Recommended Surveillance in High-Risk Bladder Cancer Unheeded

Patients with high- and low-risk bladder cancer undergo surveillance at comparable rates, despite recommendations calling for twice this frequency in high-risk patients, according to the results of a recent study (JAMA Network Open. 2018 Sept 28. Epub ahead of print).

Frequency of Cystoscopy Among Low- and High-Risk Patients

Guidelines for cancer care recommend that patients receive surveillance at a frequency based on their underlying cancer risk, meaning that there should be more frequent surveillance for patients at high-risk than for those at low-risk of cancer recurrence, explained Florian R. Schroeck, MD, MS, Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, and colleagues, who assessed the extent to which risk-aligned surveillance is practiced within US Department of Veterans Affairs facilities.

A population-based sample of patients diagnosed with low- or high-risk early-stage bladder cancer between January 1, 2005, and December 31, 2011 (and who had follow-up through December 31, 2014), were included in the retrospective cohort study by Dr Schroeck and colleagues.

The study included a total of 85 Veterans Affairs facilities throughout the United States treating patients with low- and high-risk bladder cancer, and a total of 1278 low-risk and 2115 high-risk patients (99% men; median age, 77 years). The frequency of cystoscopy for low- and high-risk patients at each facility was estimated using multilevel modeling.

Risk-Aligned Surveillance Not Widely Practiced

For low-risk patients, and over a time frame of 2 years, the adjusted frequency of surveillance procedures via cystoscopy per patient across the facilities ranged from 3.7 to 6.0. For high-risk patients, this frequency was 4.6 to 6.0.

Out of 85 facilities, 70 performed surveillance procedures at a comparable frequency for low- and high-risk patients, differing by <1 cystoscopy over 2 years. The surveillance frequency among high-risk patients exceeded surveillance among low-risk patients with statistical significance at only 4 facilities.

Across all facilities, Dr Schroeck and colleagues noted, surveillance frequencies for low- versus high-risk patients were moderately strongly correlated (P <.001).

“[O]ur study highlights that risk-aligned surveillance for early-stage bladder cancer is not widely practiced. On the contrary, patients with high- and low-risk cancer undergo surveillance at comparable frequency, despite recommendations that high-risk patients warrant surveillance at least twice as often….Our findings should alert those who care for patients with bladder cancer and those who care for patients with other neoplasms for which risk-aligned surveillance is recommended. While risk factors, natural history, and tumor-specific characteristics differ across neoplasms, the challenges clinicians face to align surveillance with underlying cancer risk are likely similar,” they concluded.—Janelle Bradley

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