Active Surveillance for Non-Muscle Invasive Bladder Cancer: A Systematic Review and Pooled-Analysis - Beyond the Abstract

According to the definition reported by the US National Cancer Institute, Active Surveillance (AS) is: “A treatment plan that involves closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. Active surveillance may be used to avoid or delay the need for treatments such as radiation therapy or surgery, which can cause side effects or other problems. During active surveillance, certain exams and tests are done on a regular schedule.[…].”


In the last decade, the role of AS in the management of several types of cancer, including prostate cancer and renal cell carcinoma, has been significantly increasing.

Bladder cancer (BC) is the fourth most frequent cancer in men and one of the most expensive to manage. Low risk Non-muscle invasive Bladder Cancers (LR-NMIBC) represent the majority of the BC diagnosis and are characterized by a low progression rate.

In 2003, Soloway was the first to propose an AS approach for LR-NMIBC patients that experienced a recurrence during the follow-up time. Since then, several Centers have implemented this strategy reporting their experience over the year.

In order to draw overall conclusions from those experiences, we carried out a systematic review and pooled-analysis of currently available evidence. Specifically, we evaluated the oncological outcomes of different AS protocols, defined as failure rate, progression rate, upstage and upgrade.

The PubMed, EMBASE, and Cochrane Library databases were included in our search.

A total of 1210 papers was identified; among these, 14 were included. Statistical analyses were performed excluding studies reporting data from the same series. The pooled-analysis of included studies shows a failure rate of 67%, with a median time on AS of 15,6 months.

As a sum of the available evidence, we found that AS is a safe and feasible approach in selected LR-NMIBC patients that experienced a recurrence during the follow-up. Since patients with BC often have comorbidities, AS can be an efficient and safe strategy to minimize the number of operations and related risks. Moreover, AS also demonstrated to reduce the lifetime cost of patients with small low-grade pTa/pT1a bladder tumors.

Although the analysis of the funnel plot shows no evidence of publication bias, future prospective randomized trials are needed.

Written by: Roberto Contieri, MD1,2 Carmen Maccagnano, MD3 Rodolfo Hurle, MD2

  1. Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
  2. IRCCS Humanitas Research Hospital -, via Manzoni 56, 20089 Rozzano, Milan, Italy
  3. Department of Surgery, Division of Urology, ASST Lariana, Nuovo Ospedale Sant’Anna, Italy

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