A Plea for Long-Term Surveillance in Bacillus Calmette-Guérin–Treated Non–Muscle-Invasive Bladder Cancer

Abstract

Guidelines provide detailed information on diagnosis and treatmentbutare less specific onhowandhowoftenpatients need to be seen for follow-up after treatment for non– muscle-invasive bladder cancer (NMIBC) [1–3]. Follow-up is essential in NMIBC, as 30–80% will recur and 1–45% will progress to muscle invasion within 5 yr [1,2]. NMIBC is a chronic disease with varying oncologic outcomes requiring frequent follow-up and repeated treatments, rendering the cost per patient from diagnosis to death the highest of all cancers [1]. It is concerning that despite the obvious importance of regular follow-up, adherence to surveillance among patients with NMIBC in a 3-yr surveillance period after initial treatment is<50%. Schrag et al. [4] reported that only 40% of patients under surveillance had undergone all cystoscopic examinations, as recommended by the clinical guidelines. Thirty-five years ago, Morales et al. [5] published their revolutionary study on the use of intravesical Bacillus Calmette-Guerin (BCG) immunotherapy for NMIBC. The choice between adjuvant intravesical treatments, namely, chemotherapy or BCG immunotherapy, depends on the risk that needs to be reduced: recurrence or progression. Several meta-analyses have shown that adjuvant intravesical treatment (chemotherapy or BCG) reduces NMIBC recurrence [1–3]. BCG is more effective but also more toxic. BCG, but not intravesical chemotherapy, also reduces the risk of progression [6]. A maintenance BCG schedule was found to be essential in preventing progression [6]. Two recently published papers—the long-term efficacy results of the European Organization for Research and Treatment of Cancer 30911 trial [7] and a meta-analysis