Noninvasive Bladder Cancer: Diagnosis and Management

Case Patient 2

A 72-year-old woman with a history of T1 bladder cancer presents for routine follow-up. She has completed a course of BCG with maintenance for her initial lesion. On follow-up cystoscopy, she is found to have multiple velvety red patches throughout the bladder and a 1-cm sessile lesion.

• What is the follow-up for bladder cancer?

Bladder cancer causes what is known as a field defect. As urine bathes the urothelium, theoretically, so do the carcinogens within the urine, exposing cells throughout the bladder. Bladder cancer therefore does not just recur at the initial site of the tumor, but can occur anywhere in the bladder. For example, Heney et al found that initial tumors were only occasionally located at the dome (5% of the time), whereas new tumor occurrences were found at the dome in 29% of patients [87].

Though there is no consensus in the literature as to the ideal timing of cystoscopic follow-up, NCCN guidelines recommend cystoscopy every 3 months with increasing intervals as indicated for low-risk lesions [88]. For all other lesions, they recommend cystoscopy and cytology every 3 to 6 months with increasing intervals as indicated, upper tract imaging every 1 to 2 years for high-grade tumors, and the optional use of urine markers for follow-up. The AUA varies slightly in recommending cystoscopy and cytology for all patients every 3 months for 2 years, followed by every 6 months for 2 to 3 years, and then annually. They recommend imaging of the upper tracts but do not specify timing, and current recommendations do not support the use of urine markers [89].

• How are recurrences/treatment failures managed?

When recurrence or treatment failure is identified, it is important to consider the initial lesion and treatment as well as stage and grade of any follow-up lesions. Low-risk disease may be treated with re-resection and BCG or mitomycin C with or without maintenance [42]. With treatment failure of intermediate disease, resection followed by a change in the modality of intravesical treatment is an option. When recurrences occur in intermediate-risk disease, one might change modalities or reinstitute a second induction therapy course after resection [66].

High-risk NMIBC provides a challenging dilemma in management. In a systematic literature review of 19 published trials, van den Bosch and Witjes [90] reported a 21% progression to muscle-invasive disease in high-risk NMIBC patients. Management of recurrences in this population in an effort to decrease progression and increase CSS is a highly debated topic, with no clear answer currently available. In the case of high-risk disease that has recurred, treatment options include a second induction course of BCG, cystectomy, or alternative intravesical chemotherapeutic options. Those patients who underwent early cystectomy for high-risk recurrence after BCG therapy had an overall greater survival compared to those who delayed cystectomy over 2 years [91]. In their study evaluating early versus delayed cystectomy, Jäger et al [92] found that as the number of TURBTs performed before cystectomy for high-risk disease went from 1 to 2–4 to greater than 4, the 10-year CSS decreased from 84% to 77% to 45%. Additionally, they found that when cystectomy was performed 1 year after initial TURBT, the 10-year CSS decreased from 79% to 61%.