52 96
Point
of
Focus Debate:
Against
Smoking
Status
Is
Not
Sufficient
to
Accurately
Target
Patients
Who Would
Benefit
from
Screening
for
Bladder
and Kidney
Cancer
Morgan
Roupreˆt
*Academic Urology Department,
Pitie´-Salpe´trie`re Hospital,
Assistance
Publique
- Hopitaux
de
Paris, Universiy
Pierre
and Marie
Curie,
Paris,
France
Screening
is
a
strategy
used
to
detect
disease within
an
asymptomatic population. The underlying hypothesis
is
that
asymptomatic
disease
detection
leads
to
earlier
staged
disease
(stage migration)
and
better
outcomes
from
treat-
ment. However,
the
disease
needs
to
be
common
or
severe
enough
to warrant
detection, must
have
a
known
natural
history
for which earlier
treatment
improves outcomes, and
the detection method
(test) must be
accurate,
safe,
reliable,
and
cost
effective.
Screening
programmes
have
yet
to
be
implemented
for
two major diseases
in
the
field of urologic
oncology
and
should
be
considered:
bladder
cancer
(BCa)
and
renal
cell
carcinoma
(RCC).
Both
cancers
have
a
poor
outcome
when
advanced,
are
extremely
expensive
to
manage, and many patients present with metastatic disease
[1] .However,
the
background
prevalence
rates
for
both
cancers
is
low; BCa
is
the sixth most common cancer overall,
with
an
estimated
72
570
new
cases
and
15
210
deaths
in
2013
in
the United
States
[1,2].
RCC
represents
2–3%
of
all
cancers, with
an
age-standardised
rate
incidence
of 5.8
and
mortality
of 1.4 per 100 000
in Western nations
[1,3] .BCa
screening
in
the
general
population
has
been
evaluated
(reviewed
by
Chou
and Dana
[4]and
Larre
et
al.
[5] ). However, partly because of
the
low overall
incidence of
BCa,
screening
is
currently
not
recommended
in
routine
practice.
For
RCC,
>
50%
of
tumours
are
detected
inciden-
tally
when
noninvasive
imaging
is
used
to
investigate
nonspecific
symptoms
or
other
diseases.
Because
advanced
disease at diagnosis
is now
rare
[1,3] ,there are no published
data
or
screening
recommendations
for
RCC
in
the
general
population.
Although
general
population-based
screening
for
BCa
and
RCC
seems
illogical,
targeted
screening
of
high-risk
populations makes
clinical
and
economic
sense. However,
as
often
the
case,
the
devil
is
in
the
details.
How
do
we
define
these
high-risk
populations
(beyond
familial
syn-
dromes
[3] ),
and what
test do we
screen with? The
answer
may
be
smokers.
Cigarette
smoking
is
the
best
established
risk
factor
for
BCa,
with
a
relative
risk
of
1.5–3
in
past
smokers
and
a
relative
risk
(RR)
of
4–5
in
active
smokers
[6] .Cigarette
smoking
is also
the best established
risk
factor
for RCC
(RR:
1.25–1.55)
[7].
In
a
previous
report,
the
most
efficient
screening
tool
for
BCa was
the
combination
of
UroVysion
(Abbott
Molecular,
Des
Plaines,
IL,
USA),
cytology,
and
urinary
dipstick
testing
[8].
Screening
a
high-risk
group
with
a
history
of
smoking
of
40
pack-years
revealed
a
significant proportion
(3.3%)
of
individuals with malignan-
cy.
Lotan
et
al.
used
the
NMP22
BladderChek
(Alere,
Waltham, MA,
USA)
to
screen
an
asymptomatic
high-risk
population.
BladderChek
can
detect
noninvasive
cancers,
but
the
low
prevalence
of
BCa
in
this
population
did
not
permit
the
assessment
of
intervention
efficacy
(ie,
the
incidence
of BCa was
0.13%)
[9] .In
a
recent
screening
trial,
the optimal high-risk population most
likely
to benefit
from
screening was men
aged
>
60
yr with
a
smoking
history
of
>
30
pack-years;
this
group
had
incidence
rates
>
2
in
1000 person-years
[10]. Consequently, a
screening
strategy
for
BCa,
particularly
in
smokers,
has
been
previously
used
without
any
convincing
data.
No
such
data
are
available
for
RCC.
E U R O P E A N U R O L O G Y F O C U S 1 ( 2 0 1 5 ) 5 2 – 5 3available
at
www.sciencedirect.comjournal
homepage:
www.europeanurology.com* Corresponding
author.
Academic Urology Department, Hoˆpital
Pitie´,
47-83
blvd
de
l’Hoˆpital,
75013
Paris,
France.
address:
morgan.roupret@psl.aphp.fr.
http://dx.doi.org/10.1016/j.euf.2014.12.0062405-4569/
#
2015
European
Association
of Urology.
Published
by
Elsevier
B.V.
All
rights
reserved.