low-grade papillary bladder cancers. This strategy allows a reasonable balance between physician visits and surgical procedures.

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