It was with great interest that we read the article concerning the long-term outcome of hematuria home screening for bladder cancer in men by Messing et al. that was published recently in Cancer.1 Although the authors reported useful data concerning bladder cancer natural history knowledge, we would like to add several considerations to their conclusions.
The first objective of a cancer screening program should be the early detection of cancer with a high risk of progression. This is important if a program is to have a significant impact on patient survival and health economy. Currently, we are not able to reach this objective, because urothelial bladder cancers present specific epidemiologic features. Approximately 80% of all newly diagnosed bladder cancers are confined to the epithelium or submucosa, and the recurrence and progression rates are 50% to 70% and 5% to 40%, respectively.2 The most frequently used urinary markers in everyday clinical urologic practice are not able to detect the high risk of progression to bladder cancer, as highlighted well in the report by Messing et al.1 Thus, the detection probability of high-risk urothelial bladder cancer is very low. Therefore, the authors, by using hematuria home screening, reported a detection rate of 1.33% (21 urothelial bladder cancers were detected in 1575 participants) with a detection rate of high risk to progression of 0.57% (there were 9 patients with Ta, T1, and in situ grade 3 tumors reported among 1575 participants).1
The first question is, if we have subjected all participants to urinary cytology, then how many high-risk to progression cancers will be detected? In our unpublished data concerning the impact of hematuria positivity in recurrence detection in a series of 403 patients with urothelial bladder cancer who underwent transurethral resection, we observed that, by using a previously planned and validated artificial neural network (ANN),3 hematuria was not able to add any information to the urinary cytology results. The test identified the hematuria contribution to a mean ± standard deviation ANN output of 11.53 ± 7.79 (expressed as Δ value). These findings support the demonstrated theory that screening for asymptomatic hematuria is not recommended, because its positive predictive value is too low (0.5%) to warrant mass screening and that routine screening for microscopic hematuria may be indicated for populations that are exposed to bladder carcinogens, including heavy smokers.4 In addition, we would stress the finding that the act of screening asymptomatic individuals for cancer may result in health consequences, even in screenees who are not identified as positive.5