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P2-3 How safe is it to discharge low-risk non-muscle invasive bladder cancer at 12 months?
David Thurtle1 & Hyoung-Jin Cho1, Emma Gordon1, Mark Johnson2, Georgina Wilson1
1. Department of Urology, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
2. Department of Pathology, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
BACKGROUND
RESULTS 1
RESULTS 2
CONCLUSIONS
2015 NICE guidelines advise that patients with low-risk non muscle-invasive bladder cancer (NMIBC) should be discharged from cystoscopic follow-up, if recurrence-free, at 12 months. This change has been met with some trepidation.
A total of 474 patients with new diagnoses of transitional cell carcinoma (TCC) bladder were found, with median age 77 and male: female ratio of 2.79:1.
The breakdown of this cohort by initial tumour grade is demonstrated in Chart (12.7%) patients were initially diagnosed with low-risk NMIBC and were analysed further (Results 2).
9(14.8%) patients with G1pTa had recurrence within 12 months. Of these, 2 had progressed to intermediate-risk G2 pTa(Chart 2). 7 patients had not yet reached 12 months but were included as ‘no recurrence’.
Of the remaining 44 patients, 7(15.9%) had recurrent disease beyond 12 months; 5 unifocal small G1pTa, and 2 intermediate-risk G2pTa over a mean total follow-up of months (Chart 3). The G2pTa histology was re-checked by our pathologist.
These data equate to a 7.9% recurrence-risk per-year after year one. 103 cystoscopies were performed after the initial 12-months, to yield these 7 recurrent cases. Table 1 demonstrates the timings of recurrences and frequency of follow-up.
Our overall progression-risk in this cohort is 6.7% across a median follow-up of months.
Low-risk NMIBC represents a minority of bladder cancer cases.
Updated NICE guidelines will change practice significantly. From our data it is clear that our current practice is to follow-up low-risk patients well beyond 12 months. More than 100 cystoscopies were performed across a 2-year period in a cohort of just 44 with recurrence free low risk NMIBC.
Recurrence rates, of 14.8% and 7.9%, are similar to those used in NICE cost- analysis calculations of 15.9% for first- year and 7.4% for subsequent annual recurrence-risk respectively.[1]
Our overall progression risk of 6.7% from low- to intermediate-risk across just 3 years exceeds used progression probabilities, which are based on a longer 5-year follow-up.
This small but significant risk of progression of disease needs to be borne in mind as centres organise cystoscopic follow-up regimes.
OBJECTIVES
We retrospectively applied the new NICE 2015 bladder cancer guidelines to assess their potential impact on our clinical practice, in terms of number of cystoscopies saved, and number of recurrences missed.
11.7%
3.3%
MATERIALS & METHODS
85%
Using a pathology database, all patients with a new histologically proven bladder cancer diagnosis between January 2010 and December 2014 were included. Risk categories were established and subsequent cystoscopic follow-up and pathological outcomes were retrospectively recorded for all low-risk non-muscle invasive cases with a minimum 1 year follow-up.
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Chart 1: Initial bladder cancer diagnoses by tumour grade. n=474.
G2pTa recurrences
Chart 2: The cystoscopic outcomes of patients with G1pTa, over the first 12 months. n=60
Chart 3: The cystoscopic outcomes of patients with G1pTa beyond the first 12 months. Median additional follow up of 23.6 months (beyond year 1). n=44
REFERENCES
Follow-up cystoscopy
---- Patient age
3 Months
6 Months
9 Months
12 Months
15 Months
18 Months
24 Months
30 Months
3 Years
4 Years
5 Years 67
Clear
Recurrence 81
N/A 53 74 79 73
G2 Recurrence 57 75 87 69 61 92 78 77
1. National Institute for Health and Clinical Excellence Guideline 2, National Collaborating Centre for Cancer , Health Economic Evidence: What are the optimal follow-up protocols for low/intermediate risk and high-risk non- muscle invasive bladder cancer?
Tips for Excel Charts
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Contact Information
Hyoung-Jin Cho:
Emma Gordon:
David Thurtle:
Table 1: The cystoscopic follow up frequency and outcome of the 16 patients within the G1pTa cohort who had recurrence or progression during follow-up. Median follow-up 35.6 months.