[speaker001:] Thank you Mr Chairman, ladies and gentlemen.... There have been suggestions in recent years that there's a sub-group of patients with bladder cancer in whom there is a reduced likelihood of recurrence, and it may be possible in those patients to amend the follow-up protocol and omit the six and nine month check cystoscopies. Before implementing such change in our practice, we reviewed our own experience and assessed the likely impact of that change and I'll present that experience today. The paper which first drew our attention to this possibility was that of Fitzpatrick in nineteen eighty six. He looked at four fourteen patients, with well differentiated on the basis of tumours, and found that both number of tumours and size of tumours were significant in determining the likelihood of recurrence. He also found that pati eighty percent of patients who had a negative three month cystoscopy never had another recurrence in the remainder of their follow up. Conversely, only ten percent of patients who had recurrence at that three month cystoscopy went on to have no further recurrence in the remainder of the follow up. Several other ones issue in a number of different ways. Palmer looked at three hundred and five patients, in an M R C study, and from a multivariate analysis, he found the number of tumours from that diagnosis was the single most feature. The size and the result of the three month check cystoscopy were also of considerable importance.... Morgan in nineteen ninety one took a hundred and seventy patients again found the number of tumours at diagnosis to be most important. Then he looked specifically at the effect of the results of the three month or si six month cystoscopies, but they did note that only those pa only those patients who had recurrence in the first year went on to progressive stage.... And the final paper of, of these. Prout in nineteen ninety two a hundred and seventy patients and again found the number of tumours the most important feature. The size was also important, but only in those patients who had single tumours at presentation.... Despite these, this data, there seems to be little evidence yet of any change in common practice of three month check cystoscopies in the first year, six monthly in the second year, and yearly checks thereafter. The papers I've mentioned did make some suggestions, in particular Palmer, in his paper recommended that if the patient had a single tumour presentation and a negative three month cystoscopy, then subsequent cystoscopy could be performed yearly. Kent performed a mathematical analysis to determine the optimum follow up erm regime, and for patients with well differentiated non-invasive tumours, and no recurrence in the first year, he recommended a nine monthly regime. And finally Morgan, looking again at solitary well differentiated tumours, suggested a regime similar to that of Palmer's, namely missing out two or three of the check cystoscopies in the first year.... We felt from this that there was, there was reasonable evidence to introduce this programme into our practice, and we, we looked at our patients erm at and, and we looked at all patients who'd had moderately or well-differentiated transition cell carcinoma of the bladder at diagnosis, a non-invasive tumour, small, solitary, with a minimum follow up of one year. We didn't routinely measure or weigh our bladder tumours over this time, erm we have excluded any patient, any patient where the weight was recorded to be over ten grammes, and similarly any patient wh where it was recorded that the diameter was greater than three centimetres. And we've also excluded those patients where the surgeon recorded that it was a large, extensive tumour. We excluded patients with carcinoma sutch or tumours at diagnosis.... We divided our patients into three groups, depending on the results of the three month check cystoscopy. Group one had no recurrence at the three months. Group two had recurrence at the site of the original tumour, and group three had recurrence elsewhere in the bladder. We calculated the recurrence rate using the formula here, the number of cystoscopies at which recurrences were found divided the total length of follow up in months, and multiplied by a hundred to produce a convenient figure.... And this is what we found. We identified a hundred and forty one patients who fitted the criteria at the diagnosis. The mean age was sixty three, and the male to female ratio was approximately three to one. The maximum length of follow up was twenty six years. Group one, which is the patients we're particularly interested in, there are ninety two patients here, and eighty percent of them, seventy four patients, had no recurrence in the first year. There were eighteen patients who had recurrence, twenty percent of patients who did have recurrence in the first year, and we've subdivided those, labelling seven patients protocol violators. These were patients who missed the one or more check cystoscopies in that first year, and went on to have recurrence when they were next cystoscopied. The mean recurrence rate for this group overall was one point nine five.... There were forty nine patients who had recurrences... at, at the three month cystoscopy. Erm and the recurrence rates were considerably increased at eight point one and nine point three. And this does tend to add weight to the suggestion that the result of the three month cystoscopy is a good guide to the likelihood of developing recurrence. Looking at recurrences a little closer, of the eighteen patients, fifty percent only had a solitary recurrence in that first year, and no patient had more than four recurrences. Of the protocol violators, those seven patients who missed out a cystoscopy and then had recurrences, six have only had occasional recurrences during the remainder of their follow up, and one required chemotherapy four years from diagnosis, when he developed multiple superficial recurrences.... If we implemented this protocol on these patients, we would certainly be leaving these eighteen patients with small tumours in their bladder for several months longer than would previously have been the case. Now we don't know the long term effect of that, but the experience with the protocol violators suggests that they won't come to any great harm, but obviously the number is small. One patient in the whole series went on erm to progress to muscle invasive disease. He was in group three. That is, he had tumour elsewhere in the bladder at his three month cystoscopy, and no patient has died of bladder cancer from these hundred and forty one patients.... To summarize, for a well flagged group of patients, with small solitary non-invasive transition cell carcinomas at d at diagnosis, and negative three month cystoscopy, we found eighty percent of our patients would certainly have come to no harm at all if their second cystoscopy had been one year from diagnosis. Twenty percent of our patients would have had recurrence in that year, but on the basis of our experience, we think it unlikely they would have come to any great harm, as a result of having their cystoscopy delayed, and we would recommend this protocol to the management of superficial bladder cancer. Thank you.
[speaker002:] [clapping] [cough] Thank you. I think what we should do, as we've got two papers on similar topics, is er... take any questions that are specifically related to the t to this paper and the, the methods used in this paper, and then after the next paper have, have both speakers up to address the topic er of er of timing of follow up cystoscopies. Are there any questions now that we would like to ask? [cough] light on the auditorium. Dazzle us a little less, so that we can see.... Right. Can I just ask you, your protocol violators who
[speaker001:] Mm.
[speaker002:] should have come back but didn't,
[speaker001:] Yes.
[speaker002:] did any of them have symptoms during that time when they had recurrences, that brought them back?
[speaker001:] I don't think they did, no. No. They all just came back for a regular routine follow up, just a little bit late.
[speaker002:] Right. Well, let's assume you're saving the questions for after the second paper. Shall we now move on to er the next paper, The Better Use of a Check Cystoscopy, by Steve.