Follow-Up Management After BCG Therapy for Bladder CIS
The next step for this 60-year-old man with a single focus of CIS who completed six doses of BCG with normal follow-up tests should be continued surveillance with cystoscopy and urinary cytology every 3 months for the first 2 years, along with consideration of maintenance BCG therapy. 1, 2
Surveillance Protocol
Immediate Follow-Up (First 2 Years)
- Cystoscopy and urinary cytology every 3 months 1, 2
- Upper tract imaging (CT urography, IVP, or MRI urogram) at least once within the first 2 years 1, 2
- Consider urine molecular tests for urothelial tumor markers (category 2B recommendation) 1
Intermediate Follow-Up (Years 3-4)
- Cystoscopy and urinary cytology every 6 months 1, 2
- Upper tract imaging every 1-2 years for high-grade tumors 1
Long-Term Follow-Up (Year 5 and Beyond)
Maintenance BCG Consideration
The National Comprehensive Cancer Network (NCCN) guidelines indicate that maintenance BCG therapy is optional for patients with complete response after induction therapy 1, 2. If maintenance BCG is chosen, the optimal schedule based on the International Bladder Cancer Group (IBCG) recommendations is:
- 3 weekly instillations at 3 and 6 months after induction
- Every 6 months thereafter for up to 3 years 1
Rationale for Surveillance
Carcinoma in situ (CIS) is a high-grade lesion considered a precursor to invasive bladder cancer 1, 2. Despite the patient's initial good response:
- Up to 30% of patients with CIS will develop recurrence despite BCG therapy 3
- The risk of progression to muscle-invasive disease remains significant, necessitating vigilant monitoring 1
- Combined cystoscopy and cytology provides 100% sensitivity for detecting recurrence, with 92.3% specificity 4
Management of Potential Recurrence
If recurrence is detected during follow-up:
- For recurrent/persistent CIS: A second course of BCG induction therapy may be given (no more than 2 consecutive courses) 1
- If disease persists after a second course of BCG: Cystectomy should be strongly considered 1
- For progression to invasive disease: Radical cystectomy is recommended 1
Important Considerations
- The prostatic urethra should be monitored, as CIS may involve this area and represents an ominous sign if detected 5
- Upper tract evaluation is critical as CIS can also affect the upper urinary tract 1, 6
- Delaying cystectomy in patients who fail BCG therapy increases the risk of progression and metastasis 7
The combination of regular cystoscopy and cytology provides the most reliable surveillance strategy for detecting recurrence early, when intervention is most likely to be successful 4, 8. This approach balances the need for thorough monitoring with minimizing unnecessary procedures.