Chapter 6: Genitourinary Disorders

BLADDER CANCER

Population

• –Asymptomatic persons.

Recommendation

AAFP 2011, USPSTF 2016

• –Do not screen routinely for bladder cancer (CA) in adults.

Sources

• –http://www.aafp.org/online/en/home/clinical/exam.html

• –http://www.ahrq.gov/clinic/uspstf/uspsblad.htm

• –http://www.cancer.gov

Comments

1. Benefits and Harms

   1. There is inadequate evidence to determine whether screening for bladder CA would have any impact on mortality. Based on fair evidence, screening for bladder CA would result in unnecessary diagnostic procedures and overdiagnosis (70% of bladder CA is in situ) with attendant morbidity. (NCI, 2017)

2. Clinical Awareness

   1. Urinary biomarkers (nuclear matrix protein 22, tumor-associated antigen p300, presence of DNA ploidy) do not have significant sensitivity or specificity to be utilized in clinical practice. Microscopic hematuria leads to a diagnosis of bladder CA in only 5% of patients.

   2. Seventy-nine thousand cases of bladder CA are expected in 2017 in the United States, with the majority being noninvasive (70%), but still 16,900 Americans are expected to die of bladder CA in 2017. (Ann Inter Med. 2010;153:461) (Eur Urol. 2013;63:4)

   3. A high index of suspicion should be maintained in anyone with a history of smoking (4- to 7-fold increased risk^a), an exposure to industrial toxins (aromatic amines, benzene), therapeutic pelvic radiation, cyclophosphamide chemotherapy, a history of Schistosoma haematobium cystitis, hereditary nonpolyposis colon CA (Lynch syndrome), and history of transitional cell carcinoma of ureter (50% risk of subsequent bladder CA). Large screening studies in these high-risk populations have not been performed.

   4. Voided urine cytology with sensitivity of 40% but only 10% positive predictive value, urinary biomarkers (nuclear matrix protein 22, telomerase) with suboptimal sensitivity and specificity. Screening for microscopic hematuria has <10% positive predictive value.

CERVICAL CANCER

Population

• –Women age <21 y.

Recommendation

ACS 2017, USPSTF 2015, ACOG 2016

• –Do not screen for cervical cancer.

Population

• –Women age 21–29 y.

Recommendations

ACS 2017, USPSTF 2018, ACOG 2016

• –Cytology alone (PAP smear) every 3 y until age 30 y.

• –Do not use human papillomavirus (HPV) DNA testing in ...