Bladder cancer is one of the cancers with the highest recurrence rate in oncology. In particular, the most common form— non-muscle-invasive urothelial carcinoma (NMIBC)—tends to recur even after seemingly complete treatment, which is why it requires long-term follow-up. The occurrence of a recurrence does not necessarily mean that the initial treatment has failed. In fact, in most cases, bladder cancer has biological characteristics that promote the formation of new lesions even months or years after the initial resection.
Why does bladder cancer recur?
There are many reasons for this: the first is the so-called “field effect” (field carcinogenesis). The entire inner lining of the bladder has often been exposed for years to the same carcinogens, chief among them cigarette smoke. Consequently, even after complete removal of the tumor, other urothelial cells may have already accumulated genetic alterations capable of giving rise to new tumors independent of the initial lesion.
A second reason is the possible presence of microscopic residual tumor cells that cannot be identified during endoscopic resection (TURB). For this reason, in high-risk tumors or when the resection is not considered complete, guidelines recommend a second endoscopic resection (re-TURB), generally within 2–6 weeks.
Finally, some cancers have a particularly aggressive biology, characterized by greater genetic instability and a high capacity to generate new lesions over time. For this reason, patients are classified into risk categories (low, intermediate, high, and very high risk), which determine both their treatment and their follow-up care plan.
A second reason is the possible presence of microscopic residual tumor cells that cannot be identified during endoscopic resection (TURB). For this reason, in high-risk tumors or when the resection is not considered complete, guidelines recommend a second endoscopic resection (re-TURB), generally within 2–6 weeks.
Finally, some cancers have a particularly aggressive biology, characterized by greater genetic instability and a high capacity to generate new lesions over time. For this reason, patients are classified into risk categories (low, intermediate, high, and very high risk), which determine both their treatment and their follow-up care plan.
Relapse and progression are not the same thing
It is important to distinguish between two concepts: recurrence refers to the reappearance of the tumor in the bladder, which is often still superficial and treatable with another resection. Progression, on the other hand, means that the tumor has become biologically more aggressive, infiltrating the muscle of the bladder wall or developing more severe histological characteristics. It is precisely the prevention of progression that is the main goal of intravesical therapies and periodic follow-up.
How can you reduce the risk of recurrence?
After endoscopic resection, treatment does not always end with the procedure: in selected patients, intravesical chemotherapy is administered immediately, which has been shown to reduce the risk of recurrence by eliminating any tumor cells remaining after the procedure.
For intermediate- or high-risk tumors, however, intravesical BCG therapy is recommended—a local immunotherapy that reduces both the risk of recurrence and the risk of disease progression. Quitting smoking is also an important measure, as smoking continues to increase the risk of new lesions even after initial treatment.
For intermediate- or high-risk tumors, however, intravesical BCG therapy is recommended—a local immunotherapy that reduces both the risk of recurrence and the risk of disease progression. Quitting smoking is also an important measure, as smoking continues to increase the risk of new lesions even after initial treatment.
Why are such frequent checkups necessary?
Because the risk of recurrence remains high for many years, follow-up is considered an integral part of treatment. The key examination is cystoscopy, which allows for direct visualization of the inside of the bladder and the detection of any new lesions while they are still very small.
European guidelines recommend that all patients undergo an initial cystoscopy three months after transurethral resection (TURB), as this follow-up is one of the most important prognostic indicators of the future risk of recurrence and progression. Subsequently, the frequency of follow-up is tailored to the patient’s risk category. In many patients, urinary cytology is also performed, especially in high-risk tumors, while radiological examinations of the upper urinary tract are reserved for cases with a higher likelihood of recurrence outside the bladder.
European guidelines recommend that all patients undergo an initial cystoscopy three months after transurethral resection (TURB), as this follow-up is one of the most important prognostic indicators of the future risk of recurrence and progression. Subsequently, the frequency of follow-up is tailored to the patient’s risk category. In many patients, urinary cytology is also performed, especially in high-risk tumors, while radiological examinations of the upper urinary tract are reserved for cases with a higher likelihood of recurrence outside the bladder.
In conclusion
The high recurrence rate of bladder cancer is due to the specific biology of this disease and the widespread involvement of the urothelium by risk factors, rather than to the insufficient effectiveness of the initial treatment. For this reason, patients must be monitored with periodic checkups—often for many years—according to a personalized plan. Rigorous follow-up allows for the early detection of any recurrences, their prompt treatment, and a reduction in the risk of progression to more aggressive forms of the disease.
