Potential screening methods

Painless haematuria is the most common presenting sign or symptom of bladder cancer.20 Unfortunately, neither the degree nor the frequency of bleeding (i.e. persistent vs. intermittent) correlates with the seriousness of its underlying cause. For these reasons, if a screening protocol to identify haematuria is developed, it should contain a sensitive test that is applied repeatedly. Once a positive test is identified, subjects should undergo a thorough evaluation. This includes upper tract imaging, cystoscopy and lavage cytology.21 The most commonly used methods to detect haematuria are the chemical reagent strip for haemoglobin and spun sediment microscopy on voided urine.

Other assays under investigation focus on detecting in urine or exfoliated cells the genetic 'signature' of TCC, specific antigens on tumour cell surfaces, and molecules believed to be important in carcinogenesis. Most of the methods discussed here have been tested primarily in populations with bladder cancer histories who undergo cystoscopic examination as part of routine surveillance, rather than general populations at risk for bladder cancer. Current methods focus on clinical or molecular markers associated with active disease, but it is likely that future screening methods will assess genetic predispositions and premalignant alterations long before overt tumours develop (Tables 3 and 4).

Currently, the simplest screening tool is the reagent strip test for haemoglobin in voided urine. Studies comparing the reagent strip to microscopy have reported excellent sensitivity, specificity and predictive values for the strips in detecting microhaematuria.22 More than three red blood cells per high-power field of centrifuged urinary sediment is the threshold for positivity in these studies. Because the intermittent nature of haematuria, even in the presence of serious disease, can result in negative tests, repetitive testing is needed to maximize the strip's sensitivity in detecting bladder

Table 3: Sensitivity.

Grade Stage

Overall*--Primary Recurrent*

12 3 pTis pTa pT1-pT3b

Grade Stage

Overall*--Primary Recurrent*

12 3 pTis pTa pT1-pT3b

Cytology

44 (54)

22 (9)

38 (24)

83 (12)

73 (11)

29 (24)

67 (12)

59 (17)

38 (37)

95% CI

31,59

3,60

19,59

52,98

39,94

13,51

35,90

33,82

22,55

BTA stat

74 (57)

33 (9)

77 (26)

100 (13)

82 (11)

60 (25)

100 (14)

89(19)

66 (38)

95% CI

60,84

7,70

56,91

75,100

48,98

39,79

77,100

67,99

49,80

NMP22 (optimised)

53 (57)

44 (9)

62 (26)

62 (13)

45 (11)

48 (25)

79 (14)

74 (14)

42 (38)

95% CI

39,66

14,79

41,80

32,86

17,77

28,69

49,95

49,91

26,59

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