Recommendations for Follow-up of Muscle-Invasive Bladder Cancer Patients: Beyond the Abstract

The standard of care for patients with non-metastatic muscle-invasive bladder cancer (MIBC) consists of neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy (RC) and pelvic lymph node dissection. Selected patients may be candidates for bladder preservation, in which case maximal transurethral resection of the tumor followed by chemotherapy and external beam radiotherapy for patients is used.

Despite extensive treatment with curative intent, 5-year overall survival averages 60% with most cases of death preceded by development of recurrent disease (1). Multiple guidelines are available on the treatment of MIBC, but most only briefly mention follow-up strategies and consensus is lacking. In this manuscript led Zuiverloon and Kamat, members of the International Bladder Cancer Network (IBCN) critically assessed the current major guidelines (n=14) on follow-up of MIBC patients and provide a comprehensive overview and summary of recommendation for surveillance of these patients. 

Independent of treatment option, two important aspects of follow-up should include: 

I) Oncological surveillance for early detection of recurrences.

II) Functional follow-up to detect treatment-related toxicity.

Oncologic follow-up is tailored to the specific risk of recurrence of cancer tempered by whether the patient desires salvage therapy or not. The IBCN recommends that the surveillance schedule after RC should be based on pathologic tumor stage (<pT2N0, pT2N0, pT3-4N0 and pTxN+). As most recurrences occur in the first two years after RC (Table 1), imaging and laboratory testing is recommended more frequently during this time interval (3-6 months depending on stage, outlined in Table 2). 

Cytology for urinary tract diversions deserves special mention: the evidence for utilization during follow-up is limited and one should be aware that analysis is difficult due to the presence of desquamated intestinal cells. Due to its low sensitivity, cytology is recommended in conjunction with computed tomography urography during follow-up (2, 3).  





For bladder sparing treatment, we recommend a cystoscopy at three months and thereafter every 3-6 months for the first 2-4 years as recurrences are more likely to occur in the first two years (Table 2). Urine cytology is recommended an adjunct to cystoscopy to guide biopsies. However, since the performance of cytology is highly operator dependent and cytologic changes post-radiation can be mistaken for tumor recurrence, we recommend that cytology should be used in centers with sufficient experience and trained staff.

Development of new treatment options will underscore the importance of early recurrence detection and more successful treatment alternatives will increase the need for quality of life preservation. The IBCN recognizes that prospective studies investigating the impact of early detection of recurrence on patient outcome is dependent and cost-effective analysis of different follow-up protocols are in needed. 

Written by: Tahlita C.M. Zuiverloon MSc, MD-PhD and Ashish M. Kamat MD

References

1. National Cancer Institute NCI: SEER Stat Fact Sheets: Bladder Cancer. Available at: https://seer.cancer.gov/statfacts/html/urinb.html.
2. Picozzi S. et al.Upper urinary tract recurrence following radical cystectomy for bladder cancer:a meta-analysis on 13,185 patients.J Urol 2012;188:2046–54.
3. Bellmunt J. et al. Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014;25(Suppl.3):iii40–8.

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