UROLOGICAL ONCOLOGY

A surveillance schedule for G1Ta bladder cancer allowing efficient use of check cystoscopy and safe discharge at 5 years based on a 25-year prospective database
Mariappan P, Smith G
Department of Urology, Western General Hospital, Edinburgh, United Kingdom
J Urol. 2005; 173: 1108-11

• Purpose: In the absence of clear evidence, surveillance of low-grade superficial bladder cancer by regular check cystoscopy may continue unnecessarily, or discharge from follow-up may occur empirically. We review the follow-up during a prospective 25-year period of patients presenting with G1Ta bladder cancer, and it is this analysis on which we base a safe schedule for discharge.
• Materials and Methods: A prospectively kept, computerized record of bladder cancers diagnosed between 1978 and 1985 and subsequently followed up at the Western General Hospital, Edinburgh was reviewed.
• Results: A total of 115 patients with G1Ta disease were followed for a mean of 19.4 years. Tumor status at 3 months was the strongest prognostic factor for recurrence. Although the absence of tumor at 1 year was also a favorable prognostic sign, it was not for 5 years that the situation entirely stabilized (recurrence developed in 8 of 66 such patients between 1 and 5 years). Of those who did not have recurrence in 5 years, 98.3% patients remained tumor-free for 20 years. In contrast in those with recurrence at 3 months the recurrence rate was much higher. Overall 12% of patients experienced progression, mostly in year 1. None of the 8 who had their first recurrence after year 1 had disease progression.
• Conclusions: Patients with G1Ta disease who are free of recurrence for 5 years after presentation can be safely discharged. We propose to alter the regime for patients with no recurrence in year 1 and discharge them at 5 years.
  
  
• Editorial Comment
  The surveillance schedule of superficial bladder cancer is empirical and based upon convenience rather than biological data. In recent times, attention has been focused on modifying the strict schedule of 3-monthly cystoscopies in certain risk groups. This paper focuses on pTa G1 cancer and bears some very interesting data. First, multiple and/or large tumors have a significantly higher risk for recurrence. Second, the first 5five years after TUR are important, with overall recurrence rates dropping from 29.1% to 14.1% (p = 0.009). Third, recurrence at 3three months is a bad prognostic sign. Patients who had recurrence at 3 months had further recurrences at 1 year compared with those who were tumor-free at 3 months (55.5% vs. 17.8%, p = 0.007). Progression occurs even in these tumors. 12.2 % had progression, which is an unexpected high figure to my opinion. 50% progressed within the first 5 years, and 35.7% within 3 months. All these patients had multiple primaries. 85.7 % of these patients had recurrence at 3 months.
  Two consequences can be drawn from this important contribution. First, without recurrence, follow-up can be terminated at 5 years. Second, even TaG1 tumors sometimes recur aggressively and may progress.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany