Active surveillance for non-muscle invasive bladder cancer

Abstract

Most of low grade (LG) bladder tumors will experience disease recurrence and very few of them (<2%) will experience disease progression. Therefore active surveillance (AS) for LG non-muscle invasive bladder cancer (NMIBC) has emerged. The goal of our study was to provide a literature review of AS for LG NMIBC including inclusion criteria, modalities and oncological outcomes. We conducted a systematic review (registered in PROSPERO: CRD42018102935) using MEDLINE and EMBASE between June 2018 and August 2018 with the following terms: LG, NMIBC, AS, urothelial neoplasm. Overall, 6 studies that reached our scope of review were included cumulating 403 patients with 2 prospective trials. Inclusion criteria were: recurrent LG (G1 and G2) Ta or T1 NMIBC, with a negative cytology, a low volume (<10 mm) and low number (<5) of tumors. Cystoscopy every 3 months during the first 2 years and every 6 months afterwards were required. AS dropout criteria were presence of tumor-related symptoms, a positive cytology, a modification of tumor morphology or size and patient’s request. Pooled data showed an overall 65% reclassification rate where 15% of patients were reclassified based on grade and 10% on stage with a median follow-up of 32 months (IQR, 24–42 months). Only one study reported on progression to MIBC in 4 patients out of 186 (2%). Most of patients enrolled in an AS protocol for recurrent LG NMIBC will undergo a TURBT eventually. Many patients may be eligible to this therapeutic approach but current knowledge does not support its use in daily practice outside of a clinical trial.

Impact of delay in cystoscopic surveillance on recurrence and progression rates in patients with non‐muscle‐invasive bladder cancer during the COVID‐19 pandemic

“…Patients with low‐risk NMIBC have an approximately 30% recurrence rate in the 5‐year follow‐up, but, despite high recurrence rates, they have progression rates under 2% 3 . Because of the very low progression rates, active surveillance protocols have been studied in this patient cohort 9 . Hernandez et al designed a prospective study and included patients with NMIBC in an active surveillance program.…”

“… 3 Because of the very low progression rates, active surveillance protocols have been studied in this patient cohort. 9 Hernandez et al designed a prospective study and included patients with NMIBC in an active surveillance program. They followed up 186 patients with a median of 72 months and stated that only 4 (2%) patients had progression to MIBC, but all of them previously had T1 disease.…”

Primary Chemoablation of Low-Grade Intermediate-Risk Nonmuscle-Invasive Bladder Cancer Using UGN-102, a Mitomycin-Containing Reverse Thermal Gel (Optima II): A Phase 2b, Open-Label, Single-Arm Trial

“… 2 , 3 NMIBC includes a clinically heterogeneous group of cancers with a wide range of recurrence and progression probabilities. 4 , 5 Treatment guidelines recommend classifying patients with NMIBC as being at low, intermediate or high risk for disease recurrence and/or progression. 2 , 4 , 6 While the management of low-risk and high-risk patients appears clear, the best treatment option for intermediate-risk (IR) patients is uncertain.…”

Biological distinction between grades 2 and 3 with respect to intravesical recurrence in T1 high-grade bladder tumors: a retrospective study

“…In addition, the latest EAU guidelines and literature have shown that the notation method of docking the WHO 1997 classification system with the WHO 2004/2016 classification system, which yields the LG/G1, LG/G2, HG/G2, and HG/G3 classifications, is more sensitive to the prognosis of NMIBC [ 6 – 8 ]. In this context, LG tumors are almost always Ta [ 9 ], and the risk of recurrence was low because of the lower pathologic grade [ 5 , 9 , 11 ]. Thus, intravesical instillation therapy for LG bladder tumors is usually not performed, given the risks and benefits.…”