Cystoscopy and urine cytology are the gold-standard tests for detection of recurrent disease during follow-up in patients with a history of non–muscle-invasive bladder cancer (NMIBC). High associated costs, as well as side effects, have driven the desire for inexpensive, noninvasive, accurate, and easy-to-use urine markers to detect bladder cancer recurrence. While many urine markers have been developed, very few have been clinically implemented. In this article, we discuss the requirements for development and validation of urine markers and the factors that hamper their clinical implementation. We also review current surveillance guidelines for NMIBC and provide an overview of approved urine markers for the detection and surveillance of NMIBC.
At first diagnosis, approximately 75% of bladder cancer patients present with non–muscle-invasive bladder cancer (NMIBC), with 70% having Ta disease, 20% having T1, and 10% having Tis. All patients initially undergo transurethral resection of the bladder tumor (TURBT) for diagnostic and staging purposes. This allows patients with NMIBC to be stratified into low-, intermediate-, and high-risk groups, based on the probability of recurrence and progression. Whereas the high rate of recurrence (70%) is the key clinical concern in low- and intermediate-risk disease, the fairly high rate of progression to muscle-invasive disease (30%) is the main problem in patients with high-risk NMIBC. Therefore, patients are monitored frequently by urine cytology and cystoscopy, the “gold standard” for detection of bladder cancer recurrence.[3,4]
Side effects and costs associated with surveillance, cytology, and cystoscopy in the setting of bladder cancer have driven the discovery of urine markers to detect recurrences. The ideal marker would be noninvasive and urine-based, would yield results at least as accurate as those obtained with cytology and cystoscopy in patients with low- and intermediate-risk disease, and would make possible earlier detection of recurrence or progression in patients with high-risk disease. The net result would be a reduction in costs, improved compliance and comfort, and reduced rates of advanced disease—which would follow from earlier detection of recurrences in patients with high-risk disease.[5,6] Multiple urine-based tests have been approved by the US Food and Drug Administration (FDA) and are commercially available, yet none have been incorporated as routine into American Urological Association and European Association of Urology clinical guidelines for treatment of bladder cancer.[7-9] In this article, we discuss requirements for development and validation of urine markers, discuss which factors hamper clinical implementation of these markers, and provide an overview of approved urine markers.
The Standard of Care: Current Follow-up Guidelines for NMIBC
Depending on the risk of recurrence and progression determined by the initial workup and pathology, patients are monitored every 3 to 6 months for the first 2 years, with longer follow-up intervals thereafter.[3,4] Table 1 summarizes the published guidelines from major oncology organizations for follow-up in NMIBC. Flexible cystoscopy is invasive, relatively expensive, and associated with some discomfort, triggering reduced compliance with established follow-up regimens.[10,11] In addition, approximately 10% of patients develop a urinary tract infection, and 10% to 20% of tumors are missed by conventional white-light cystoscopy (WLC).[12,13] Recently, in a meta-analysis of 1,345 patients, blue-light (fluorescence) cystoscopy (BLC), which uses a photosensitizer (5-aminolevulinic acid or hexaminolevulinate) instilled in the bladder 1 to 3 hours prior to cystoscopy, showed improved detection of bladder tumors independent of tumor stage (Ta, T1, and Tis), risk category (low, intermediate, and high), and primary or recurrent disease compared with WLC.[14,15] The improved detection rate was most pronounced in Tis tumors (40.8%; odds ratio, 12.4; 95% CI, 6.3–24.1; P < .001), and improved detection and subsequent treatment led to reduction of recurrences at 12 months.
In contrast, BLC has a lower specificity than WLC (63% vs 81%), with false-positive biopsies caused by recent TURBT, the presence of inflammation, or intravesical instillations of bacillus Calmette-Guérin (BCG).[15,16] Most guidelines recommend urine cytology as an adjunct to cystoscopy for follow-up of high-risk patients. Urine cytology lacks sufficient sensitivity for detection of low-grade tumors (27% for G1 tumors, 54% for G2 tumors, and 78% for G3 tumors), and its specificity ranges from 83% to 88%. The utility of both urine cytology and cystoscopy in bladder cancer diagnosis and decision making is dependent upon the type of technique used for urine collection and preparation; the presence of stones, urinary tract infections, and intravesical instillations of chemotherapy or immunotherapy; and whether the sample is reviewed by a general pathologist or specialized genitourinary pathologist.[17-21]
Considerations in Urine Marker Development and Validation
Many urine-based tests have been developed for detection and monitoring of bladder cancer. While some of these have been approved by the FDA, none have been mandated in current guidelines; this is because their value—either as a replacement for cystoscopy and cytology or as providing additional relevant diagnostic information—is unclear.[8,9,18] However, in specific cases clinicians can use fluorescence in situ hybridization (FISH) and/or ImmunoCyt to assess response to immunotherapy with intravesical BCG, to determine which patients should be monitored closely (eg, those with a positive FISH test but negative cystoscopy), or to differentiate between subtypes in patients with high-grade bladder cancer of atypical cytology. We will discuss the characteristics of an ideal urine marker and factors that currently hamper the clinical utility of urine markers.
Characteristics of an ideal urine marker
Use of a particular urine marker in clinical practice will occur if it satisfies the need for “easier, better, faster, and cheaper” means of diagnosing and monitoring bladder cancer. The concept of an “easier” marker relates to its analytical performance and robustness in different clinical settings (ie, both community and academic cancer centers). While academic medical centers generally have the ability to snap-freeze and store human samples, many community hospitals cannot do this. “Better” refers to performance of the new marker that is equal or superior to the current standard of care. “Faster” means that the new biomarker readout should be available in a timely manner. “Cheaper” means that the new marker is more cost-effective than the standard of care, in terms of both direct and downstream costs (ie, costs of false-positive results that lead to unnecessary additional diagnostic testing).
Assessing the performance of urine markers
Clinical context. A urine test should be developed and validated in the specific group of patients in whom it will be used in clinical practice, such as for screening (where the prevalence of bladder cancer is low), diagnosis (in which the prevalence of bladder cancer is higher than that of the screening population), or follow-up (high disease prevalence). The importance of this concept is highlighted by studies demonstrating that test sensitivities were higher in bladder cancer patients with a primary tumor compared with those under surveillance, due to the presence in the former group of larger tumor sizes and malignant tissues of higher stages and grades.[9,23-26] Hence, test sensitivity of a follow-up marker will be overestimated if evaluated in primary tumors, leading to “validation failure” in the surveillance setting. This can also occur when validating a urine marker for follow-up of low/intermediate-grade disease in high-risk patients (larger tumors, more genetic changes).
Cross-sectional vs longitudinal study design. Most studies compare the performance of a new marker with that of the standard of care at a single time point (cross-sectional sensitivity). This is not ideal because many such markers can yield a positive result before the tumor is visible on cystoscopy.[28,29] This “anticipatory” positive test emphasizes the need for a longitudinal analysis that incorporates future recurrences. For example, a large multicenter study to detect recurrences by FGFR3 mutations in patients under surveillance showed a cross-sectional sensitivity of 58% and a high number of false-positive results. Since FGFR3 mutations are tumor-specific, these false positives indicate that tumor cells are present in the urinary tract, and findings must be anticipatory or reflect the presence of an upper tract tumor. A subsequent longitudinal analysis showed testing for FGFR3 mutations to have a sensitivity of 81% when future recurrences were included. It also showed that in the presence of a tumor, urine does not always contain tumor cells, highlighting the need to evaluate multiple samples. A follow-up investigation demonstrated that the sensitivity for detection of recurrence increased with sampled urine volume (pooled urine over 24 hours), suggesting that analysis of multiple urine samples would improve test performance.
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