Hematuria screening for bladder cancer

A global, regional, and national survey on burden and Quality of Care Index (QCI) of bladder cancer: The global burden of disease study 1990-2019

INTRODUCTION

Bladder cancer (BCa) is the second most common genitourinary cancer and among the leading causes of cancer-related deaths. We aimed to assess BCa quality of care (QOC) utilizing a novel multi-variable quality of care index (QCI).

MATERIALS AND METHODS

Data were retrieved from the Global Burden of Disease 1990-2019 database. QCI scores were calculated using four indices of prevalence-to-incidence ratio, Disability-Adjusted Life Years-to-prevalence ratio, mortality-to-incidence ratio, and Years of Life Lost-to-Years Lived with Disability ratio. We used principal component analysis to allocate 0-100 QCI scores based on region, age groups, year, and gender.

RESULTS

Global burden of BCa is on the rise with 524,305 (95% UI 475,952-569,434) new BCa cases and 228,735 (95% UI 210743-243193) deaths in 2019, but age-standardized incidence and mortality rates did not increase. Global age-standardized QCI improved from 75.7% in 1990 to 80.9% in 2019. The European and African regions had the highest and lowest age-standardized QCI of 89.7% and 37.6%, respectively. Higher Socio-demographic index (SDI) quintiles had better QCI scores, ranging from 90.1% in high SDI to 30.2% in low SDI countries in 2019; however, 5-year QCI improvements from 2014 to 2019 were 0.0 for high and 4.7 for low SDI countries.

CONCLUSION

The global QCI increased in the last 30 years, but the gender disparities remained relatively unchanged despite substantial improvements in several regions. Higher SDI quintiles had superior QOC and less gender- and age-based inequalities compared to lower SDI countries. We encourage countries to implement the learned lessons and improve their QOC shortcomings.

Molecular Oncology of Bladder Cancer from Inception to Modern Perspective

Within the last forty years, seminal contributions have been made in the areas of bladder cancer (BC) biology, driver genes, molecular profiling, biomarkers, and therapeutic targets for improving personalized patient care. This overview includes seminal discoveries and advances in the molecular oncology of BC. Starting with the concept of divergent molecular pathways for the development of low- and high-grade bladder tumors, field cancerization versus clonality of bladder tumors, cancer driver genes/mutations, genetic polymorphisms, and bacillus Calmette-Guérin (BCG) as an early form of immunotherapy are some of the conceptual contributions towards improving patient care. Although beginning with a promise of predicting prognosis and individualizing treatments, "-omic" approaches and molecular subtypes have revealed the importance of BC stem cells, lineage plasticity, and intra-tumor heterogeneity as the next frontiers for realizing individualized patient care. Along with urine as the optimal non-invasive liquid biopsy, BC is at the forefront of the biomarker field. If the goal is to reduce the number of cystoscopies but not to replace them for monitoring recurrence and asymptomatic microscopic hematuria, a BC marker may reach clinical acceptance. As advances in the molecular oncology of BC continue, the next twenty-five years should significantly advance personalized care for BC patients.

A 25-year perspective on evaluation and understanding of biomarkers in urologic cancers

The past 25 years have witnessed an explosion of investigative attempts to identify clinically useful biomarkers which can have meaningful impacts for patients with urologic cancers. However, in spite of the enormous amount of research aiming to identify markers with the hope of impacting patient care, only a handful have proven to have true clinical utility. Improvements in targeted imaging, pan-omics evaluation, and genetic sequencing at the tissue and single-cell levels have yielded many potential targets for continued biomarker investigation. This article, as one in this series for the 25th Anniversary Issue of Urologic Oncology: Seminars and Original Investigations, serves to give a perspective on our progress and failures over the past quarter-century in our highest volume urologic cancers: prostate, bladder, and kidney cancers.

Implementation of Humane Endpoints in a Urinary Bladder Carcinogenesis Study in Rats

BACKGROUND/AIM

This study aimed to evaluate the utility of several biological parameters for the prediction of tumor development and animal welfare in a rat model of urinary bladder cancer.

MATERIALS AND METHODS

The control group (n=9) received tap water while the test group (n=12) received the carcinogen N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) in drinking water. A score sheet with biological variables was used to monitor animals' welfare. Body weight, food and drink consumption and rectal temperature were measured weekly. Blood and urine samples were collected.

RESULTS

Animals from the control group exhibited a slightly higher body weight and body weight gain. The final urine volume was higher in BBN group (p<0.05). All animals from the BBN group exhibited macroscopic hematuria at 35th week. Four animals were anemic in the last week of the experiment.

CONCLUSION

The routine control of hematuria was a useful non-invasive biomarker of disease progression that may be used as a potential earlier humane endpoint. Animals did not show clinical signs of suffering that justified their sacrifice before the end of the study.

Value of urinary topoisomerase-IIA cell-free DNA for diagnosis of bladder cancer

PURPOSE

Topoisomerase-II alpha (TopoIIA ), a DNA gyrase isoform that plays an important role in the cell cycle, is present in normal tissues and various human cancers, and can show altered expression in both. The aim of the current study was to examine the value of urinary TopoIIA cell-free DNA as a noninvasive diagnosis of bladder cancer (BC).

MATERIALS AND METHODS

Two patient cohorts were examined. Cohort 1 (73 BC patients and seven controls) provided bladder tissue samples, whereas cohort 2 (83 BC patients, 54 nonmalignant hematuric patients, and 61 normal controls) provided urine samples. Real-time quantitative polymerase chain reaction was used to measure expression of TopoIIA mRNA in tissues and TopoIIA cell-free DNA in urine samples.

RESULTS

The results showed that expression of TopoIIA mRNA in BC tissues was significantly higher than that in noncancer control tissues (p<0.001). The expression of urinary TopoIIA cell-free DNA in BC patients was also significantly higher than that in noncancer patient controls and hematuria patients (p < 0.001 and p < 0.001, respectively). High expression of urinary TopoIIA cell-free DNA was also detected in muscle invasive bladder cancer (MIBC) when compared with nonmuscle invasive bladder cancer (NMIBC) (p=0.002). Receiver operating characteristics (ROC) curve analysis was performed to examine the sensitivity/specificity of urinary TopoIIA cell-free DNA for diagnosing BC, NMIBC, and MIBC. The areas under the ROC curve for BC, NMIBC, and MIBC were 0.741, 0.701, and 0.838, respectively.

CONCLUSIONS

In summary, the results of this study provide evidence that cell-free TopoIIA DNA may be a potential biomarker for BC.

Current state of screening for bladder cancer

Bladder cancer is the fourth most commonly diagnosed cancer in men and the eighth most common cancer in women in the USA. Efforts to reduce mortality from bladder cancer must focus on three areas: prevention, development of effective therapies for muscle-invasive and metastatic disease, and early detection of potentially invasive lesions while they are still superficial and amenable to less morbid, but still effective, treatments. As more effective therapies for metastatic transitional cell carcinoma are not on the immediate horizon and preventive measures (except for smoking cessation) have been disappointing, if we are to reduce this disease's morbidity and mortality rates significantly, early detection strategies need to be improved and implemented. The goal of screening for any type of cancer is to detect the disease in its early stages in order to increase the chances for cure or prolongation of life (before micro or gross metastases occur). Since all patients who die of bladder cancer do so from metastases and since almost all patients with metastases have muscle-invading cancers appearing as the first bladder cancer event, diagnosing cancers destined to become muscle invading before they actually are should reduce bladder cancer mortality. This special report reviews the current state of bladder cancer screening in the USA.

Urinary biomarkers of bladder cancer: an update and future perspectives

Bladder cancer is one of the most prevalent cancers worldwide. Early detection of bladder tumors is critical for improved patient outcomes. The standard method for detection and surveillance of bladder tumors is cystoscopy with urinary cytology. Limitations of cystoscopy and urinary cytology have brought to light the need for more robust diagnostic assays. Ideally, such assays would be applicable to noninvasively obtained, voided urine, and be designed not only for diagnosis, but also for monitoring disease recurrence and response to therapy. Consequently, the development of a noninvasive urine-based assay would be of tremendous benefit to both patients and healthcare systems. This article reports some of the more prominent urine-based biomarkers reported in the literature. In addition, some new technologies that have been used to identify novel urinary biomarkers are highlighted.

Cytological findings in routine voided urine samples with hematuria from a tertiary care center in south India

Background:

Regardless of the availability of newer and more sophisticated modalities of investigation, urinary tract cytology still remains the most commonly used non-invasive test for the diagnosis of bladder cancer.

Aims:

As hematuria is the commonest presenting symptom in patients with malignancy of urinary tract, we undertook this study to know the usefulness of urine cytology in evaluation of the hematuric patients for malignancy.

Materials and Methods:

A total of 21,557 fresh voided urine samples received at our tertiary care referral centre over a period of three years were included in the study. Of these, 1428 cases had hematuria, criteria of either gross or microscopic.

Results:

Among these hematuric cases included in the study, 32.5% (464 cases) were found to have positive finding of atypical cells. In these cases with atypia, 9.5% (136 cases) were proved to have malignancy both with the histopathological biopsy and cystoscopic findings. Other cases of atypia were found to be of reactive origin, either due to instrumentation or foreign body. A large number of hematuric cases, that is, 964 cases (67.5%) were negative for atypical cells.

Conclusions:

The limited ability of urine cytology to detect low grade bladder tumors, its subjectivity and lack of uniformity in reporting, all render urine cytology a less than perfect tool. With added collaboration between clinician and cytopathologist, urine cytology can be used an adjunct tool in evaluation of patients with hematuria.

Biomarkers for detection and surveillance of bladder cancer

INTRODUCTION

Bladder cancer is the fourth most common cancer in men and the ninth most common cancer in women in Canada. Early detection of tumours is essential for improved prognosis and long-term survival. The standard method for detection and surveillance is cystoscopy together with urine cytology. Cystoscopy is relatively sensitive but is expensive and invasive. Urinary cytology is a noninvasive method that has poor sensitivity but high specificity; it is relied on for the detection of carcinoma in situ. Currently, several urinary-based bladder tumour biomarkers with USFDA/Health Canada approval are available commercially, but none have been widely adopted by urologists despite their offering high sensitivity and/or specificity. We present here a review of recent studies evaluating 7 commercial biomarker assays for the detection and/or surveillance of bladder cancer.

RESULTS

SENSITIVITY AND SPECIFICITY RANGES, RESPECTIVELY, FOR EACH MARKER WERE REPORTED AS FOLLOWS: BTA Stat (Polymedco), 52.5%-78.0% and 69.0%-87.1%; BTA Trak (Polymedco), 51%-100% and 73%-92.5%; cytology, 12.1%-84.6% and 78.0%-100%; hematuria dipstick, 47.0%-92.6% and 51.0%-84.0%; NMP22 Bladder Cancer Test (Matritech), 34.6%-100% and 60.0%-95.0%; NMP22 BladderChek (Matritech), 49.5%-65.0% and 40.0%-89.8%; ImmunoCyt/uCyt+ (DiagnoCure), 63.3%-84.9% and 62.0%-78.1%; ImmunoCyt/uCyt+ and cytology, 81.0%-89.3% and 61.0%-77.7%; and UroVysion (Abbott Molecular)/florescence in situ hybridization, 68.6%-100% and 65.0%-96.0%.

CONCLUSION

We find that no currently available bladder cancer urinary marker is sensitive enough to eliminate the need for cystoscopy. In addition, cytology remains integral to the detection of occult cancer. However, owing to their relatively high sensitivities, these markers may be used to extend the period between cystoscopies in the surveillance of patients with transitional cell carcinoma. Further study is required to determine which markers, alone or in panel, would best accomplish this.

The role of haematuria in bladder cancer screening among men with former occupational exposure to aromatic amines

Study Type - Diagnostic (validating cohort).

LEVEL OF EVIDENCE

1b. What's known on the subject? and What does the study add? Microscopic haematuria (µH) is frequently detected in elderly adults. The American Urological Association recommends the follow-up of subjects with µH on bladder cancer. Whereas gross haematuria is considered an important sign of the presence of bladder cancer, the disease-predictive value of µH is less clear. No association of µH with the development of bladder tumours in a prospective screening cohort of chemical workers was observed. The positive predictive value of µH for bladder cancer was as low as 1.2%. Haematuria interfered with NMP22 but not with cytology and UroVysion(TM) test results.

OBJECTIVE

• To assess the positive predictive value (PPV) of microhaematuria (µH) and gross haematuria (GH) in bladder cancer screening and the influence of haematuria on tumour tests in a prospective study.

PATIENTS AND METHODS

• From September 2003 to January 2010, 1323 men took part in an annual voluntary bladder cancer screening programme for chemical workers with former exposure to aromatic amines. • In 5315 urine samples haematuria was determined with a dipstick, followed by a microscopic blood cell count in the sediment. Haematuria was categorized into traces, µH and GH. • Urinary leukocytes and other factors were investigated as potential predictors of haematuria using a generalized estimating equation model for repeated urinalysis. The risk of haematuria for positive tumour tests was analysed correspondingly. • The bladder cancer risk was estimated for the highest degree of haematuria occurring during the study with Poisson regression.

RESULTS

• As of July 2010, 15 bladder tumours were detected in 14 participants. • GH was found in four out of nine high-grade tumours and associated with a rate ratio of 3.82, 95% confidence interval (CI) 0.50-29.15 for the development of bladder lesions. • The PPV of GH was 11.4%, but only 1.2% for µH. µH occurred in 18.8% of urine samples and was not associated with bladder cancer [rate ratio (RR) 0.72, 95% CI 0.11-4.78]. • Abundant urinary leukocytes were associated with µH [odds ratio (OR) 8.34, 95% CI 2.26-30.69] and even stronger with GH (OR 22.25, 95% CI 6.42-77.06). • Haematuria and leukocytes influenced NMP22 positivity (µH: OR 1.63, 95% CI 1.06-2.51, abundant leukocytes: OR 8.90, 95% CI 1.58-50.16), but not test results for urine cytology and UroVysion(TM) .

CONCLUSION

• While the PPV of µH for bladder cancer was low, there was a strong influence of haematuria and leukocytes on the protein-based tumour test NMP22®. • Erythrocytes and leukocytes should be determined at least semi-quantitatively for the interpretation of positive NMP22 test results. • In addition, a panel of tumour tests that includes methods not affected by the presence of erythrocytes or leukocytes such as cytology and UroVysion(TM) would improve bladder cancer screening.

Using urine microscopy and cytology for early detection of bladder cancer in male patients with lower urinary tract symptoms

OBJECTIVES

Irritative urinary symptoms and micro-hematuria are the common findings in bladder cancer patients. In this study, we investigated the use of urine microscopy and cytological examination for early detection of bladder cancer in patients with lower urinary tract symptoms (LUTS).

METHODS

Male patients presented with LUTS to urology clinic were enrolled. Voiding symptoms were evaluated with international prostate symptoms score, and urine samples were collected for microscopy and cytological examination. Cystoscopy was performed in patients with microscopic hematuria, suspicious/malignant cells in urine or at the time of transurethral resection of prostate. Subjects, who had no indication and did not receive cystoscopy, were followed up in clinic for progress of symptoms, including gross hematuria and occurrence of bladder cancer.

RESULTS

Nine hundred and eighty-eight patients were enrolled during the period of 2005-2007. Fifty-two (5.26%) urine samples were documented as atypical, and 936 (94.7%) were negative. There was no suspicious or malignant cytology result in this series. Micro-hematuria was noticed in six patients (0.61%). The mean follow-up time was 29.1 ± 12.5 months. One (0.10%) patient had bladder cancer 44 months after the first visit in the cohort, who had micro-hematuria, atypical urine cytology, but normal cystoscopy before diagnosis.

CONCLUSION

The prevalence rate of bladder cancer in male patients with LUTS is low. This study adds to information that microscopy and cytological examination are not useful to detect bladder cancer. Due to the economic concerns and burden of unnecessary investigations, the routine use of these tests is in doubt.

Long-term outcome of patients with a negative work-up for asymptomatic microhematuria

OBJECTIVES

To assess the validity of the American Urological Association guidelines, we investigated 14-year outcomes of men aged > or = 50 years who had hematuria detected in a bladder cancer (BC) screening trial, were thoroughly evaluated, and were not found to have urological cancers. The American Urological Association guidelines for follow-up of adults with asymptomatic microhematuria (MH) who have negative evaluations include repeat urinary cytologies, urinalyses, and office visits for several years, primarily to detect BC (Cohen and Brown, N Engl J Med 348: 2330-2338, 2003; and Grossfeld et al, Urology 57:604-610, 2001).

METHODS

Of 1575 screening participants, 258 had MH detected by daily home testing with the Ames hemastix during two 14-day periods. This test has been shown to accurately reflect MH on microscopic urinalysis when each is correctly performed. Any man with at least 1 positive test (> or = "trace") underwent a complete evaluation including microscopic urinalysis, culture, cytology, complete blood count, serum creatinine, coagulation profile, intravenous urography or computed tomography scan, and cystoscopy. BC or other urological tumors was not detected in 234 participants. Using Wisconsin state tumor registry and death certificate data, the outcomes of these men were tracked for 14 years since their last testing.

RESULTS

Two of the 234 men (0.85%) developed BC during the 14-year follow-up, at 6.7 and 11.4 years after their negative evaluations; one died of BC 7.6 years after his last screening. During this follow-up, 0.93% of the screenees who tested negatively for hematuria had BC diagnosed, none within a year of their last testing date.

CONCLUSIONS

Patients who have negative complete evaluations for asymptomatic MH have little chance of subsequently developing BC. The recommended "appropriate" follow-up for these patients may require reconsideration in light of these data.

Bladder cancer screening in a high risk asymptomatic population using a point of care urine based protein tumor marker

PURPOSE

We evaluated whether screening high risk asymptomatic individuals with a bladder tumor marker can lead to earlier detection and resultant down staging of bladder cancer.

MATERIALS AND METHODS

Subjects at high risk for bladder cancer based on age and smoking or occupational status were solicited from 2 well patient clinics from March 2006 to November 2007. NMP22 BladderChek testing was performed on voided urine samples. Those with positive test results underwent office cystoscopy and cytology testing. Participants were contacted for followup at 12 months after study enrollment to evaluate for unrecognized bladder cancer.

RESULTS

A total of 1,175 men and 327 women underwent BladderChek testing. Mean participant age was 62.5 years (range 46 to 92). Based on 10-year or greater smoking history 1,298 participants were enrolled while 513 were enrolled based on a greater than 15-year high risk occupation for bladder cancer. Positive BladderChek testing was observed in 85 (5.7%) participants and 69 agreed to undergo cystoscopy. Three types of lesions were diagnosed including multifocal, high grade Ta (1); Ta, low grade tumor (1) and marked atypia (1). Followup was available in 1,309 subjects. Mean followup was 12 months (range 0.9 to 25.5) and 2 of 1,309 participants had low grade noninvasive bladder cancer. Evaluation of patient records revealed that 73.4% of participants had urinalysis within 3 years before screening.

CONCLUSIONS

NMP22 BladderChek for screening an asymptomatic, high risk population can detect noninvasive cancers but the low prevalence of bladder cancer in this population did not permit assessment of intervention efficacy. Frequent use of urinalyses in high risk persons may attenuate future efforts to study the effects of bladder cancer screening tests.

Contemporary diagnosis of bladder cancer

BACKGROUND

Early diagnosis of bladder cancer is mandatory, as a delay in treatment has been shown to affect prognosis. The current diagnostic standard of cystoscopy and cytology is costly, invasive and inconvenient, whereas advances in molecular biology have resulted in the evolvement of several markers.

OBJECTIVE

To review diagnostic considerations in the use of old and new technical modalities and tests for the detection of bladder cancer.

METHODS

A PubMed search of the literature concerning bladder cancer diagnosis was performed. Reviews are included on certain topics to avoid extensive reference to separate studies.

CONCLUSION

Recent technical advances have an impact on the management of patients with suspected bladder cancer. Cytology is still an important adjunct in the diagnostic work-up, whereas urine-bound tests may have a role in screening and surveillance. However, cystoscopy is the standard of care for the detection of bladder cancer. Fluorescence cystoscopy is an adjunctive tool, especially for the prompt identification of carcinoma in situ.

Cost-effectiveness of bladder cancer screening

Bladder cancer is the fourth most common cancer in men and 25% of patients present with advanced disease resulting in a poor prognosis. Urine-based tests, including evaluation for blood in the urine or tumor markers, may allow early detection of cancer with resultant improved survival. Studies need to be performed to evaluate the feasibility and cost-effectiveness of screening high-risk populations such as smokers.

Markers of detection

Three applications of markers of detection: screening, replacing surveillance cystoscopies, and guiding evaluation of asymptomatic hematuria, are discussed. In one study, repetitive hematuria screening in men age >or=50 effectively shifted the stage of high grade cancers at diagnosis from muscle invasive to earlier ones, reducing bladder cancer, and all cause mortality. This technique is sensitive, but is not terribly specific. Testing other markers alone or in combination with each other and/or hemoglobin screening in similar or higher risk populations is now beginning. Currently, no commercially available marker is sufficiently sensitive to replace all surveillance cystoscopies for low risk bladder cancer, although some cystoscopic examinations can probably be replaced by markers. Available markers are too insensitive for small, high grade cancers to replace any surveillance cystoscopies in this group. No single marker or combination of markers can safely replace cystoscopy in the work-up of patients with microhematuria who are at high risk for harboring bladder cancer. However, markers may be useful for directing which patients age <or=40 with asymptomatic microhematuria without histories of smoking, particularly women, require cystoscopic evaluation.

Detection of newly diagnosed bladder cancer, bladder cancer recurrence and bladder cancer in patients with hematuria using quantitative rt-PCR of urinary survivin

BACKGROUND/AIMS

Survivin mRNA in urine was measured to detect newly diagnosed bladder cancer, bladder cancer recurrence and bladder cancer in patients with hematuria.

METHODS

We have investigated urinary survivin mRNA of 118 voided urine specimens, including 24 patients with bladder cancer, 50 with bladder cancer history, 68 not known to harbor bladder cancer, and 55 with hematuria using quantitative reverse transcriptase polymerase chain reaction. beta-Actin mRNA expression was also examined and used as an endogenous control to ensure validity of the assay for each sample.

RESULTS

The survivin expression in urological patient urine had sensitivities and specificities for all patients of 79 and 93%, for detection of newly diagnosed bladder cancer 83 and 95%, for bladder cancer recurrence 82 and 90%, and for bladder cancer in patients with hematuria 80 and 90%.

CONCLUSION

Our results indicate that quantitative reverse transcriptase polymerase chain reaction of urinary survivin is a sensitive, noninvasive and highly specific assay to detect both newly diagnosed bladder cancer and bladder cancer recurrence. Furthermore, this assay may be useful in stratifying the hematuria population in urological practice.

Imaging of Bladder Cancer

Bladder cancer is a heterogeneous and frequently multifocal disease with a variable clinical course. The management of bladder cancer is therefore challenging and complicated. CT and MR imaging have replaced the traditional excretory urography and are emerging as the imaging modalities of choice for work-up of patients who have bladder cancer. Imaging provides essential diagnostic information for detection, staging, and post-treatment follow-up of bladder cancer.

Should we screen for bladder cancer in a high-risk population?: A cost per life-year saved analysis

BACKGROUND

The U.S. Food and Drug Administration recently approved screening high-risk patients for bladder cancer using urine-based markers. The cost and life-years saved associated with bladder cancer screening were evaluated.

METHODS

A Markov model was created to estimate cumulative cancer-related costs and efficacy of screening (vs. no screening) of a high-risk population for bladder cancer using a urine-based tumor marker over a 5-year period. Assumptions were based on literature review of survival and progression rates for patients with bladder cancer and costs associated with different bladder cancer disease states.

RESULTS

Screening for bladder cancer in a population with a 4% incidence of bladder cancer resulted in a gain of 3.0 life years per 1000 subjects at a cost savings of $101,000 for the population, assuming a 50% downstaging in the screened population from muscle-invasive to nonmuscle-invasive disease. One-way sensitivity analyses found that screening is the most cost-effective strategy if cancer incidence is >1.6%, tumor marker costs <$126, marker sensitivity is >26%, marker specificity is >54%, downstaging with screening is >20%, and office cystoscopy costs <$694. Varying costs of cystectomy, transurethral resection of bladder tumor (TURBT), chemotherapy, end-of-life care, costs of metastatic disease, and a computed tomography scan over a wide range did not affect the superiority of screening.

CONCLUSIONS

The model found that urine-based markers are cost-effective in a high-risk population. Prospective randomized trials in a completely asymptomatic high-risk cohort are indicated before bladder cancer screening can be recommended.

Economic impact of screening for bladder cancer using bladder tumor markers: A decision analysis

PURPOSE

The Food and Drug Administration recently approved the use of bladder markers such as BladderChek (NMP22; Matritech, Inc., Newton, MA) and UroVysion (Abbott Laboratories, Abbott Park, IL) for use in screening for bladder cancer. The purpose of this analysis was to assess the cost associated with implementing a widespread screening program using a noninvasive bladder tumor marker.

METHODS

Data for the accuracy of NMP22 in detecting bladder cancer was gathered from a comprehensive literature review. A decision tree analysis was constructed to evaluate the total cost of screening a low and high-risk population for bladder cancer using NMP22. Sensitivity analyses were conducted to evaluate the effect of relaxing the various assumptions in the model.

RESULTS

Application of the model to all men, regardless of the degree of risk, rendered a cost per cancer detected of $783,913, $269,028, and $139,305 for ages 50-59, 60-69, and 70-79 years, respectively. Screening only patients at high-risk for bladder cancer (annual incidence 6%) would yield a cost per cancer detected of $3,310. Incidence of cancer and marker specificity had the highest influence on cost per cancer detected.

CONCLUSIONS

Application of NMP22 to the entire population would render an extremely high cost per cancer detected. However, application to an appropriate high-risk target population could achieve cost per cancer detected comparable to currently used screening programs for prostate, colon, and breast cancer. Further studies are needed to assess the accuracy of bladder tumor markers in detecting bladder cancer in a completely asymptomatic cohort.

Bladder tumor markers beyond cytology: International Consensus Panel on bladder tumor markers

This is the first of 2 articles that summarize the findings of the International Consensus Panel on cytology and bladder tumor markers. The objectives of our panel were to reach a consensus on the areas where markers are needed, to define the attributes of an ideal tumor marker, and to identify which marker(s) would be suitable for diagnosis and/or surveillance of bladder cancer. Our panel consisted of urologists and researchers from Europe, Asia, and the United States who reviewed original articles, reviews, and book chapters on individual bladder tumor markers published in the English language mainly using the PubMed search engine. Panel members also met during 3 international meetings to write recommendations regarding bladder tumor markers. The panel found that the most practical use of noninvasive tests is to monitor bladder cancer recurrence, thereby reducing the number of surveillance cystoscopies performed each year. Markers also may be useful in the screening of high-risk individuals for early detection of bladder cancer. However, more prospective studies are needed to strengthen this argument. Case-control and cohort studies show that several markers have a higher sensitivity to detect bladder cancer. However, cytology is the superior marker in terms of specificity, although some markers in limited numbers of studies have shown specificity equivalent to that of cytology. Our panel believes that several bladder tumor markers are more accurate in detecting bladder cancer than prostate-specific antigen (PSA) is in detecting prostate cancer. However, bladder tumor markers are held to a higher standard than PSA. Therefore, use of bladder tumor markers in the management of patients with bladder cancer will require the willingness of both urologists and clinicians to accept them.

Bladder cancer: Epidemiology, staging and grading, and diagnosis

Bladder cancer is a heterogeneous disease with a variable natural history. At one end of the spectrum, low-grade Ta tumors have a low progression rate and require initial endoscopic treatment and surveillance but rarely present a threat to the patient. At the other extreme, high-grade tumors have a high malignant potential associated with significant progression and cancer death rates. In the Western world, bladder cancer is the fourth most common malignancy in men and the eighth most common in women. In Europe and the United States, bladder cancer accounts for 5% to 10% of all malignancies in men. The risk of developing bladder cancer at <75 years of age is 2% to 4% for men and 0.5% to 1% in women compared with the risk of lung cancer, for example, which is 8% in men and 2% in women. For the geographic and temporal comparison of bladder cancer incidence, it is crucial to separate the low-grade from the high-grade tumors. In epidemiologic studies on risk factors for bladder cancer, it is important to distinguish the low-grade Ta tumors from high-grade carcinoma in situ (CIS) and tumors >T1. Current studies do not support the routine screening for bladder cancer. However, prospective long-term studies are required to evaluate the benefits of bladder cancer screening, particularly in those at high risk. After assessing all available evidence, the Epidemiology and Diagnosis Committee has made recommendations on various diagnostic issues, including pathologic evaluation, urinary cytology, and imaging studies. Optimal resection techniques, role of repeat transurethral resection in high-grade T1 tumors, random bladder biopsy, and prostatic urethral biopsy are discussed, and appropriate recommendations are made according to the strength of available evidence.

The usefulness of urinary cytology testing in the evaluation of irritative voiding symptoms

OBJECTIVE

The purpose of this study was to assess the clinical usefulness of urinary cytology testing for the evaluation of urothelial cancer in women with irritative voiding symptoms who were examined at a urogynecology service.

STUDY DESIGN

Urinary cytology studies results that were obtained from January 1, 2000, to December 31, 2002, were cross-matched with the Rhode Island Department of Health Cancer Registry to identify those women who were diagnosed with urinary tract malignancies. The prevalence of urothelial cancer was determined, and the sensitivity, specificity, and positive and negative predictive values of urinary cytologic testing were calculated for 2 common classification strategies: (1) consideration of atypical cytologic test results to be normal and (2) consideration of atypical cytologic test results to be abnormal.

RESULTS

Among 1516 cross-matched cytologic test results from 1324 patients, 5 urothelial cancers were identified. Two of the 5 malignancies were associated with positive cytology results. The prevalence of urothelial cancer was 0.38% (95% CI, 0.1%, 0.9%). When atypical cytology studies were classified as normal, the sensitivity of urinary cytology was 40% (95% CI, 7.2%, 83.0%); the specificity was 99.9% (95% CI, 99.5%, 100%); the positive predictive value was 66.7% (95% CI, 12.5%, 98.2%), and negative predictive value was 99.8% (95% CI, 99.2%, 100%). In contrast, when atypical cytology results were classified as abnormal, the sensitivity and negative predictive value remained the same, but the specificity declined to 93.6% (95% CI, 92.1%, 94.8%), and the positive predictive value decreased to 2.3% (95% CI, 0.4%, 8.8%).

CONCLUSION

The low prevalence of urothelial cancers and low sensitivity of urinary cytology studies severely limit the usefulness of this test in the evaluation of women with irritative voiding symptoms.

Bladder cancer in patients with spinal cord injuries

OBJECTIVE

To evaluate the age-standardized incidence rate of bladder cancer in patients with spinal cord injury (SCI) and the overall risk for this population.

PATIENTS AND METHODS

We reviewed 1334 patients with SCI whose dates of SCI, or first attendance at our centre, were between 1940 and 1998. The length of follow-up was calculated for each patient and age-specific incidence rates of bladder cancer calculated using 5-year age bands. This was used to calculate the overall incidence rate, using direct standardization with the European standard population. The cancers were analysed histochemically to characterize the phenotype.

RESULTS

The 1324 patients contributed a total of 12 444 person-years of follow-up. There were four cases of bladder cancer, giving an age-standardized incidence rate of 30.7 per 100 000 person-years. Histochemistry showed areas were positive for cytokeratin 14, which was also positive in the undifferentiated areas. Immunohistochemical staining was positive for cytokeratin 14 and consistently negative for cytokeratin 20, suggesting a pure squamous phenotype.

CONCLUSIONS

The age-standardized incidence of invasive bladder cancer in patients in our SCI unit is not statistically different from that of the general population. However, the incidence of invasive bladder cancer in the present study appears to be lower than that reported in other series. Histochemical analysis confirmed a squamous cell phenotype in these tumours.

Bladder cancer screening program for a petrochemical cohort with potential exposure to beta-napthylamine

Approximately 1800 workers in pipe manufacturing plants in the United States may have been exposed to beta-napthlyamnine between 1970 and 1996. Once the chemical was detected, the contaminated additive in the resin was identified and discontinued. A bladder cancer-screening program was initiated in 1999. An annual two-stage screening program was developed to test for microscopic hematuria (stage one) and cytology (stage two), with a urology referral of positive or suspicious cytology. This paper presents the program methodology, cohort enumeration, recruitment, and enrollment strategies, and screening protocol. Enrollment data from the first 3 years are presented. Annual screening of a cohort of current and former employees is feasible. Original personnel records are often incomplete, making cohort identification important. Personal contact and follow-up are key elements of successful recruitment and retention.

[The role of tumor markers in urologic consultation for screening, diagnosis, and follow-up of bladder cancer]

PURPOSE

Review the tumor markers for screening and diagnosis of transitional cell carcinoma of the bladder.

METHODS

The published literature on bladder cancer markers was identified using a MEDLINE search and critically analyzed. The sensitivity and specificity of the various markers were compared.

RESULTS

Conventional non-invasive methods for diagnosis (symptoms and urine cytology) and for screening and follow-up of transitional cell carcinoma of the bladder are not very sensitive and must not be considered sufficient. Some tumor markers seem to be a good alternative to the routine urinary cytology.

CONCLUSION

The role of tumor markers for screening and follow-up of bladder tumors as an alternative to cytology deserve consideration. In the future, more sensitive and specific markers may replace routine cystoscopy.

Biomarkers in cancer screening: a public health perspective

The last three decades have witnessed a rapid advancement and diffusion of technology in health services. Technological innovations have given health service providers the means to diagnose and treat an increasing number of illnesses, including cancer. In this effort, research on biomarkers for cancer detection and risk assessment has taken a center stage in our effort to reduce cancer deaths. For the first time, scientists have the technologies to decipher and understand these biomarkers and to apply them to earlier cancer detection. By identifying people at high risk of developing cancer, it would be possible to develop intervention efforts on prevention rather than treatment. Once fully developed and validated, then the regular clinical use of biomarkers in early detection and risk assessment will meet nationally recognized health care needs: detection of cancer at its earliest stage. The dramatic rise in health care costs in the past three decades is partly related to the proliferation of new technologies. More recent analysis indicates that technological change, such as new procedures, products and capabilities, is the primary explanation of the historical increase in expenditure. Biomarkers are the new entrants in this competing environment. Biomarkers are considered as a competing, halfway or add-on technology. Technology such as laboratory tests of biomarkers will cost less compared with computed tomography (CT) scans and other radiographs. However, biomarkers for earlier detection and risk assessment have not achieved the level of confidence required for clinical applications. This paper discusses some issues related to biomarker development, validation and quality assurance. Some data on the trends of diagnostic technologies, proteomics and genomics are presented and discussed in terms of the market share. Eventually, the use of biomarkers in health care could reduce cost by providing noninvasive, sensitive and reliable assays at a fraction of the cost of definitive technology, such as CT scan. The National Cancer Institute's Early Detection Research Network (EDRN) has begun an innovative, investigator-initiated project to improve methods for detecting the biomarkers of cancer cells. The EDRN is a consortium of more than 32 institutions to link discovery of biomarkers to the next steps in the process of developing early detection tests. These discoveries will lead to early clinical validation of tests with improved accuracy and reliability.

Imipramine hydrochloride and desipramine hydrochloride as new reagents for detection of microamounts of blood in urine

Benzidine and o-tolidine, the hazardous carcinogens are still in use for the detection of blood in urine. Development of safer substitutes are of paramount importance. Unfortunately, the alternate available reagents lack specificity, sensitivity and reproducibility. Imipramine hydrochloride (IPH) and desipramine hydrochloride (DPH) are proposed as new reagents for the detection of blood in urine. Both the reagents impact to blood a green-blue to blue color, in the presence of acetic acid and hydrogen peroxide and the development of this color is explored under laboratory conditions. IPH or DPH compares favorably with benzidine and multistix methods. Both the reagents are relatively inexpensive, and have required sensitivity and stability. The proposed reagents offer advantages of relatively low sensitivity to endogenous vegetable peroxidases; hence, the test can be performed on samples taken from patients who are on a normal diet and the results are reproducible. Besides, the reagents, are non-carcinogenic and can replace benzidine and o-tolidine without any extra procedural difficulties as they also exhibit a similar blue color.

Detection and diagnosis of blood in feces and urine: an overview

BACKGROUND

Detection of blood in feces or urine has long been regarded as an indicator of patient's state of health. The ease with which feces or urine may be obtained and patient's willingness to provide the specimen make detection of fecal occult blood or urine analysis one of the most commonly performed screening examinations. Historically, the inspection of feces or urine for diagnostic purpose has been practiced for centuries. Of late, management of renal or urinary tract abnormalities or investigation of anemia, gastrointestinal diseases and for early detection of colorectal cancer has assumed greater importance.

METHODS

The never-ending list of techniques for the diagnosis of disorders producing bleeding such as urine microscopy, urine cytology, urine based marker test, cytoscopy, ultra sonography, computed tomography, magnetic resonance imaging, to mention a few, and four categories of detection of fecal occult blood namely, radioanalytical, physical, immunochemical and chemical methods makes the study very interesting.

PURPOSE

This review attempts to overview various techniques, methods and methodologies for the diagnosis and detection of blood in feces and urine, in the direction of looking at past and current tests with an eye on future needs.

Prevention and treatment of urothelial premalignant and malignant lesions

Bladder cancer is believed to develop through reversible premalignant stages followed by irreversible steps, and ending in invasive cancer giving rise to distant metastases. Because of the variation in the clinical course it has also been suggested that different forms of cancer develop along different molecular pathways leading to tumor presentations of various malignant potential. Today we treat and prognosticate bladder cancer on the basis of clinical and histologic findings that are insufficient to assess all the biologic potential of these tumors. Understanding the pathogenesis of bladder cancer might lead to a more precise identification of particular tumors with regard to clinical aggressiveness, resulting in individualized strategies for treatment and prophylaxis. Bladder cancer is seldom diagnosed in its preclinical stage, it is instead detected at cystoscopy and virtually never recognized as an incidental finding on autopsy. Therefore its "natural history" largely reflects that of "treated" disease. The true incidence of premalignant and malignant epithelial changes is not known. Incidences of hyperplasia and dysplasia of approximately 10% and approximately 5%, respectively and only occasional findings of cancer itself were reported in two autopsy series. Urothelial dysplasia is generally believed to be premalignant and a putative precursor of invasive cancer but unfortunately there has been a lack of standardization in terms of terminology and diagnosis. There is also a need for an agreed definition of the boundary between premalignancy, i.e. urothelial changes that have some but not all the features of carcinoma in situ, and malignancy, especially when considering potentially harmful treatments to prevent this transition. Most new diagnostic tools available and being tested today compare new detection techniques with traditional methods such as cytology or conventional histology of malignant rather than premalignant changes. There is probably also a short preclinical latency, as implied by the incidental findings of bladder cancer at autopsy, which makes it necessary to define how and when to promote early detection and treatment. Future studies therefore have to concentrate on methods for early detection of disease as well as characterization of host susceptibility, evaluation of exposure to carcinogens and potential effects of preventive measures. It is also likely that the improved tools of molecular prognostication will allow us to design trials more precisely in order to tailor therapeutic strategies.

Specificity of human complement factor H-related protein test (Bard BTA stat Test)

OBJECTIVE

The Bard BTA stat Test is a new, rapid, non-invasive qualitative test that detects bladder tumour-associated antigen (human Complement Factor H-related protein) in urine. The objective of this study was to evaluate the specificity of the Bard BTA start Test in a healthy population.

MATERIALS AND METHODS

Voided urine samples from 100 healthy volunteers were collected and tested using the BTA stat Test. In the case of a positive BTA stat result, i.v. urography, cystoscopy, ultrasound and-re-testing were performed and the BTA stat Test was repeated three months later.

RESULTS

Two subjects tested positive by the BTA stat Test, but no bladder cancer was found. The specificity of the BTA stat Test in the studied healthy population was 98%.

CONCLUSIONS

The BTA stat Test has very high specificity with a true test-dependent false-positive rate occurring in only 2% of the healthy population. These results justify further studies with the BTA stat Test for bladder cancer diagnosis, monitoring, and screening.

Evaluation of asymptomatic microhematuria

OBJECTIVES

The purpose of this study was to evaluate a comprehensive urine cytodiagnostic assay to assist in localizing the site of origin and the etiology of asymptomatic microhematuria. This analysis, which assesses various qualitative and quantitative aspects of the voided urine, is compared simultaneously with controls obtained from the established routine urologic evaluation.

METHODS

One hundred consecutive subjects who presented solely for the evaluation of asymptomatic microhematuria were evaluated by the established routine urologic evaluation and a refined urine cytodiagnostic assay. For the purpose of this study, only calculi and neoplasms were considered significant findings.

RESULTS

The incidence of significant urologic disease was 13% (3 renal neoplasms, 2 urothelial bladder carcinomas, and 8 urinary calculi). The refined urine cytodiagnostic assay identified both uroepithelial vesical neoplasms, 7 of the 8 urinary calculi, and none of the 3 renal neoplasms. The presence of dysmorphic urinary red blood cells (RBCs) and RBC casts was strongly suggestive of renal parenchymal bleeding. Overall, 43 of 44 subjects (98%) with dysmorphic RBCs and RBC casts failed to demonstrate any significant urologic etiology.

CONCLUSIONS

These preliminary results suggest that the refined cytodiagnostic urine assay may be helpful in distinguishing whether a given patient's microhematuria is of a significant urologic or a renal parenchymal cause. The addition of this specialized urinalysis may prove a useful adjunct in improving the diagnostic yield in patients with asymptomatic microhematuria.

Hematuria home screening: repeat testing results

To determine at what interval screening should be repeated to detect bladder cancer before it becomes muscle invasive 856 men who had 14 negative daily home tests for hematuria with a chemical reagent strip 9 months previously performed repeat tests. Of these men 50 (5.8%) had at least 1 positive test during the second 14-day screening period and 38 were evaluated, 15 of whom (39.5%) had significant urological pathological conditions, including 8 with malignancies. Bladder cancer was noted in 7 men, with no tumor invading the muscularis propria. The finding of 7 bladder cancers in 856 men (0.82%) who had a negative test 9 months previously indicates that bladder cancer has a brief preclinical duration and that testing must be repeated at least annually for screening to detect bladder cancer consistently before invasion occurs.

Comparison of bladder cancer outcome in men undergoing hematuria home screening versus those with standard clinical presentations

OBJECTIVES

Because repetitive hematuria home screening with a chemical reagent strip can detect early stage bladder cancer (BC) in asymptomatic middle-aged and elderly men, the ability of this screening to effect earlier detection and reduce BC mortality was investigated.

METHODS

Grades, stages, and outcomes of BCs detected by hematuria screening in 1575 men were compared with those of all newly diagnosed BCs in men age 50 years or older reported to the Wisconsin cancer registry in 1988. BC grades and stages were assigned by review of all pathology slides/blocks, and causes of deaths were determined from cancer registry records. As an additional control group, outcomes of BC cases diagnosed in men solicited to take part in screening, who declined, were also determined.

RESULTS

The proportions of low-grade (grades 1 and 2) superficial (Stages Ta and T1) versus high-grade (grade 3) or invasive (Stage T2 or higher) cancers in cases detected by hematuria screening (screened cases) and those reported to the tumor registry (unscreened cases) were not significantly different (52.4% versus 47.7% in 21 screened and 56.8% versus 43.3% in 511 unscreened cases) (P > 0.20). Of the high-grade or invasive cases, however, the proportion of late stage (T2 or higher) tumors was significantly lower in the screening-detected BCs compared to unscreened ones (P = 0.007). No screened case has died of BC (3- to 9-year follow-up), whereas 16.4% of unscreened cases have within 2 years of diagnosis (P = 0.025). Twenty-three of 1940 (1.2%) men who were solicited but chose not to participate in screening were diagnosed with BC within 18 months after what would have been their last home screening date, compared with 1.3% of participants having BC detected by screening. Thus, screening participants and those who were solicited and declined had similar likelihoods of developing BC.

CONCLUSIONS

Hematuria home screening detects high-grade cancers before they become muscle invading and significantly reduces BC mortality.