Provocative data may re-shape bladder cancer treatment

Is routine screening for bladder cancer on the horizon? Is it cost-effective? Is it practical?

According to Badrinath Konety, MD, associate professor of urology at the University of California, San Francisco, the answers may produce a shift in the way urologists approach bladder cancer, a disease that has seen very few changes in mortality and survival rates over the past 3 decades.

This population-based study enrolled 1,575 men, age 50 years or older, to take part in repetitive home hematuria testing for two 14-day periods, 9 months apart. The men used chemical reagent strips, and a positive test prompted a standard hematuria workup.

At 14 years follow-up, none of the men with screening-detected bladder cancer had died from the disease compared with 20.4% of a control group of unscreened men diagnosed with bladder cancer who died from the disease.

"It's interesting to note that in patients who have dipstick screening, are worked up, and are found not to have bladder cancer, you can stop after a single workup because the likelihood of later finding cancer that was missed is the same as it is in people who have never been screened," Dr. Konety said.

He added that this study might raise calls for routine bladder cancer screening, as this method uses a simple test that can be performed on easily obtainable urine samples.

Screening for bladder cancer using a urine-based marker is most cost-effective and, in certain instances, cost-saving.

A group from the University of Texas Southwestern Medical Center, Dallas, found that urine-based cancer screening is especially cost-effective when the incidence of cancer in the screening population is above 1.6%, when marker sensitivity is >26% and specificity is >54%, when down-staging with screening is >20%, and when office cystoscopy costs less than $694.

"We need parameters by which to measure these tumor marker tests," Dr. Konety said. "The parameters set forth by this group are met by most markers. That would lead us to conclude that screening looks to be feasible and cost-effective, given the markers we have now."

A downloadable table uses simple parameters, such as prior recurrence rate, number of tumors, tumor diameter, T-stage, grade, and the presence/absence of concomitant carcinoma in situ, to predict risk of recurrence and progression.

While the elements used to design this table aren't new in themselves, the way they are packaged is.

"It becomes much easier to use them, especially in an era in which we're seeing more diagnostic tools accessible to patients, as well as providers," Dr. Konety said. "People are getting used to the idea of keying in pathological or clinical features and coming up with probability of progression or cure in various cancers."

As Dr. Konety noted, bladder cancer had been one of the few urologic cancers for which a recurrence/progression probability table such as this had not yet been constructed.

Intravesical immunotherapy using Bacillus Calmette-Guerin (TheraCys, TICE BCG) plus interferon-alpha (Intron A) is significantly less effective in patients who are more than 80 years old.

A similar AUA presentation showed that BCG alone does not work as well in relatively older patients. That's especially important in bladder cancer, where patients have a median age of about 69 years.

"The standard of care may need to change in this subset of patients, and we need to decide whether we should use more combination therapies or chemotherapy, rather than immunotherapy," Dr. Konety said. "BCG-based regimens rely on immuno-stimulation, and older patients are somewhat immuno-suppressed."