Low-grade Ta nonmuscle-invasive bladder cancer (NMIBC) has a low rate of progression and mortality, but surveillance testing and treatment contrary to guidelines may still be occurring and at excess cost, a new study indicates.

Surveillance cystoscopy rates significantly increased from 79.3% in 2004 to 81.5% in 2013, with patients receiving a median of 3 cystoscopies per year, Stephen B. Williams, MD, MS, of the University of Texas Medical Branch at Galveston and colleagues reported in JAMA Network Open. Upper tract imaging significantly increased from 30.4% to 47.0% over the same period, with most patients receiving a median of 2 tests such as computed tomography and magnetic resonance imaging per year. Urine cytologic testing and other urine biomarker assessments also significantly increased from 44.8% to 54.9%.

Adherence to current guidelines remained suboptimal with 55.2% receiving 2 or fewer cystoscopies annually from 2004 to 2008 compared with 53.8% from 2009 to 2013, “suggesting overuse of all surveillance testing modalities.”

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With respect to treatment, 17.2% received intravesical bacillus Calmette-Guérin and 6.1% received intravesical chemotherapy.

The total annual median costs of low-grade Ta surveillance testing and treatment increased by 60%, from $34,792 in 2004 to $53,986 in 2013, even though disease progression occurred in only 0.4% of patients, the investigators reported. Median expenditures over 1 year was higher for patients with than without disease recurrence: $76,669 vs $53,909 in 2013.

“These results suggest that, despite low rates of disease recurrence and progression in this patient population, efforts to limit overuse of surveillance testing and treatment are warranted to help mitigate increasing costs of care,” the authors wrote.

The study population included 13,054 adults aged 66 to 90 years with low-grade Ta bladder tumors from the 2004-2013 Surveillance, Epidemiology and End Results–linked Medicare database.

“As we strive to improve bladder cancer care and health care spending, it will be important that clinicians be thoughtful about tests and procedures being performed,” Dr Williams’ team wrote. “Goals might include delivery of risk-aligned surveillance that comprises more frequent surveillance of patients with high risk of disease progression and death as well as deescalation of surveillance among patients with low risk of worse cancer outcomes.”

In an accompanying editorial, Grayden S. Cook, BS, and Jeffrey M. Howard, MD, PhD, of University of Texas Southwestern Medical Center, Dallas, commented that “it is imperative to move forward with initiatives that provide higher value and are more evidence-based and patient-centered.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Bree KK, Shan Y, Hensley PJ, et al. Management, surveillance patterns, and costs associated with low-grade papillary stage Ta non-muscle-invasive bladder cancer among older adults, 2004-2013. JAMA Netw Open. Published online March 1, 2022. doi:10.1001/jamanetworkopen.2022.3050

Cook GS, Howard JM. Patterns in the management of low-grade non–muscle-invasive bladder cancer—the human and economic costs of excessive surveillance. JAMA Netw Open. Published online March 1, 2022. doi:10.1001/jamanetworkopen.2022.3055