NEITHER study: NICE versus EAU inconsistent triage, expenses and reliability in non-high-risk non-muscle invasive...

This study aimed to quantify discrepancies in non-high-risk non-muscle-invasive bladder cancer (NMIBC) stratification between the National Institute for Health and Care Excellence (NICE) and the European Association of Urology (EAU) guidelines, compare discriminative performance for predicting recurrence, estimate potentially missed recurrences under shorter surveillance and calculate per-patient surveillance costs.

This is a retrospective cohort study of patients undergoing transurethral resection of bladder tumour (TURBT) at a UK tertiary centre (2018-2020). Patients with low- or intermediate-risk NMIBC who completed 5-year follow-up or experienced recurrence were included. Each patient was stratified according to both NICE and EAU (WHO 1973) guidelines. Outcomes included recurrence rate, discriminative accuracy (Harrell's C-index), proportion of recurrences occurring beyond NICE discharge timepoints and surveillance cost based on NHS reference prices.

Of the 158 eligible patients (78% male; mean age 68 years), 40% were assigned different risk categories depending on guideline applied. NICE classified significantly more patients as low risk than EAU (31.1% vs. 12.7%; p < 0.001). Overall, 5-year recurrence was 48.7%, with no significant difference in recurrence rates between corresponding risk groups under each guideline. NICE demonstrated superior discrimination (C-index 0.605 vs. 0.511; p = 0.006). Among NICE low-risk patients, 45% of recurrences occurred between Years 2 and 5-beyond the recommended 1-year discharge point. Mean per-patient surveillance cost was £1412 under NICE versus £3525 under EAU, representing a 60% reduction.

NICE can reduce cost with comparable discrimination efficiency to EAU guidelines, but risks missed recurrences; a hybrid NICE-EAU approach may offer the optimal balance.