[speaker001:] Mr Chairman, ladies and gentlemen. We're all aware that for th for their number patients with superficial bladder cancer provide an enormous amount of our workload, and for reasons partly of... husbanding our precious resources and also because lots of these patients come up with negative checks reducing the amount of irritation and upset to them it would be useful if we could do less than we do. Many people have looked at this before and they've come up with various prognostic markers, some of which are extremely complicated. But perhaps the... erm the simplest... erm... prognostic routes were... suggested by the M R C working parties which general urology which was mentioned in the last presentation.... They combined... erm the four hundred and fifty odd erm... four hundred and seventeen sorry patients in er several M R C studies and looked at them from the point of view of... erm prognostic markers for occurrence and they came up with two factors which overridingly were more important than the others. The first one was the result of the three month check cystoscopy either positive or negative... and the second one the number of tumours at presentation either single or multiple.... And from these two factors you can... erm form three prognostic routes. A low risk route... will have a single tumour at diagnosis and a negative three month cystoscopy. An intermediate risk group with multiple tumours at diagnosis or a positive three month cystoscopy. And a high risk group, multiple tumours at diagnosis and a positive three month cystoscopy.... The suggested protocols for these patients were as follows. The low risk category one patients would go straight onto annual check cystoscopy following the first three month check. The intermediate risk group would have a three monthly cystoscopy for a year and then go onto six monthly for a further year and then annual thereafter. And the high risk group would have three monthly check cystoscopies for two years and then go onto annual check cystoscopies. Any patient who recurs after the three month check cystoscopy is reassessed going back to the beginning and they may be reassigned to one of the the o o one or other of the... groups erm depending on that.... one of the criticisms or possible criticisms of the M R C figures was that these were all patients who had been entered into superficial bladder cancer studies and they don't therefore re represent all because people are selected to go into the trial and perhaps they are lower risk patients than others and in fact... I believe that the recurrence rate in the M R C studies are lower than you would expect for... er superficial bladder cancer in general. And so we did a sort of what if analysis looking a at the impact of implementing erm these... er prognostic categories on our patients. Now this was a retrospective analysis bit it was done on prospectively recorded information. hundred and fifty nine patients all come as presenting with superficial transitional cell carcinoma of the blood, and they all have prospectively follow-up date for more than twelve months following the first check cystoscopy.... You'll see that there is a mix er er of grades and stages and because it's the... the real world... erm in some of the tumours a a precise T category was not... erm decided by the pathologist. Again a mix of single and multiple tumours.... When you look at... er the arrangement of these patients in the prognostic groups you'll see that... the information from the... er the number of tumours at presentation and the the result of the three-month check cystoscopy is quite independent of grade and stage. Er there's no well there looks to be a trend towards higher grade er in in category three patients an and again more er more T one tumours. I the differences are not statistically significant.... Now this is a a sort of cost benefit benefit analysis based on what would have happened... if we'd followed these protocols ourselves. You'll see that the majority of patients fall into the low risk group with progressively smaller numbers in the intermediate and high risk group. Erm... four patients... erm... fro from the group overall subsequently developed cancer.... If we look at the actual numbers of cystoscopies performed you will you see... that... there were... the vast majority of work was done in the lower and intermediate risk group patients er and the positive er cystoscopy rate erm was much lower in the lower risk group, as you would expect, than in the higher risk group. If we had... followed the M R C protocols... er the numbers... er would have been much smaller in the lower risk group and erm... the erm... there was more effort placed in the high risk group than erm... there would have been we actually did. And a as a result of that our... positive cystoscopy rate was more comparable across the three groups than it was previously. You can only say what's.... what this... a doctor in this policy would have done in terms of delaying diagnosis in the lower risk group patients because clearly the other groups of patients are actually having more cystoscopies performed, but because it's a retrospective analysis you cannot say that you are... advancing the diagnosis of er of more frequently occurring tumours. There were thirty tumours from patients that had their diagnosis delayed by a mean of... four months. If we followed the rules... er the M R C rules strictly... one of the lower risk group of patients was a G three P T one tumour and that patient er progressed and in fact all the patients who progressed, all the four out of the hundred and fifty nine patients who progressed erm from the total group had either G two or G three P T one tumours at diagnosis, and I think there's a very strong case for making these a totally separate group of patients erm for follow up.... That just shows graphically what the change in the workload would have been. This is our actual workload and this is what it would have happened if we'd followed the M R C... er protocols. There would actually be a two percent increase in the number of... cystoscopies done but the... work would have be been much better targeted... er than we actually... we actually did.... So in conclusion adoption of the M R C follow up follow up policy would have resulted in... targeting of cystoscopic follow up to higher risk group patients, a two percent increase in the cystoscopic resources required and delayed diagnosis of tumour progression in one patient, and as I've said I I think that G three P T one tumours should be excluded from... er... this type of protocol. Perhaps other uses of... er this type of erm... protocol would be to... use.... flexible cyst er flexible check cystoscopy early in the lower risk group patients, and perhaps give the intermediate and higher risk group patients prophylactic chemotherapy. Thank you. [applause]
[speaker002:] Er I think it would be useful to have er Mr back and we could er... discuss both of these papers together. questions? [clears throat].... Microphone number one.
[speaker003:] P K from Lincoln. A question to both the speakers. Do you consider the smoker as a high risk group and do you... change your... attitude in checking them?
[speaker004:] Erm... I think it j just adds a little bit of complexity t to it. I think... trying to keep something very simple... erm you know a simple rule for everyone to follow and all that that following this protocol requires is that er... that the urologist is at least partially sighted. It doesn't depend on a pathologist or any oth other information.
[speaker001:] Yes I I'd agree. I I think if you've got a moderately or well differentiated tumour and i it's solitary and it's small and they're clear at three months tell them to stop smoking by all means [sound of microphone being brushed against].
[speaker005:] Can I just ask you both... er are you unwilling to modify the standard follow up er cystoscopy for G three tumours and for T one tumours, or is it just for the G three T one. I think Steve you were you were suggesting that it was only the G three T one.
[speaker004:] Erm... well... all the patients who pr progressed had either G two or G three P T one tumours at diagnosis. They seemed to be a very high risk group of patients.
[speaker005:] Right and a a G three P T A?
[speaker004:] Erm well there quite a few of those and none of them progressed.
[speaker002:] Microphone three.
[speaker006:] , Chelmsford. If I come to you... at three months with a P T... A tumour, that's grade one or two, how long would you be... er willing to accept that I should have a recurrence before you treat it? How
[speaker004:] But you sorry a G two?
[speaker006:] A a... G one
[speaker004:] G one
[speaker006:] P T A tumour. How how soon should I get it treated? Does it matter
[speaker004:] I think it probably... it probably doesn't. I mean the r the risk of progression is i i I would think is minuscule... erm and erm you're only talking about changes in size not risk of... of... erm muscle invasion, and I think therefore
[speaker006:] So if it's not causing me any symptoms I should?
[speaker004:] No what I'm say what I'm saying is... that that leaving it for a few months probably isn't going to do you any harm. I mean clearly it will continue to grow and therefore any that you do will be will be greater. the longer you leave it...
[speaker001:] I do think answer for that one er erm I'm not aware of any paper that's published presenting that and we came as close as we could to answering that but nobody really knows for sure. [recording ends]