Year : 2011 | Volume
: 27 | Issue : 2 | Page : 161--162
Bladder cancer - When will the paradigm change?
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Nitin S Kekre
Department of Urology, Christian Medical College, Vellore, Tamil Nadu
|How to cite this article:|
Kekre NS. Bladder cancer - When will the paradigm change?.Indian J Urol 2011;27:161-162
|How to cite this URL:|
Kekre NS. Bladder cancer - When will the paradigm change?. Indian J Urol [serial online] 2011 [cited 2019 Dec 13 ];27:161-162
Available from: http://www.indianjurol.com/text.asp?2011/27/2/161/82830
Among the urological cancers, bladder cancer is the most common. The worldwide age standardized incidence rate is 10.1 and 2.5 per 100,000 for men and women, respectively.  Non-invasive bladder cancer accounts for nearly two-third of these cancers, and has a good predictable outcome. The same is unfortunately not true for invasive bladder cancer. Little has changed, as far as the prognosis is concerned, in the last three decades. Disease-specific risk mortality remains at 50%. There is no effective second line therapy, if surgical extirpation leaves behind a microscopic residue. Despite level 1 evidence, there is a reluctance to use neo-adjuvant chemotherapy. Articles on urothelial cancer published with catchy titles like — 'Paradigm change in the management of urothelial cancer' are attractive, but very often offer little or no substantial information.
The few real changes in management strategies have had minimal impact. It appears that Re-TURBT can reduce the risk of recurrence and potential understaging. Intravesical instillation of a single dose of mitomycin post Transurethral Resection of Bladder Tumor (TURBT) appears to be effective in reducing recurrence in low grade Ta disease, with possible reduction in the number of surveillance cystoscopies, ultimately reducing the economic burden. Intravesical Bacillus Calmette-Guérin (BCG)) has become the standard of care for T1 G3, but the debate continues about the dose and duration. Both computed tomography (CT) and magnetic resonance imaging (MRI) have poor sensitivity for lymph node involvement. A controversy continues about the therapeutic implications of extended lymphadenectomy.
In 1968, the World Health Organization published what has become a health classic, 'Principles and practice of screening for disease,' by James Maxwell Glover Wilson and Gunner Jungner.  It has attempted to lay down and elaborate the principles of early disease detection. A screening program needs to be valid, reliable, with good yield, and universally acceptable, with reasonable costs and follow-up services. These criteria have been revisited 40 years later, in the genomic age, by Andermann et al. A fundamental and overriding principle remains, a defined target population and scientific evidence of the effectiveness of the screening program.
Bladder cancer unfortunately does not meet many of these criteria, particularly with respect to quality assurance and access to facilities. The definite benefit of bladder cancer screening has never been proved. Cystoscopy and urinary cytology are the two investigations used for screening. The first is invasive and cytology has poor sensitivity. Population-based screening efforts for bladder cancer cannot, therefore, be recommended at this point in time. Molecular markers, despite the hype and aggressive marketing, have been disappointing and are unlikely to replace cystoscopy in the near future.
Screening efforts for prostate cancer are revealing. Prostate-specific antigen levels as a screening tool for prostate cancer have not fulfilled the desired dream. Recent evidence does not support the routine use of screening for prostate cancer with prostate-specific antigen, with or without digital rectal examination. The screening for breast cancer too remains controversial.  Just because a 'PSA mistake' has been made, we must not embark upon another one.
How does one address the issue of screening in bladder cancer? The obvious answer is to initially implement a screening program in a very well-defined, well-selected population, who have proven to be at high risk of developing bladder cancer. Such an attempt has been reported by Zlotta et al. They followed a cohort of 48 patients exposed to aristolochic acid. Forty-three had biannual cystoscopies for a period of 10 years; starting five years after the initial exposure. Bladder cancer was detected in 25 / 48 patients. The population screened were detected with non-muscle invasive disease, but none died of bladder cancer. All three patients who refused screening were diagnosed, and died with advanced metastatic disease.
We need sound basic research to improve detection and treatment strategies, to help patients with bladder cancer. Availability of technology and promotion by the industry is likely to create pressure to introduce screening programs, without adequate evidence or safeguards, and even before the regulatory frameworks are in place. This must be resisted. The words of Wilson and Jungner remain relevant even today, 'in theory, screening is an admirable method of combating disease, in practice, there are snags'.
The money would be better spent in this country if we educate fellow physicians that macro or microscopic hematuria needs prompt evaluation by a urologist and not multiple courses of antibiotics. Refractory storage symptoms in the elderly must raise a suspicion of urothelial cancer. Education of the general public, to not ignore even a single episode of hematuria and that tobacco consumption in any form is harmful and can lead to bladder cancer, is imperative. And last but not the least, the urologists must adhere to a standard plan of management .This issue's symposium on bladder cancer is guest edited by one of the giants in this field - Prof. Mark Soloway. I am sure all will find it informative and would help toward a policy of uniform management. I thank him and his team for an informative symposium.
With best wishes.
|1||Ploeg M, Aben KK, Kiemeney LA. The present and future burden of urinary bladder cancer in the world. World J Urol 2009;27:289-93.|
|2||Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva: WHO; 1968. Available from: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf [Last accessed on 2011 Jun 02].|
|3||Andermann A, Blancquaert I, Beauchamp S, Déry V. Revisiting Wilson and Jungner in the genomic age: A review of screening criteria over the past 40 years. Bull World Health Organ 2008;86:317-9.|
|4||Djulbegovic M, Beyth RJ, Neuberger MM, Stoffs TL, Vieweg J, Djulbegovic B, et al. Screening for prostate cancer: Systematic review and meta-analysis of randomised controlled trials. BMJ 2010;341:c4543. |
|5||U.S. Preventive Services Task Force (USPSTF) recommendations on breast cancer screening. Available from: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. [Last accessed on 2011 June 25].|
|6||Zlotta AR, Roumeguere T, Kuk C, Alkhateeb S, Rorive S, Lemy A, et al. Select screening in a specific high-risk population of patients suggests a stage migration toward detection of non-muscle-invasive bladder cancer. Eur Urol 2011;59:1026-31.|