Screening for bladder tumours in men aged 60–70 years with a bladder tumour marker (UBC) and dipstick-detected haematuria using both white-light and fluorescence cystoscopy

Estimates of the lead time in screening for bladder cancer

Some studies have suggested a survival benefit from early treatment of bladder cancer (BC). This benefit may be due in part to a "lead-time" bias (LT), i.e., the time interval between the detection of BC in asymptomatic individuals and the development of symptoms ("backward prolongation of survival"). To estimate the LT of BC, it was assumed that LT corresponds to the ratio between the prevalence of pre-symptomatic BC and the incidence of symptomatic BC. Data on the prevalence of pre-symptomatic BC were derived from published screening studies. Data on the annual incidence of symptomatic BC at the age and gender of the study populations were derived from national registries in the countries in the years in which the screening studies were conducted. The ratios of the prevalence of presymptomatic BC to the incidence of symptomatic BC ranged from 3.3 to 12.1 years when derived from screening for microhematuria, and from 1.8 to 5.3 years when derived from screening for urine cytology and cell markers. The estimates of the LT of BC derived from the ratios between its prevalence in asymptomatic persons and its incidence in the corresponding population were consistent with those previously reported in retrospective and prospective cohort studies. Since these estimates may account for the survival benefit from early treatment of BC, the gain of screening for BC remains uncertain and should be confirmed by controlled randomized trials.

Potential of an mRNA-Based Urine Assay (Xpert® Bladder Cancer Detection1) in Hematuria Patients - Results from a Cohort Study

BACKGROUND AND OBJECTIVE

Assessment of patients with hematuria (aH) remains a challenge in urological practice, balancing the benefits of diagnosing a potentially underlying bladder cancer (UCa) against the risks of possibly unnecessary diagnostic interventions. This study analyzes the potential of an mRNA-based urine assay, the Xpert® Bladder Cancer Detection- CE-IVD (Xpert BC-D), in patients with hematuria.

MATERIALS AND METHODS

Overall, 368 patients with newly observed painless hematuria and no history of UCa were included in this observational study. Patients received urological workup, including urethrocystoscopy (WLC), upper tract imaging, urine cytology and Xpert BC-D. Patients with positive WLC were recommended to undergo tumor resection (TUR-B).

RESULTS

After excluding non-assessable cases, 324 patients were considered for analysis (188 males, 136 females; median age: 61 years). Eight of twenty-eight patients with a positive TUR-B had Ta low grade (LG) tumors; the others were diagnosed with high grade (HG) lesions (Ta: 4, CIS: 2, T1:11, > T1:3). The Xpert BC-D was more sensitive than urine cytology (96% vs. 61%) (p = 0.002). Increased risk ratios (RR) were observed for gross hematuria, gender, urine cytology, and positive Xpert BC-D (all p < 0.05). Age and positive Xpert BC-D remained independent predictors of UCa in multivariate analysis. Simulating a triage with WLC restricted to patients with positive Xpert BC-D could have saved 240 (74.1%) assessments at the cost of missing one pTa LG tumor.

CONCLUSIONS

The results suggest a potential role for Xpert BC-D in preselecting patients with hematuria for either further invasive diagnosis or an alternate diagnostic procedure.

Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria

BACKGROUND & OBJECTIVE

Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations.

MATERIAL & METHODS

Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included.

RESULTS

The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup.

CONCLUSIONS

Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.

Prevalence of prostate cancer in men with haematuria: a systematic review and meta-analysis

OBJECTIVES

To investigate the prevalence of prostate cancer in men attending evaluation for haematuria, as this could help healthcare providers to determine whether men with haematuria should have prostate examinations performed.

METHODS

The study was performed according to a pre-specified protocol uploaded to the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022299383). A systematic search of MEDLINE, Ovid and Google Scholar was performed in December 2021. Two independent researchers evaluated all titles, available abstracts, and full texts. We included studies on adult men (aged ≥18 years) describing haematuria and prostate cancer.

RESULTS

We screened 4252 titles and abstracts when available and assessed 350 studies in full text. In total, 65 studies were included and 42 was summarised in a meta-analysis. In total, 18 752 men with haematuria were included, and the pooled prevalence (95% confidence interval [CI]) of prostate cancer was 3.0% (2.0-4.1%). In men with macroscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 5.9% (2.9-9.9%; n = 265/5373). In men with microscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 1.4% (0.8-2.2%; n = 71/6642).

CONCLUSION

Our findings indicate that the prevalence of prostate cancer is considerable in men attending evaluation for haematuria. Therefore, digital rectal examination and prostate-specific antigen measurement should become a standard procedure for all men with haematuria, especially for men with macroscopic haematuria.

Epidemiology, Screening, and Prevention of Bladder Cancer

CONTEXT

Bladder cancer (BC) represents a significant health problem due to the potential morbidity and mortality associated with disease burden, which has remained largely unaltered over time.

OBJECTIVE

To provide an expert collaborative review and describe the incidence, prevalence, and mortality of BC and to evaluate current evidence for BC screening and prevention.

EVIDENCE ACQUISITION

Data on the estimated incidence and mortality of BC for 2020 in 185 countries were derived from the International Agency for Research on Cancer GLOBOCAN database. A review of English-language articles published over the past 5 yr was conducted using PubMed/MEDLINE to identify risk factors in addition to contemporary evidence on BC screening and prevention.

EVIDENCE SYNTHESIS

BC is the tenth most common cancer worldwide, with 573 278 cases in 2020. BC incidence is approximately fourfold higher in men than women. Tobacco smoking remains the principal risk factor, accounting for approximately 50% of cases. There is insufficient evidence to recommend routine BC screening. However, targeted screening of high-risk individuals (defined according to smoking history or occupational exposure) may reduce BC mortality and should be the focus of prospective randomized trials. In terms of disease prevention, smoking cessation represents the most important intervention, followed by a reduction in exposure to occupational and environmental carcinogens.

CONCLUSIONS

BC confers a significant disease burden. An understanding of BC epidemiology and risk factors provides an optimal foundation for disease prevention and the care of affected patients.

PATIENT SUMMARY

Bladder cancer is the tenth most common cancer worldwide and is approximately four times more common among men than among women. The main risk factors are tobacco smoking, followed by exposure to carcinogens in the workplace or the environment. Routine screening is not currently recommended, but may be beneficial in individuals at high risk, such as heavy smokers. Primary prevention is extremely important, and smoking cessation represents the most important action for reducing bladder cancer cases and deaths.

Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review

Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.

[Microscopic hematuria : Reasonable and risk-adapted diagnostic evaluation]

BACKGROUND

Microscopic hematuria that is not explained by an obvious underlying condition is a frequent and often an incidental finding that commonly triggers urological or nephrological evaluation. Potential underlying conditions range from benign to severe malignant diseases of the kidneys and urinary tract.

MATERIALS AND METHODS

A nonsystematic literature search was performed, focusing on potential urological and nephrological causes of hematuria. National and international guidelines were considered and diagnostic as well as follow-up strategies are discussed. We provide a recommendation for practices in the clinical evaluation of hematuria.

RESULTS

The overall prevalence for microscopic hematuria is estimated at approximately 2%, whereas risk populations show an increase to around 30%. In 13-35% of patients presenting with microscopic hematuria, a medical or surgical intervention is required. Malignant tumors of the kidneys or urinary tract can be diagnosed in 2.6-4% of all patients and in up to 25.8% of at-risk populations. "Idiopathic microscopic hematuria" without an obvious underlying medical condition accounts for approximately 80% of patients with asymptomatic hematuria. After exclusion of nephrological diseases, standard diagnostic procedures by means of medical history, physical and laboratory examination as well as ultrasound of the kidneys and the urinary tract should be performed. In the presence of risk factors, an extended diagnostic work-up using cystoscopy, urinary cytology, and cross-sectional imaging of the upper urinary tract is indicated.

CONCLUSION

Evidence-based strategies of a risk-adapted diagnostic evaluation for microscopic hematuria are not available. The development of reliable clinical and molecular markers offers great potential for the identification of patients at higher risk for harboring severe diseases.

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

Bladder cancer screening in aluminum smelter workers

Objective:

To present results of a bladder cancer screening program conducted in 18 aluminum smelters in the United States from January 2000 to December 2010.

Methods:

Data were collected on a cohort of workers with a history of working in coal tar pitch volatile exposed areas including urine analysis for conventional cytology and ImmunoCyt/uCyt+ assay.

Results:

ImmunoCyt/uCyt+ and cytology in combination showed a sensitivity of 62.30%, a specificity of 92.60%, a negative predictive value of 99.90%, and a positive predictive value of 2.96%. Fourteen cases of bladder cancer were detected, and the standardized incidence ratio of bladder cancer was 1.18 (95% confidence interval, 0.65 to 1.99). Individuals who tested positive on either test who were later determined to be cancer free had undergone expensive and invasive tests.

Conclusions:

Evidence to support continued surveillance of this cohort has not been demonstrated.

Comparison of frequency of asymptomatic microhematuria in patients with stage 2-4 versus stage 0-1 pelvic organ prolapse

OBJECTIVE

To compare the frequency of asymptomatic microhematuria (AMH) in patients with stage 2-4 and stage 0-1 pelvic organ prolapse (POP).

METHODS

The hospital database was searched for women diagnosed with pelvic floor disorders and all medical records were reviewed retrospectively for the presence of AMH. An additional search was conducted for women with other benign gynecological conditions such as myoma uteri, endometrial hyperplasia or adnexal masses without evidence of pelvic organ prolapse (control group). The control group was created using 1:1 matching for age and menopausal status. The frequency of AMH in these patients were compared. The degree of hematuria was categorized as reported by the laboratory as 3 to 25 (low grade hematuria), 26 to 50 (intermediate grade hematuria) and 51 or more (high grade hematuria) red blood cell/high powered field.

RESULTS

AMH is statistically significant more often seen in study group than in control group (p:0.016). In the prolapse group 20 women (13.7%) had AMH compared with 9 (6.2%) in the control group. All of 29 patients with AMH had low grade hematuria defined as < 25 red blood cell/high powered field. Patients were followed up for 22 ± 7 (12 to 33) months. No bladder cancer and no cancer of the upper urinary tract has been detected in these 29 patients with AMH during follow-up.

CONCLUSIONS

Women with stage 2-4 POP are more likely to be diagnosed with AMH than those with stage 0-1 prolapse.

Molecular markers for bladder cancer screening, early diagnosis, and surveillance: the WHO/ICUD consensus

Due to the lack of disease-specific symptoms, diagnosis and follow-up of bladder cancer has remained a challenge to the urologic community. Cystoscopy, commonly accepted as a gold standard for the detection of bladder cancer, is invasive and relatively expensive, while urine cytology is of limited value specifically in low-grade disease. Over the last decades, numerous molecular assays for the diagnosis of urothelial cancer have been developed and investigated with regard to their clinical use. However, although all of these assays have been shown to have superior sensitivity as compared to urine cytology, none of them has been included in clinical guidelines. The key reason for this situation is that none of the assays has been included into clinical decision-making so far. We reviewed the current status and performance of modern molecular urine tests following systematic analysis of the value and limitations of commercially available assays. Despite considerable advances in recent years, the authors feel that at this stage the added value of molecular markers for the diagnosis of urothelial tumors has not yet been identified. Current data suggest that some of these markers may have the potential to play a role in screening and surveillance of bladder cancer. Well-designed protocols and prospective, controlled trials will be needed to provide the basis to determine whether integration of molecular markers into clinical decision-making will be of value in the future.

In search of a consensus: evaluation of the patient with hematuria in an era of cost containment

OBJECTIVE

The purpose of this article is to describe the current consensus guidelines for nonimaging triage and ultimate preferred imaging approach for the patient with unexplained hematuria.

CONCLUSION

Numerous consensus guidelines from varying societies have outlined preferred imaging pathways for the patient with unexplained urologic causes of hematuria. Future guidelines will need to take into account disease prevalence, radiation considerations, and cost.

Screening for bladder cancer: rationale, limitations, whom to target, and perspectives

CONTEXT

Bladder cancer (BCa) is the fourth most common cancer in men. Survival from the disease has not improved in the last 25 yr. Population-based screening theoretically provides the best opportunity to improve the outcomes of aggressive BCa.

OBJECTIVE

To review the current literature regarding the usefulness and feasibility of screening for bladder cancer.

EVIDENCE ACQUISITION

We conducted a nonsystematic review restricted to English using the keywords urinary bladder neoplasms, mass screening, mandatory testing, and early detection of cancer. We retrieved 184 articles and selected 22.

EVIDENCE SYNTHESIS

There was no level 1 evidence (obtained from a randomised controlled trial [RCT]) addressing the impact of screening on BCa survival or tumour downstaging. No study assessed the diagnostic performance of urinary markers in the context of screening. Two case-control series suggested a benefit of screening on survival, and a third found a nonsignificant beneficial trend in favour of screening. Two studies suggested downstaging of BCa at diagnosis. Other reports concluded that most cancers detected with screening were of low grade and that current urinary testing cannot detect all tumours. Screening is likely to be of benefit in high-risk populations using cost-efficient high-performing urinary biomarkers. There was insufficient evidence to define an efficient screening protocol.

CONCLUSIONS

Although BCa screening is theoretically feasible in a high-risk population, there is currently insufficient evidence to recommend it. This is due to insufficient data to define an efficient screening protocol with selection of an appropriate population and the lack of accurate and cost-effective urinary markers able to discriminate low-risk from high-risk cancers. Major improvements are needed in the evaluation of urinary biomarkers before evaluation in a RCT can be achieved.

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.

Survival in bladder and renal cell cancers is familial

Having family members with cancer has been associated with increased risk for bladder and renal cell cancers, but its association with survival has not been examined. This study was an analysis of the nationwide Swedish Family-Cancer Database and revealed that survival for bladder and renal cell cancers was similar whether the cancer was familial or sporadic; however, when survival in offspring was analyzed according to the affected parents' length of survival, prognosis was concordant. Cox proportional hazard regression models revealed that for bladder cancer, the risk for death among offspring whose parents survived > or =5 yr was approximately one third that of offspring whose parents survived <5 yr, after adjustment for gender, age at diagnosis, time period of diagnosis, socioeconomic status, and geographic region (adjusted hazard ratio 0.34; 95% confidence interval 0.15 to 0.80, for overall mortality). A risk of similar magnitude was found for renal cell cancer (adjusted hazard ratio 0.38; 95% confidence interval 0.16 to 0.87, for overall mortality). These population-level findings suggest heritability of prognosis for bladder and renal cell cancers. Genetic factors likely contribute to the mechanism underlying this observation.

Importance of red patches diagnosed in cystoscopy for haematuria and lower urinary tract symptoms

BACKGROUND

Biopsy of the red patches in the bladder, when found at cystoscopy, is routinely performed in urological practice. This is done to establish the sinister diagnosis of carcinoma-in-situ among other causes.

OBJECTIVE

To analyse the pathology of the red patches and to determine if routine biopsy of these patches is warranted.

PATIENTS AND METHODS

This was a retrospective study conducted over a period of 36 months, in which 50 patients were identified, who underwent biopsies of their red patches. All patients with a history of bladder carcinoma and obvious bladder tumours were excluded from this study.

RESULTS

The mean age of the patients was 60.8 years. 25 patients had cystoscopy for lower urinary tract symptoms, 21 for haematuria and 4 for recurrent urinary tract infection. Carcinoma in situ was found in 4 (8%) patients, of whom only 2 had positive urine cytology.

CONCLUSION

It is prudent to perform a biopsy of all incidentally diagnosed red patches because of a major yield rate of carcinoma in situ. This procedure also picks up other important pathologies, which help in further management.