0
Clinical Guidelines |

Screening for Bladder Cancer: U.S. Preventive Services Task Force Recommendation Statement FREE

Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force
[+] Article and Author Information

For a list of the members of the USPSTF, see the Appendix.


From the U.S. Preventive Services Task Force, Rockville, Maryland.


Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Financial Support: The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1530.

Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.uspreventiveservicestaskforce.org).


Ann Intern Med. 2011;155(4):246-251. doi:10.7326/0003-4819-155-4-201108160-00008
Text Size: A A A

This article has been corrected. For original version, click "Original Version (PDF)" in column 2.

Description: Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for bladder cancer.

Methods: The USPSTF performed a targeted literature search for new evidence on the benefits and harms of screening, the accuracy of primary care–feasible screening tests, and the benefits and harms of treatment.

Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults (I statement).

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.

It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.

The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults (I statement).

See the Clinical Considerations section for additional information and suggestions for practice regarding the I statement for screening.

See the Figure for a summary of the recommendation and suggestions for clinical practice.

Grahic Jump Location
Figure.
Screening for bladder cancer: clinical summary of U.S. Preventive Services Task Force recommendation.

For a summary of the evidence systemically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.uspreventiveservicestaskforce.org/.

Grahic Jump Location

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit.

Table Jump PlaceholderTable 1.  What the USPSTF Grades Mean and Suggestions for Practice
Table Jump PlaceholderTable 2.  USPSTF Levels of Certainty Regarding Net Benefit
Importance

Bladder cancer is the fourth most commonly diagnosed cancer in men and the ninth most commonly diagnosed cancer in women in the United States. It is the seventh-leading cause of solid cancer–related deaths. An estimated 70 980 new cases of bladder cancer were diagnosed in the United States during 2009 (52 810 cases in men and 18 170 cases in women), and approximately 14 330 people died of the disease (10 180 men and 4150 women). More than 90% of all cases of bladder cancer are classified as transitional cell carcinomas. Most newly diagnosed transitional cell carcinomas present as superficial tumors. The stages of bladder cancer include superficial (Ta or T1) and muscle-invasive tumors. Many superficial tumors (50% to 70%) will recur after treatment, with a 10% to 20% risk for the tumor to progress to the invasive stage. One fourth of all cases of bladder cancer and 20% to 40% of all invasive tumors have already metastasized to the lymph nodes at the time of diagnosis. Invasive bladder cancer is associated with a poor prognosis.

Detection

The evidence is inadequate regarding the diagnostic accuracy of potential tests (urinalysis for microscopic hematuria, urine cytology, or tests for urine biomarkers) for identifying bladder cancer in asymptomatic persons with no history of bladder cancer.

Benefits of Detection and Early Intervention

The USPSTF found inadequate evidence that screening for bladder cancer or treatment of screen-detected bladder cancer leads to improved disease-specific or overall morbidity or mortality.

Harms of Detection and Early Intervention

Screening may yield false-positive results. False-positive results may lead to anxiety, labeling, pain, and additional complications that result from diagnostic cystoscopy and biopsy (such as bladder perforation, bleeding, and infection) or imaging. The USPSTF found inadequate evidence on the harms of screening for bladder cancer. Evidence on the harms associated with early treatment, which may occur more frequently with greater detection of cases of early-stage cancer, is also inadequate.

USPSTF Assessment

The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening for bladder cancer in asymptomatic adults.

Patient Population Under Consideration

This recommendation applies to asymptomatic adults. Although adults with mild lower urinary tract symptoms (such as urinary frequency, hesitancy, urgency, dysuria, or nocturia) are not strictly asymptomatic, these symptoms are quite common and are not believed to be associated with an increased risk for bladder cancer. The USPSTF considered it reasonable to include these persons in the population under consideration for screening. Adults with gross hematuria or acute changes in lower urinary tract symptoms are not included in this population.

Screening Tests

Primary care–feasible screening tests for bladder cancer include identifying hematuria with a urine dipstick or microscopic urinalysis, urine cytology, and tests for urine biomarkers.

Treatment

Once bladder cancer has been diagnosed, several factors determine treatment, including tumor grade, cancer stage (superficial vs. invasive), whether the tumor is recurrent, the patient's age and overall health status, and patient and physician preferences. The principal treatment for superficial (Ta or T1) bladder cancer is transurethral resection of the bladder tumor, which may be combined with adjuvant radiation therapy, intravesical chemotherapy, immunotherapy, or photodynamic therapies. Radical cystectomy, often with adjuvant or neoadjuvant systemic chemotherapy, is used in cases of surgically resectable invasive bladder cancer.

Suggestions for Practice Regarding the I Statement

In deciding whether to screen for bladder cancer, clinicians should consider the following.

Potential Preventable Burden

Bladder cancer is similar to many other types of cancer in that it is a heterogeneous condition. Approximately 70% of all cases of newly diagnosed transitional cell carcinomas present as superficial tumors (including in situ); some of these tumors may never progress to advanced disease. However, some cases of bladder cancer invade the muscle tissue, progress, and metastasize; treatment has limited efficacy in these cases. Early detection of tumors with malignant potential may have an important effect on the mortality rate of bladder cancer. One challenge of screening for bladder cancer is accurately identifying cases of early-stage cancer (subepithelial and in situ) with a high risk for progression. Another area of uncertainty is determining whether providing earlier, less toxic treatment (such as immunotherapy) with the intention of preventing symptomatic progression results in fewer overall harms to the patient than providing more toxic treatment (such as radical cystectomy) only to those patients who develop symptomatic or advanced tumors. Persons at increased risk for bladder cancer include those who work in the rubber, chemical, or leather industries, as well as those who smoke, are male, are older, or have a family or personal history of bladder cancer.

Potential Harms

False-positive test results may result in anxiety and unneeded evaluations, diagnostic-related harms from cystoscopy and biopsy, harms from labeling or unnecessary treatments (such as transurethral resection of a bladder tumor, intravesical chemotherapy, or biologic therapies), and overdiagnosis.

Current Practice

Screening tests feasible for use in primary care include urine dipstick or microscopic urinalysis for hematuria, urine cytology, and tests for urine biomarkers. Tests for urine biomarkers are not commonly used in primary care in part because of their cost, although this varies substantially. Patients with positive screening results are typically referred to a urologist for further evaluation, which may include cystoscopy (and biopsy if a tumor is found), imaging, and other studies.

Research Needs and Gaps

Several gaps in the evidence led the USPSTF to issue an I statement. Addressing these research needs could potentially provide sufficient evidence for the USPSTF to issue future screening recommendations. Cohort studies are needed to evaluate the natural history of early-stage, untreated bladder cancer (particularly that detected by screening) to allow a greater understanding of the potential overdiagnosis and overtreatment associated with screen-detected bladder cancer. Studies that compare the diagnostic accuracy of urine screening tests in representative populations are needed, as well as studies that assess the effect of screening on the incidence of bladder cancer, tumor characteristics, and subsequent treatments. Randomized, controlled trials or well-designed case–control studies that evaluate clinical outcomes in screened versus unscreened populations, which would provide direct evidence on benefits and harms of screening, have highest priority. Targeting populations at increased risk for bladder cancer because of patient characteristics or occupational exposure may be preferred to enhance feasibility and maximize clinical relevance. A better understanding of the harms related to screening and treatment are required. Methods for evaluating these harms could include conducting observational studies based on patient registries or large pharmacoepidemiologic databases. As noted, prospective cohort studies are needed to more accurately identify cases of early-stage cancer (subepithelial and in situ) with a high risk for progression. Future research should also clarify the trade-offs of using less-toxic treatments earlier and more frequently, to prevent symptomatic progression, versus using treatments with greater toxicity, which are typically reserved for those patients who develop symptomatic or advanced tumors.

Burden of Disease

The incidence of bladder cancer in the United States is approximately 21 cases per 100 000 persons or 0.02%. It is the seventh-leading cause of death due to solid cancer in the United States. In 2009, an estimated 70 980 new cases of bladder cancer were diagnosed, and approximately 14 330 people died of the disease. In comparison, in 2009 there were an estimated 219 440 new cases of lung cancer and 159 390 deaths, 146 970 new cases of colorectal cancer and 49 920 deaths, 192 280 new cases of prostate cancer and 27 360 deaths, and 11 270 new cases of cervical cancer and 4070 deaths (1).

Bladder cancer is a heterogeneous condition with a variable natural history. It also has a relatively low mortality rate relative to the incidence of new cases. As a result, risk for overdiagnosis and overtreatment is a major issue in bladder cancer screening. Thus, it is important to identify superficial tumors that are at high risk for progression and target treatment at an earlier, more treatable stage in persons with such tumors, while minimizing unnecessary treatments in those unlikely to have disease-specific morbidity or mortality (1).

Persons at increased risk for bladder cancer include those who smoke or have occupational exposure to carcinogens, such as those who work in the rubber, chemical, or leather industries. Other risk factors for bladder cancer include male sex, older age, white race, infections caused by certain bladder parasites, and a family or personal history of bladder cancer (1).

Scope of Review

To update its 2004 recommendation on screening for bladder cancer in asymptomatic persons (2), the USPSTF reviewed the current state of the evidence and identified new evidence that addresses previously identified gaps. The USPSTF reviewed new evidence on the benefits and harms of screening, the accuracy of primary care–feasible screening tests, and the benefits and harms of treatment.

Accuracy of Screening Tests

Primary care–feasible screening tests for bladder cancer include urinalysis for hematuria, urinary cytology, and tests for other urine biomarkers. No evidence was found regarding the diagnostic accuracy of screening tests in asymptomatic persons (3).

Effectiveness of Detection and Treatment

The USPSTF found no direct evidence that bladder cancer screening is associated with improved health outcomes compared with no screening. The USPSTF could not evaluate the effectiveness of treatments for screen-detected bladder cancer because of a lack of studies that compare clinical outcomes associated with treatment versus no treatment (3).

Potential Harms of Detection and Treatment

The USPSTF found inadequate evidence on the harms associated with bladder cancer screening. In screening studies, the positive predictive value of various tests was less than 10%, which suggests a significant burden of unnecessary follow-up procedures and associated harms (3). However, the USPSTF found no reliable data with which to estimate the incremental harms associated with screening for bladder cancer compared with no screening, or the harms associated with treatment of screen-detected bladder cancer versus no treatment.

Potential harms of screening for bladder cancer include false-positive test results and unnecessary subsequent diagnostic procedures, as well as earlier initiation of routine surveillance. Follow-up of positive screening results typically includes cystoscopy and may include imaging studies. Potential harms include anxiety, labeling, discomfort or pain related to cystoscopy, and complications related to cystoscopy and biopsy (such as perforation, bleeding, or infection) or imaging (such as adverse effects related to the use of intravenous contrast) (47).

In lower-prevalence populations, more patients are potentially exposed to unnecessary harms because of a higher rate of false-positive results than in higher-prevalence populations.

One large, uncontrolled observational study of 2821 patients (8) reported bleeding and perforation in 2.8% and 1.3%, respectively, of patients who underwent transurethral resection of a bladder tumor. However, the incremental harms that may have occurred because of screening cannot be estimated from the data. As noted, the risk for overdiagnosis and overtreatment is substantial because of the relatively low mortality rate. Thus, it is important to assess the harms related to overtreating screen-detected bladder cancer that is unlikely to progress to death or disability.

Estimate of Magnitude of Net Benefit

The USPSTF found inadequate evidence on the diagnostic accuracy of screening tests for bladder cancer. The USPSTF also found inadequate evidence on the effectiveness of treatment and the harms of screening or treatment. Therefore, the USPSTF concluded that the evidence on the benefits and harms of screening is lacking.

Response to Public Comments

A draft of this recommendation statement was posted for public comment on the USPSTF Web site from 30 November 2010 to 28 December 2010. Six comments were received from individuals or organizations. All comments were reviewed during the creation of this final document. Specifically, input from clinical specialists led to changes in the description of treatments. In general, the comments supported the USPSTF's specified research agenda.

In 2004, the USPSTF recommended against routine screening for bladder cancer in adults because the USPSTF concluded that the harms outweighed the benefits of screening (D recommendation) (2). In 2009, the USPSTF performed a targeted literature review and found insufficient evidence to assess the benefits and harms of screening for bladder cancer. In 2004, the USPSTF concluded that the harms outweighed the benefits; however, this time the USPSTF reviewed mortality statistics and other epidemiologic data that suggested heretofore undemonstrated benefits of screening. As a result, the USPSTF changed its recommendation from a D to an I statement (insufficient evidence).

No major organization recommends screening for bladder cancer in asymptomatic adults. In 2011, the American Academy of Family Physicians endorsed the USPSTF recommendation (9). The European Association of Urology states that the best approach to primary prevention of muscle-invasive bladder cancer is to eliminate active and passive smoking (10). The American Cancer Society states that prompt attention to bladder symptoms is the best approach for finding bladder cancer in its earliest, most treatable stages in persons with no known risk factors (11).

Chou R, Dana T.  Screening Adults for Bladder Cancer: Update of the 2004 Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 78. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
 
U.S. Preventive Services Task Force.  Screening for Bladder Cancer: Brief Evidence Update. Rockville, MD: Agency for Healthcare Research and Quality; 2004.
 
Chou R, Dana T.  Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010; 153:461-8.
PubMed
 
Aaronson DS, Walsh TJ, Smith JF, Davies BJ, Hsieh MH, Konety BR.  Meta-analysis: does lidocaine gel before flexible cystoscopy provide pain relief? BJU Int. 2009; 104:506-9.
PubMed
CrossRef
 
Burke DM, Shackley DC, O'Reilly PH.  The community-based morbidity of flexible cystoscopy. BJU Int. 2002; 89:347-9.
PubMed
 
Stav K, Leibovici D, Goren E, Livshitz A, Siegel YI, Lindner A. et al.  Adverse effects of cystoscopy and its impact on patients' quality of life and sexual performance. Isr Med Assoc J. 2004; 6:474-8.
PubMed
 
Turan H, Balci U, Erdinc FS, Tulek N, Germiyanoglu C.  Bacteriuria, pyuria and bacteremia frequency following outpatient cystoscopy. Int J Urol. 2006; 13:25-8.
PubMed
 
Collado A, Chéchile GE, Salvador J, Vicente J.  Early complications of endoscopic treatment for superficial bladder tumors. J Urol. 2000; 164:1529-32.
PubMed
 
American Academy of Family Physicians.  Recommendations for Clinical Preventive Services: Bladder Cancer, Adults. Leawood, KS: American Academy of Family Physicians; 2011. Accessed atwww.aafp.org/online/en/home/clinical/exam/bladdercancer.htmlon 30 June 2011.
 
Stenzl A, Cowan NC, De Santis M, Jakse G, Kuczyk MA, Merseburger AS. et al.  The updated EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol. 2009; 55:815-25.
PubMed
 
American Cancer Society.  Bladder Cancer. Atlanta: American Cancer Society; 2010. Accessed atwww.cancer.org/Cancer/BladderCancer/DetailedGuide/bladder-cancer-detectionon 30 June 2011.
 
Appendix: U.S. Preventive Services Task Force

Members of the U.S. Preventive Services Task Force† at the time this recommendation was finalized are Virginia A. Moyer, MD, MPH, Chair (Baylor College of Medicine, Houston, Texas); Michael L. LeFevre, MD, MSPH, Co-Vice Chair (University of Missouri School of Medicine, Columbia, Missouri); Albert L. Siu, MD, MSPH, Co-Vice Chair (Mount Sinai School of Medicine, New York, New York); Kirsten Bibbins-Domingo, PhD, MD (University of California, San Francisco, California); Susan Curry, PhD (University of Iowa College of Public Health, Iowa City, Iowa); Glenn Flores, MD (University of Texas Southwestern, Dallas, Texas); Adelita Gonzales Cantu, RN, PhD (University of Texas Health Science Center, San Antonio, Texas); David C. Grossman, MD, MPH (Group Health Cooperative, Seattle, Washington); George Isham, MD, MS (HealthPartners, Minneapolis, Minnesota); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York); Joy Melnikow, MD, MPH (University of California Davis Medical Center, Sacramento, California); Bernadette Melnyk, PhD, RN (Arizona State University College of Nursing and Healthcare Innovation, Phoenix, Arizona); Wanda Nicholson, MD, MPH (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Carolina Reyes, MD (University of Southern California, Los Angeles, California); J. Sanford Schwartz, MD (University of Pennsylvania Medical School and the Wharton School, Philadelphia, Pennsylvania); and Timothy Wilt, MD, MPH (University of Minnesota Department of Medicine and Minneapolis Veteran Affairs Medical Center, Minneapolis, Minnesota). Previous Task Force members who also made significant contributions to this recommendation are Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio) and Diana B. Petitti, MD, MPH (Arizona State University, Phoenix, Arizona).

† For a list of current Task Force members, go to www.uspreventiveservicestaskforce.org/about.htm.

Figures

Grahic Jump Location
Figure.
Screening for bladder cancer: clinical summary of U.S. Preventive Services Task Force recommendation.

For a summary of the evidence systemically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.uspreventiveservicestaskforce.org/.

Grahic Jump Location

Tables

Table Jump PlaceholderTable 1.  What the USPSTF Grades Mean and Suggestions for Practice
Table Jump PlaceholderTable 2.  USPSTF Levels of Certainty Regarding Net Benefit

References

Chou R, Dana T.  Screening Adults for Bladder Cancer: Update of the 2004 Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 78. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
 
U.S. Preventive Services Task Force.  Screening for Bladder Cancer: Brief Evidence Update. Rockville, MD: Agency for Healthcare Research and Quality; 2004.
 
Chou R, Dana T.  Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010; 153:461-8.
PubMed
 
Aaronson DS, Walsh TJ, Smith JF, Davies BJ, Hsieh MH, Konety BR.  Meta-analysis: does lidocaine gel before flexible cystoscopy provide pain relief? BJU Int. 2009; 104:506-9.
PubMed
CrossRef
 
Burke DM, Shackley DC, O'Reilly PH.  The community-based morbidity of flexible cystoscopy. BJU Int. 2002; 89:347-9.
PubMed
 
Stav K, Leibovici D, Goren E, Livshitz A, Siegel YI, Lindner A. et al.  Adverse effects of cystoscopy and its impact on patients' quality of life and sexual performance. Isr Med Assoc J. 2004; 6:474-8.
PubMed
 
Turan H, Balci U, Erdinc FS, Tulek N, Germiyanoglu C.  Bacteriuria, pyuria and bacteremia frequency following outpatient cystoscopy. Int J Urol. 2006; 13:25-8.
PubMed
 
Collado A, Chéchile GE, Salvador J, Vicente J.  Early complications of endoscopic treatment for superficial bladder tumors. J Urol. 2000; 164:1529-32.
PubMed
 
American Academy of Family Physicians.  Recommendations for Clinical Preventive Services: Bladder Cancer, Adults. Leawood, KS: American Academy of Family Physicians; 2011. Accessed atwww.aafp.org/online/en/home/clinical/exam/bladdercancer.htmlon 30 June 2011.
 
Stenzl A, Cowan NC, De Santis M, Jakse G, Kuczyk MA, Merseburger AS. et al.  The updated EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol. 2009; 55:815-25.
PubMed
 
American Cancer Society.  Bladder Cancer. Atlanta: American Cancer Society; 2010. Accessed atwww.cancer.org/Cancer/BladderCancer/DetailedGuide/bladder-cancer-detectionon 30 June 2011.
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Screening for Bladder Cancer: U.S. Preventive Services Task Force Recommendation Statement
Posted on August 31, 2011
Christopher C.K. Ho
Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre
Conflict of Interest: None Declared

TO THE EDITOR:

I read with interest the article by the U.S . Preventive Services Task Force (USPSTF) recommendation on screening for bladder cancer (1). In this article, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults. This is not encouraging for the following reasons.

About 70-75% of bladder cancers are non-muscle invasive (Ta/T1) while 25-30% are muscle invasive (T2 and higher) at presentation. Out of this, 20-40% of the non-muscle invasive bladder cancers progress to muscle invasion. The 10-year disease-free survival of muscle-invasive disease is 50-60% (2). Therefore, early detection is extremely important to improve the prognosis of bladder cancer. Messing et al. has also shown that screened group has better survival than that among individuals diagnosed with symptomatic bladder cancer (3).

Furthermore, bladder cancer has a fairly short potential lead time. In other words, the interval between diagnosing it because of screening and diagnosing when it is symptomatic is very brief. Therefore, it can be argued that patients in whom bladder cancer is detected through screening would not undergo any unnecessary tests or treatments, only earlier ones (4).

Khochikar (5) very aptly stated that early detection and screening of bladder cancer is needed as delay in the diagnosis and treatment does alter the overall outcome. Indeed, there is a role of screening for bladder cancers especially those in the high-risk group. We should not deprive our patients of the rights to be screened since the incidence of bladder cancer is increasing globally.

This should be a challenge to researchers to carry out more robust studies as concrete recommendation is needed to address this issue.

References

1.Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for Bladder Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2011;155(4):246-251.

2.Thalmann GN, Stein JP. Outcomes of radical cystectomy. BJU Int. 2008;102:1279-88

3.Messing EM, Madeb R, Young T, Gilchrist KW, Bram L, Greenberg EB, et al. Long term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-9.

4.Goldstein MM, Messing EM. Prostate and Bladder Cancer Screening. J Am Coll Surg. 1998;186(1): 63-74.

5.Khochikar MV. Rationale for an early detection program for bladder cancer. Indian J Urol. 2011;27(2):218-25.

Conflict of Interest:

None declared

Submit a Comment

Supplements

Supplemental Content
Original Version

Summary for Patients

Screening for Bladder Cancer: Recommendations from the U.S. Preventive Services Task Force

The full report is titled “Screening for Bladder Cancer: U.S. Preventive Services Task Force Recommendation Statement.” It is in the 16 August 2011 issue of Annals of Internal Medicine (volume 155, pages 246-251). The author is the U.S. Preventive Services Task Force.

Read More...

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)