**INDICATIONS**  
  
Gross painless hematuria is often the first manifestation of a urothelial
tumor. Since the degree of hematuria bears no relation to the seriousness of
the underlying disease, the microscopic finding of blood in the urine is a
serious symptom until significant pathology has been excluded.  
  
At this time, there is no published consensus from the following national
organizations: National Comprehensive Cancer Network (NCCN), American Society
of Clinical Oncology (ASCO), American Urological Association (AUA) and the
International Bladder Cancer Consensus Group (IBCCG) regarding the management
of persistent asymptomatic microscopic hematuria. Due to insufficient
supporting data, the AUA's 2001 best practices policy could not recommend
routine use of voided urinary markers in the evaluation of patients with
microscopic hematuria.(3)  
  
Recommended surveillance schedules for patients with a previous negative
evaluation for unexplained microscopic hematuria include annual urinalysis and
voided urinary cytology until the hematuria resolves, or for up to three years
if microscopic hematuria persists. The AUA has been silent regarding practice
guidelines due to the paucity of prevalence studies on asymptomatic
microscopic hematuria.  
  
Cystoscopy in conjunction with bladder tumor markers is the standard practice
to evaluate patients with symptoms suggesting bladder cancer and to monitor
treated patients for recurrence or progression. Although cystoscopy is
considered the "gold standard", studies have shown that up to 20% of tumor can
be missed. Urinary cytology has close to a 90%-100% specificity, but only
10%-50% sensitivity for low grade urinary cancer (UC) detection. Due to this
deficit, clinicians have sought noninvasive tumor markers detectable in urine.  
  
Upwards of 50% of patients have recurrence of bladder cancer within five (5)
years.  
  
After initial diagnosis and treatment, patients with UC are frequently
monitored every three months for the first two years, every four months for
the third year, and then usually twice a year for the fourth year. Annual
monitoring is recommended during years 5 through 15.  
  
**Diagnostic and Surveillance Tests**

  * **BTA TRAK ** \- a quantitative determination of human complement factor H-related protein
  * **Nuclear matrix protein 22 (NMP-22 )** - detects nuclear mitotic apparatus protein believed to be released during apoptosis; a quantitative assay, which is either positive of negative
  * **NMP-22  BladderChek** - a CLIA-waved assay, point of care test with an immunochromographic qualitative format taking 20 minutes to perform
  * **The UroVysion ** Bladder Cancer Kit is fluorescence in situ hybridization (FISH) DNA probe technology. It is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus. This assay involves visualization of nucleic acid sequences within cells by creating short sequences of fluorescently labeled, single-strand DNA probes that match target sequences. The probes bind to complementary strands of DNA to identify the targeted chromosome(s) location. It is used to detect chromosomal abnormalities in voided urine to assist not only in bladder cancer surveillance, but also in the initial identification of bladder cancer.

  
Scientific studies demonstrate the sensitivity of BTA and NMP-22 are superior
to urinary cytology.(1) Studies affirm the adjunctive value of BTA stat and
NMP-22 in suspected and known bladder cancer in conjunction with cystoscopy.
However, false positive results occur more frequently in the presence of
hematuria, nephrolithiasis, recent GU instrumentation, inflammation and other
urological malignancies. Administration of Bacillus Calmette-Guerin (BCG)
within 2 years of testing decreases specificity to 28%.  
  
The DNA probe assay has high sensitivity (81%) and specificity (96%) for high
grade tumors but lower sensitivity (36-57%) for low grade and stage tumors.
The assay specificity approaches that of cytology, and can be utilized in
patients recently treated with intravesical BCG. This can result in a positive
UroVysion test with a negative study for UC. This assay has also been shown
to be useful in predicting tumor recurrence following BCG therapy.  
  
At present the IBCCG has recommended that tumor markers be used in conjunction
with cystoscopy. They also concluded that routine screening for bladder cancer
is not cost-effective.(3) The US Preventive Services Task Force concluded
bladder tumor markers do not have a proven role in screening of asymptomatic
patients for early detection of bladder cancer.(3) NCCN, ASCO, and AUA are
silent regarding the utilization of these bladder tumor markers.  
  
 **Surveillance Tests**

  * **BTA (bladder tumor antigen) stat ** \- a qualitative CLIA-waved test that identifies a human complement factor H-related protein produced by several human bladder cell lines
  * **The ImmunoCyt TM** test is cleared for monitoring bladder cancer recurrence only in conjunction with cytology and cystoscopy. The assay uses fluorescent labeled antibodies to 3 markers (carcinoembryonic antigen, and musicians LDQ10 and M344) commonly found on malignant exfoliated urothelial cells. The ImmunoCytTM assay has also been shown to be more sensitive than urine cytology.

  
**LIMITATIONS**  
  
Cystoscopy in conjunction with bladder tumor markers is standard practice to
evaluate patients with symptoms suggesting bladder cancer and to monitor
treated patients for recurrence or progression. Exceptions, such as high grade
bladder cancers s/p radical cystectomy, do exist which preclude cystoscopy
prior to testing. Testing indications, limitations and frequency do not apply
to urine cytology.  
  
Bladder cancer tumor markers performed by any technology, immunoassay,
molecular or FISH testing are not covered for screening of all patients with
hematuria. Bladder tumor markers are not expected to be performed until other
diagnostic studies fail to identify the etiology of the hematuria. Urine
cytology is not considered a bladder tumor marker.  
  
All other bladder cancer marker assays, including but not limited to the
following, regardless of the methodology are considered investigational and
not covered by Medicare:

  * BCLA-4
  * BLCA-1
  * Hyaluronic acid
  * Hyaluronidase
  * Lewis X antigen
  * Microsatellite markers
  * Quanticyt
  * Soluble FAS TATI (tumor associated trypsin inhibitor)
  * Soluble e-cadherin
  * Survivin
  * Telomerase
  * UBCTM Rapid Test (urinary bladder cancer test for cytokeratins 8 and 18)

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