CTF Structured Abstract: Screening for Bladder Cancer

Canadian Task Force on Preventive Health Care

Structured Abstract

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Screening for Bladder Cancer

Prepared by Sarvesh Logsetty, MD, Division of General Surgery, Hospital for Sick Children, Toronto, Ontario

These recommendations were finalized by the Task Force in June 1993

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations about screening for superficial bladder cancer among the general and at-risk populations in Canada. This updates a 1979 report.

Burden of Suffering

In 1993 the estimated incidence of bladder cancer in Canada was 4,900 cases (3,700 men and 1,200 women, a 3:1 ratio). The overall age-standardized annual incidence rate in 1988, was 21.8 per 100,000 population/yr in males, 7.0 in females. More than 95% of new cases were found in individuals over 45 years of age, especially in the 65 to 74 year age group in both sexes. Incidence rates increased with age, reaching a maximum of 313 cases per 100,000 population in males and 81 in females in those over 85 years old. Deaths related to bladder cancer in Canada in 1993 numbered approximately 1,310. The 1988 age-specific mortality rates are as high as 198 deaths per 100,000 per year in older males and 63 per 100,000 in older females. Exposure to aromatic amines, 4 aminobiphenyl, or a number of chemicals in the dye industry, or employment in the leather, tire, or rubber industries have been shown to increase the risk of developing bladder cancer. Smoking has also been associated with an increased incidence of bladder cancer and is now the leading cause of bladder cancer in Canada.

Options

Screening methods include microscopic hematuria testing using routine or, dipstick testingurinalysis,; cytology and cytoscopy.

Outcomes

Main health outcomes were bladder cancer recurrence and survival. Sensitivity, specificity, costs and adverse effects of screening tests were also examined.

Evidence

MEDLINE was searched from 1976 to February 1993 (keywords not specified). Additional articles were identified from the bibliographies of retrieved articles.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

The sensitivity and specificity of dipstick urinalysis for identifying hematuria are 91% and 99% respectively. However, hematuria is not specific to bladder cancer. Data from cohort studies suggest that only 14% to 24% of abnormalities detected in men >50 years with hematuria are due to bladder cancer. Estimates for groups with the highest risk (e.g., men aged 55 to 64 years who were machine trade workers and smoked heavily) indicate that for each person with bladder cancer, 3 healthy persons would undergo invasive tests. Dipstick testing is faster and less expensive than microscopic hematuria, and patients can do intermittent tests at home.

Cohort and case-control studies report sensitivities of 48% to 100% and specificities of 40% to 93% for urine cytology.

Screening the general population using cytoscopy combined with intravenous pyelography or ultrasound was not considered appropriate because of exposure to X-ray radiation and patient discomfort.

Based on the October 1992 guide to the Ontario Health Insurance Plan, hematuria tests cost $3.90 per test; urine cytology costs $18.82 per test (includes professional and pathologist fees); and cytoscopy costs $120.50 per test (includes surgeon and anesthetist fees, but not costs related to equipment maintenance and nursing support).

Initial treatment of bladder cancer involves local excision (transurethral resection) and intravesical therapy with chemotherapeutic (doxorubicin, thiotepa) or immunologic agents (bacillus Calmette-Guerin [BCG]). Trials on chemotherapy after transurethral resection report delays or reductions in recurrence, but some studies lacked controls, used different doses and had confounding factors.

RCTs comparing doxorubicin with thiotepa and BCG found no significant improvements and increased adverse effects. There is mixed evidence from RCTs on the efficacy of thiotepa in reducing recurrence or time to recurrence.

One 1 RCT found that BCG reduced recurrence rates but not survival. There is insufficient evidence regarding quality of life or the long term effects of BCG.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is fair evidence to exclude (from the PHE) routine urine dipstick testing or microscopy for hematuria for the general population [D, I, II-2].
There is poor evidence to include or exclude routine dipstick testing or microscopy for hematuria for persons at high risk (men >60 years of age who smoke or have smoked, are/were employed in a trade that potentially exposes them to aromatic amines) [C, I, II-2].

Validation

This report was externally peer-reviewed. Recommendations and background papers were sent for external peer review.

Selected References

Source Document

Logsetty S. Screening for bladder cancer. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 826-36.

Other

Canadian Task Force of the Periodic Health Examination: the periodic health examination. Can Med Assoc J 1979;121:1193-1254.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

Top of Page

CTFPHC Home Page

A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.