209 Bladder Cancer Surveillance and Survivorship
As described in the preceding sections, bladder cancer is the fourth most common cancer in U.S. men, although not even the 10th most common cancer in U.S. women (1). For all stages combined, the 5-year relative survival is 77%. Survival decreases to 70% at 10 years, and 65% at 14 years after diagnosis, contrasting with only 10% to 15% of patients alive 5 years after the diagnosis of metastatic disease. With an estimated 74,000 new cases diagnosed in 2016, there will be 17,900 deaths, consistent with the excellent survival of low-stage disease.
There are estimated to be over 500,000 patients alive in the United States living with bladder cancer. With a median age at diagnosis of 65 years, medical comorbidities are more common than in a younger population. These factors, as well as disease-specific elements of stage, grade, and histology, all impact the discussion of future surveillance and care. Advanced age predicts greater risk of other-cause mortality; locally advanced or distant disease most strongly predicts worse cancer-specific survival. Involvement of a multidisciplinary team can benefit a patient’s long-term survival. By integrating care, providers can encourage the patient to pursue a healthy lifestyle, decrease weight if indicated, and to avoid or quit any tobacco use or exposure.
NONMUSCLE INVASIVE BLADDER CANCER
Recurrence: The approximate probability of recurrence in 5 years varies from 50% for low-grade Ta to 60% to 90% for Tis, with risk of progression ranging from 5% in low-risk Ta 210disease and approaching 50% for high-risk disease. The most important prognostic factors for disease progression and disease-specific survival are stage and grade. For patients with high-grade nonmuscle invasive bladder cancer (NMIBC), the cancer-specific survival has been shown to be 70% to 85% at 10 years (2). While there is a high risk of recurrence (up to 55%) for low-grade Ta lesions, only 6% of these progress to high-grade or invasive disease (3). In contrast, high-grade T1 lesions will recur at an elevated rate (45%), with 1- and 5-year disease-progression rates of 11.4% and 19.8%, respectively.
All patients with diagnosed NMIBC must understand that surveillance is the key to proactive monitoring and identification of recurrence. The American Urological Association (AUA) NMIBC guidelines provide a framework for risk groups that informs treatment recommendations, recurrence risk, and surveillance (see Chapter 24).
Surveillance: Guidelines are available from National Comprehensive Cancer Network (NCCN) and the AUA. First cystoscopy after resection is recommended at 3 months, with cytology, and then every 3 to 6 months and at increasing intervals thereafter, depending on risk stratification. Further, upper tract imaging is recommended at 1- to 2-year intervals for intermediate- and high-risk patients. Imaging should be contrast enhanced with delayed phase images, such as CT or magnetic resonance (MR) urogram. Patients with allergy or renal insufficiency may undergo noncontrast CT or ultrasound with retrograde pyelograms. Bone scan, PET/CT, and brain imaging are not recommended for routine monitoring.
MUSCLE INVASIVE BLADDER CANCER
Recurrence: Risks of disease recurrence and progression depend on treatment given and pathologic details. High-risk features which can be identified at resection or cystectomy include lymphovascular invasion, extravesical extension of disease, node positivity, presence of carcinoma in situ (CIS), aberrant histology, and positive soft tissue margins at cystectomy. Following cystectomy, the site of relapse will be local in 10% to 30% of cases and distant in 70% to 90%. The European Organization for Research and Treatment of Cancer (EORTC) 211estimates that patients with muscle invasive bladder cancer (MIBC) have 5-year survival rates of between 30% and 60%.
Surveillance: The NCCN guidelines recommend chest imaging in early stages of disease and disease follow-up with chest x-ray or CT if there are or were previously observed questionable changes in the thorax. PET/CT may be performed if not previously done to rule out metastases in selected patients. Upper tract imaging should be offered at 3 to 6 month intervals for 2 years, and then at 1-year intervals. In cases of definitive whole bladder radiation or the rare case of partial cystectomy, bladder surveillance with cystoscopy is necessary. The presence of residual or recurrent-invasive disease should prompt a discussion of salvage cystectomy if appropriate. With known advanced or metastatic disease, serial axial imaging of chest, abdomen, and pelvis can be done by PET/CT, standard CT, or MRI.
After radical cystectomy, surveillance must include imaging, lab studies, and urine cytology to monitor the upper urothelial tracts and urethra. Results of a meta-analysis of 13,185 patients who underwent cystectomy had a recurrence of upper tract pathology of between 0.75% and 6.4% (4). However, it is important to note that urine cytology only discovered 7% of these recurrences and upper urinary tract imaging detected 30%, so the physician must use clinical judgment to pursue further treatment if hematuria or other clinical signs point toward the need for further investigation. Urethral wash cytology should also be performed, particularly in those with high-risk features such as prostatic urethral disease or concomitant CIS. Monitoring of renal function with creatinine is important, as changes could indicate an anatomic issue such as a ureteral stricture. Further, if ileum was used for the bladder reconstruction, serum B12 levels should be screened annually. The key side effects of systemic treatments such as chemotherapy must also be monitored during and after therapy.
Quality of life is a key outcome for patients receiving these treatments. Some patients face anxiety, fear, and depression, and these diagnoses may impact their ability to return for follow-up appointments and tests. There is clear benefit to 212working with a multidisciplinary team, including psychologists and social workers, to ensure that each bladder cancer survivor will be adherent with first their treatment and later their surveillance and follow-up visits.
Diagnostic and therapeutic interventions can affect urinary and sexual function, as well as body image. These factors should be discussed before surgery and followed prospectively at subsequent visits in patients who have undergone resection, intravesical therapy, radiation, or cystectomy. As patients are at times reluctant to bring up these issues, the provider should question the patient directly for impairment or distress. Validated questionnaires such as the International Prostate Symptom Score (IPSS) and bladder cancer specific tools, such as the EORTC-Quality of Life Questionnaire (QLQ), can assist in these discussions.
Overall, for survivors with no known disease, providers must monitor for recurrence and for sequelae of treatments (both medical and surgical). Multiple organizations provide guidelines for long-term evaluation of patients after treatment of their bladder cancer (see general references listed). The 5-year relative survival rate for bladder cancers diagnosed during 2005 to 2011 was 69%, up from 49% during the period 1975 to 1977 (1). Many specialists are excited about the potential gains to be made with new immunotherapy choices, and 2016 marked the first time in over 20 years a new drug was approved by the Food and Drug Administration (FDA) for bladder cancer.
The goals remain to treat the initial cancer appropriately with selected surgical and medical therapy; screen for recurrence; provide psychosocial and quality of life support; and work in multidisciplinary teams to optimize care for these patients.