Surveillance

NMIBC Surveillance Often Misses the Mark

Surveillance is a cornerstone of non-muscle-invasive bladder cancer (NMIBC) management, but real-world follow-up may not consistently reflect a patient's risk of recurrence and progression. A population-based analysis of 2,791 primary and recurrent NMIBC tumors found substantial differences between recommended surveillance schedules and the care patients actually received. The pattern was striking: patients with low-risk disease were frequently monitored more intensively than recommended, while patients with high-risk disease were often monitored less intensively.

Researchers evaluated surveillance data from two population-based cohorts in the Netherlands and compared cystoscopy use with European Association of Urology recommendations for low-, intermediate-, and high-risk NMIBC. Among low-risk cases, 37.6% were initially monitored more frequently than recommended, with some patients receiving as many as three additional cystoscopies beyond the first surveillance examination. Surveillance intensity decreased over time, but intervals between cystoscopies remained consistently shorter than recommended.

The opposite pattern emerged in high-risk NMIBC. During the first year of follow-up, 88.2% of high-risk cases received fewer cystoscopies than recommended after the initial surveillance cystoscopy at approximately three months. Adherence improved during subsequent follow-up, but cystoscopy intervals were generally longer than recommended during the first two years. This discrepancy is particularly relevant because higher-risk disease carries a greater need for close monitoring for recurrence and progression.

Intermediate-risk NMIBC presented a different challenge. Although surveillance generally aligned with recommendations initially, adherence declined from 78.1% to 59.3% by the fifth year, while the proportion receiving less surveillance than recommended increased from 21.7% to 39.8%. Considerable variation was also observed in the types of tests used. Across risk groups, clinicians incorporated cytology, imaging, and biopsies alongside cystoscopy, with use generally increasing as risk increased. The variability was especially pronounced among intermediate-risk patients, underscoring the difficulty of applying a uniform surveillance strategy to a heterogeneous population.

The findings highlight an important opportunity to better align NMIBC follow-up with individual patient risk. More surveillance does not necessarily mean better surveillance, particularly when low-risk patients undergo potentially unnecessary procedures while higher-risk patients receive less monitoring than recommended. The authors suggest that more standardized, risk-adapted approaches could help reduce unwarranted variation while making better use of healthcare resources. Intermediate-risk NMIBC remains a particular area of uncertainty, and further risk stratification may ultimately be needed to determine which patients warrant more or less intensive follow-up.