USPSTF Softens Stance on Bladder Cancer Screening

The U.S. Preventive Services Task Force, or USPSTF, has updated its recommendation related to screening asymptomatic adults for bladder cancer, which is the fourth most common cancer in men, the ninth most common in women and the seventh leading cause of solid cancer-related deaths.

The USPSTF, which recommended against bladder cancer screening in 2004, recently published a new recommendation in the Annals of Internal Medicine that states that evidence is insufficient to assess the balance of benefits and harms of screening asymptomatic adults. After a review by the AAFP Commission on Health of the Public and Science, the Academy has adopted the USPSTF recommendation.

"This should not be interpreted as meaning there is good new evidence that supports screening for bladder cancer," USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., said of the change. "There isn't."

LeFevre, who also is a professor and assistant chair in the department of family and community medicine at the University of Missouri, Columbia, explained that in its recent review of the 2004 recommendation, the task force found no new high-quality evidence related to either the benefits or the harms of screening.

Task force members did raise concerns, however, about the certainty with which the task force had reached its previous recommendation. Moreover, the latest recommendation statement notes that "this time, the USPSTF reviewed mortality statistics and other epidemiologic data that suggested heretofore undemonstrated benefits of screening."

Ultimately, the USPSTF decided to soften its stance from a D recommendation against screening to an I statement.

In USPSTF recommendations overall, a D grade means that the task force recommends against a service, and there is moderate or high certainty that a service has no net benefit or that its harms outweigh the benefits.

An I statement means the USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of a service. In instances in which a recommendation is given an I statement, the task force suggests that physicians read the recommendation's clinical considerations section. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

"We just don't know," said LeFevre of that uncertainty. "This is a genuine I."

Furthermore, said the task force, evidence is inadequate regarding the diagnostic accuracy of tests -- including urinalysis for microscopic hematuria, urine cytology and tests for urine biomarkers -- for identifying bladder cancer in asymptomatic patients with no history of bladder cancer. The task force also found inadequate evidence that screening for bladder cancer or treatment of screen-detected bladder cancer leads to improved outcomes.

"We don't have any studies of treatment of screen-detected bladder cancers," LeFevre noted.

That's an important point, according to LeFevre, because most cancers detected by screening are not biologically the same as those that would be detected without screening.

"Just in general, screening has the tendency to detect much more slow-growing, or more indolent, cancers than would symptomatic discovery," he pointed out.

"It's not, 'What's so hard about urinalysis?'" LeFevre said. "It's about what happens next in terms of diagnostic testing and the side effects of treatment that we've become uncertain about. I don't think anyone would argue that a urine test carries a lot of complications by itself. It's the downstream effect of doing the test in the first place that has some potential for negative effects."

The task force called for new research on the topic in its recommendation.

"It begs for more research so we can determine the benefits and harm," LeFevre said.