Active Surveillance An Option for Bladder Cancer

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LONDON—Low-risk non-muscle invasive bladder cancer (NMIBC) could be safely managed by periods of active surveillance rather than aggressive resection surgery and frequent cystoscopic follow up, Jeremy Crew, MD, a consultant urologist surgeon at Oxford University Hospital, experienced in the technique, told attendees at the Renal and Bladder Cancer 3rd National Conference.

Guidelines from the European Association of Urology state that low-risk NMIBC should be managed by frequent cystoscopy, at three months and (if negative) subsequent cystoscopies at nine months and yearly for a minimum of five years. When a recurrent tumor is detected, a resection under general anesthetic is indicated, allowing for histopathological examination and grade of the tumor.

Active surveillance is not a new concept, Dr. Crew said. “Urologists have been ahead of the game on this, with low-risk prostate cancers and for small renal masses.” He proposes that the strategy could be an option for patients with low-risk NMIBC.

Avoiding unnecessary surgery might be beneficial to the patient particularly if the tumor is low risk. “There is a suggestion that by not resecting the tumor you are not going to disseminate bladder cancer cells throughout the bladder, which can then implant in the raw area that was just resected. So perhaps by applying a more conservative approach you may actually reduce the rate at which the tumor recurs.”

Cost, in terms of managing the patient and the surgeon's time, is another advantage for active surveillance, Dr. Crew said.

Typically, patients with significant comorbidities, whereby general anesthetic and resection could be a risk, could be managed with active surveillance or other conservative options, but Dr Crew said he thinks that the treatment option could be extended to a cohort of patients with low-risk NMIBC tumors who are otherwise fit and healthy.

There are, however, disadvantages, Dr. Crew said, such as lack of histologic data. Without such data, it cannot be ascertained whether a tumor seen through a cystoscope is a low-grade cancer, and this can cause patient anxiety. “Some patients are not cut out for active surveillance and they may be anxious about leaving the cancer untreated,” he said.

By looking at the evidence base, Dr. Crew said the progression rate and growth rate of tumors under 5 mm in diameter was zero or minimal within a one-year surveillance period. “I think low-risk NMIBC can be safely managed by periods of active surveillance,” he said.

Some data suggest patients can safely undergo active surveillance for up to a year, but he pointed out that stronger evidence, such as that from a randomized, controlled trial, is needed.

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