Comparison of surveillance strategies for low-risk bladder cancer patients.

OBJECTIVE: Low-grade noninvasive disease comprises approximately half of incident bladder cancer cases. These lesions have exceedingly low rates of progression to aggressive, muscle-invasive bladder cancer, and there is salient discordance with regard to management recommendations for these patients between the principal clinical practice guidelines. In this context, we compare the international guidelines with alternative surveillance strategies for low-risk bladder cancer patients.
METHODS: We used a partially observable Markov model based on states that defined patient risk levels associated with recurrence and progression of bladder cancer. The model also included states defining the effects of treatment, death from bladder cancer, and all other-cause mortality. Simulation was done to estimate quality-adjusted life years (QALYs), expected lifelong progression probability, and lifetime number of cystoscopies.
RESULTS: We compared current international guidelines and additional proposed surveillance strategies on the basis of QALYs. We conducted a bicriteria analysis to compare expected lifelong progression rate v. the number of cystoscopies. One-way sensitivity analysis was used to evaluate the influence of model parameters, including a patient's disutility associated with cystoscopy, bladder cancer mortality, and all other-cause mortality.
CONCLUSIONS: Age and comorbidity significantly affect the optimal surveillance strategy. Results suggest that younger patients should be screened more intensively than older patients, and patients having comorbidity should be screened less intensively.