Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle‐invasive bladder cancer

BACKGROUND: To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder‐preserving trimodality treatment (TMT). METHODS: Patients with muscle‐invasive bladder cancer receiving definitive TMT follow‐up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six‐monthly COSR and six‐monthly TA. RESULTS: A total of 630 follow‐up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non‐muscle invasive) at a median follow‐up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle‐invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle‐invasive recurrence (AUC = 0.848 each) and non‐muscle‐invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively. CONCLUSION: Cystoscopy at suspected recurrence during follow‐up is safe and the most cost‐effective for detecting muscle‐invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.