Major Finding: Cystoscopy alone, the least expensive of five surveillance strategies, picked up two invasive bladder cancers that were missed by urine testing.
Data Source: A study in 200 consecutive patients.
Disclosures: Dr. Karam reported having no conflicts of interest related to the study. A coauthor received honoraria from Abbott Molecular.
SAN FRANCISCO — Cystoscopy alone offers the best combination of cost and sensitivity for surveillance after treatment of superficial bladder cancer, new data show.
In a prospective study comparing five surveillance strategies in 200 patients, the addition of various urine tests to cystoscopy increased the cost per cancer detected, but did not find more invasive tumors, researchers reported at a symposium on genitourinary cancers.
“Our data suggest that cystoscopy alone is the most cost-effective strategy, and that the addition of urinary markers adds to cost without improved detection of invasive disease,” said first author Dr. Jose A. Karam, a urologic oncology fellow at the University of Texas M.D. Anderson Cancer Center in Houston.
Evidence-based data are lacking on the outcomes of surveillance strategies among patients who have been treated for superficial (non–muscle invasive) bladder cancer. Many urinary-based markers are now available for use, but cystoscopy remains the standard of care, he said.
In the study, consecutive patients needing surveillance after treatment of superficial bladder cancer underwent these tests at study entry: cystoscopy, urine cytology, NMP22 BladderChek test (a urine test marketed by Inverness Medical Innovations that measures a protein associated with bladder cancer), and FISH (fluorescence in situ hybridization) UroVysion test (a urine test marketed by Abbott Molecular that detects chromosomal abnormalities associated with bladder cancer).
The bladder cancers for which they had been treated were mainly of Ta stage (71%) and low grade (58%). In 25 patients, new tumors were found at study entry or by the first follow-up assessment, a median of 4.1 months later, Dr. Karam reported at the symposium, sponsored by the American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Urologic Oncology.
Based on 2009 Medicare reimbursement rates, the cost per cancer detected was lowest with cystoscopy alone ($7,692), and highest with cystoscopy plus FISH ($19,111). Values were intermediate for cystoscopy plus cytology ($10,267), cystoscopy plus NMP ($11,143), and cystoscopy plus NMP with FISH confirmation in the event of a positive NMP result ($9,557).
The cancer detection rate was lowest with cystoscopy alone (52%) and highest with cystoscopy plus FISH (72%). Values were intermediate for cystoscopy plus cytology (60%), cystoscopy plus NMP (56%), and cystoscopy plus NMP with FISH confirmation (56%). Subsequent analyses showed that cystoscopy plus FISH picked up more early, noninvasive (carcinoma in situ and Ta) tumors than did cystoscopy alone. But it similarly missed the two more advanced (T1 and T2) tumors that were found, “which arguably are the ones that matter the most,” Dr. Karam commented.
Cystoscopy alone appears to be the most cost-effective approach, he concluded, cautioning that “these [urinary-based] markers should be used carefully and judiciously in patients with bladder cancer.” Because all patients received care from bladder specialists, the findings may not be generalizable to community practices, he added.
Dr. Nicholas J. Vogelzang, one of the developers of the NMP22 assay, chaired a press briefing at which the study was discussed. Dr. Vogelzang, chair and medical director of the developmental therapeutics committee of U.S. Oncology, said he found the results “very chagrining but nonetheless very important.”
Urinary-based markers 'should be used carefully and judiciously in patients with bladder cancer.'
Source Dr. Karam