Description of the Evidence
The outcomes of men diagnosed with bladder cancer through a hematuria home screening program using a chemical reagent strip were compared with a statewide population-based sample of 87% of all men aged 50 years and older from the Wisconsin tumor registry. Histologic sections were blindly reviewed, and similar proportions of low-grade superficial versus high-grade or invasive cases were found; the proportion of late-stage (T2 or higher) disease was lower in the screened patients. At 14 years, 20.4% of tumor registry patients had died from bladder cancer (including 50% of those with muscle-invading grade III lesions); however, at 14 years of follow-up, no participant with bladder cancer detected by screening had died of bladder cancer. Whether these differences resulted from some combination of lead-time effect, overdiagnosis, or selection biases, a real screening effect cannot be determined.
The measurement of a variety of molecules and cellular elements screened in urine has been proposed, and in some cases marketed, to monitor previously diagnosed bladder cancer patients; however, the specificity and sensitivity of these markers have not been assessed in a screening setting in a general population, but several such studies are under way.
In populations at particularly high risk for developing bladder cancer (other than those with histories of bladder cancer), few screening studies that have assessed bladder cancer mortality have been published.[67,68,69,70] A study of annual cytology in aluminum workers exposed to coal tar pitch in Quebec showed a nearly 40% reduction in bladder cancer case-fatality 6 years after diagnosis, compared with a historical control group of workers from the same plants who were not screened; the difference, however, was not statistically significant. Awareness of adverse outcome in the unscreened predecessors may have influenced participation in the program and workers' awareness of symptoms, the willingness of workers and physicians to initiate diagnostic investigations based on signs and symptoms, and the compliance of workers with medical recommendations for evaluation and treatment. The brief duration of follow-up in the screened group may have artifactually improved the outcome.
No randomized controlled bladder cancer screening trials have been conducted in environmentally or industrially exposed cohorts. Completed studies have usually not had comparable control groups, have not been of sufficient sample size to show an effect on outcome, and have been of insufficient length to show a mortality benefit (or lack thereof) for the modality or modalities being assessed.[68,69] One study described the usefulness of measuring three biomarkers in voided urine for risk assessment and cancer detection in a large cohort of Chinese workers at increased risk of bladder cancer. The workers were individually stratified, screened, monitored, and diagnosed on the basis of predefined molecular biomarker profiles. These techniques remain investigational.
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