There is no program for bladder cancer screening. Studies have shown that detection rates on testing a healthy population are extremely low, and therein no consistent advantage is achieved. However, it is evident that ignoring bladder symptoms, particularly visible blood in the urine, can lead to delays in cancer diagnosis; and consequent delays in treatment are associated with worse treatment outcomes. Bladder cancer outcomes can be be less good in women, though the reasons for this are not entirely clear; it is very important therefore to not ignore symptoms or misattribute them to other causes such as urinary infection or menopause.
Bladder cancer is found in around 20% of people presenting with blood in the urine – usually visible blood, but also microscopic blood in those over 50 years of age. The diagnosis of bladder cancer is usually first suspected on examination of the bladder by cystoscopy, though tumours can be evident on radiological imaging tests. Sometimes, bladder cancer can be suspected with specific urinary tests, but these do not replace the need for cystoscopy. After bladder cancer has been treated, where the bladder is left in place, new tumours may develop in the future, and regular cystoscopy checks are usually necessary.
Prostate cancer screening is available on request, however careful consideration beforehand is advised, as it is not always or necessarily beneficial (link Principles of Screening). It may be considered in men over the age of 50 years, or younger if the individual is potentially at increased risk on a genetic or ethnic basis or positive family history. Prostate cancer tends to grow slowly, and without specific symptoms in the early stage. Screening aims to detect the not-so aggressive cancers that might be cured by early treatment; the aggressive cancers tend to spread beyond the prostate very quickly even microscopically before they are diagnosed. There is also a converse problem, particularly for older men, that many prostate cancers are not sufficiently life-threatening for there to be any absolute survival benefit within a 10 year period, which has been borne out in clinical trials, and beyond that the advantage may be confined to a very small proportion of treated men, perhaps fewer than 5%. The symptomatic and therapeutic merits of early cure need to be considered in relation to treatment related side effects and overall quality of life.
There is no formal program to screen for kidney cancer. However, blood in the urine should be investigated with tests that include radiological examination of the kidneys by which most renal cancers will be identified. Increasingly in recent years, small kidney tumours are found as an incidental finding on radiological investigations for unrelated reasons, before there are any kidney symptoms. Again, it is important not to ignore blood in the urine so that the cause can be identified early.
Men should examine the testes periodically, and once a month is generally recommended. Testis cancer most frequently develops after puberty, between the age of 20 and 50 years. The risk of testis cancer is increased if one testis failed to develop or descend normally. When it develops, testis cancer tends to grow, and spread, rapidly. A change in size or swelling on a testis should be investigated urgently, as delay in diagnosis of testis cancer can be very significant in adversely affecting outcome after treatment.
Cancer is often more treatable when detected early. Tumours may grow to a significant size before they declare themselves with symptoms, and by that stage they may have invaded adjacent tissues or sometimes spread. The spread of cancerous cells makes the possibility of cure less likely. For these reasons, screening – that is, testing for disease before it becomes symptomatic – may appear worthwhile, but as a strategy it needs careful consideration of some important underlying assumptions.
Real life situations need to take account all of the medical factors that may be relevant and individual circumstances before the value of an intervention can be appreciated. Some tumours may not be actually life-threatening; some tumours can be multiple at diagnosis; sometimes after successful treatment of early tumours, an affected organ may develop further new tumours; other factors define whether cure is beneficial or necessary in the context of age and other medical conditions.
There are clearly situations where there is the need for medical investigations and treatment – for instance when there is pain or discomfort, bleeding or failure of a normal body function. It could never be recommended to ignore those types of symptoms, as they need to be relieved by treatment after proper medical assessment. Identifying the same underlying causes early by testing people with no indication of any underlying health problems can raise difficult questions, as the outcome may not be universally beneficial.
For screening to actually be of benefit, treatment of early stage cancer must be effective and acceptable in terms of outcome, taking account side effects and possible complications. Also, before considering screening, there should be evidence of benefit in testing for the disease and treating it, compared to its “natural” presentation. There have been a considerable number of studies on screening for urological conditions, and while it may have a place, cure is not thereby assured for everyone having early treatment. It is probably more important to know that delay in investigating abnormal symptoms or investigation findings can have a significant negative impact on treatment outcomes.
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