BJU Int 2021; 127: 198–204 doi:10.1111/bju.15194 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Original Article Comparison of the performances of the ADXBLADDER test and urinary cytology in the follow-up of non-muscle-invasive bladder cancer: a blinded prospective multicentric study Paulo Gontero1, Emanuele Montanari2, Morgan Roupret3, Fabrizio Longo2, Jacqueline Stockley4 , Ashleigh Kennedy4, Oscar Rodriguez5 , Stuart R.C.  3, Marco Allasia1, McCracken6, Tim Dudderidge7, Caroline Sieverink8, Felicien Vanie J. Alfred Witjes , Richard Sylvester , Marc Colombel and Juan Palou5 8 9 10 1 Department of Urology, Ospedale Molinette, Turin, 2Department of Urology, Universita’ Policlinico Milano, Milan, Italy, 3 Urology Department, GRC n°5, ONCOTYPE-URO, AP-HP, Hopital^  -Salpe Pitie ^ trie  re, Sorbonne Universite  , Paris, F-75013, France, 4Arquer Diagnostics, R&D, Sunderland, UK, 5Department of Urology, Fundacio Puigvert, Barcelona, Spain, 6 Sunderland Royal Hospital, Sunderland, 7University Hospital Southampton, Southampton, UK, 8Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands, 9EAU Non-muscle-Invasive Guidelines Panel, EAU Guidelines Office, Brussels, Belgium, and 10Department of Urology, Ho ^ pital Edouard Herriot, Lyon, France Objective To compare directly the performance of the ADXBLADDER test with that of cytology in the detection of non-muscle- invasive bladder cancer (NMIBC) recurrences. Background ADXBLADDER is a urine test based on the detection of MCM5, a DNA licensing factor expressed in all cells capable of dividing. Expression is usually restricted to the basal stem cell compartment; however, in malignancy, MCM5-expressing cells can be found throughout the epithelium. Detection of MCM5 in urine sediment can be indicative of the presence of a bladder tumour. Patients and Methods A multicentre prospective, blinded study was carried out from August 2017 and July 2019 at 21 European Union centres, 14 of which collected matching cytology data. Urine was collected from patients prior to cystoscopy. Urine cytology and ADXBLADDER were performed and compared to the diagnosis obtained by cystoscopy. The performance of cytology and ADXBLADDER were then compared. Results The overall performance of ADXBLADDER demonstrated a sensitivity of 51.9%, a specificity of 66.4%, and a negative predictive value (NPV) of 92%. The sensitivity of ADXBLADDER for low- and high-grade recurrences was 44.1% and 58.8%, respectively. By contrast, cytology sensitivity was 16.7%, specificity was 98% and NPV was 90.7%. Cytology sensitivity for both low- and high-grade disease was 17.6%. Conclusions ADXBLADDER detection of both low- and high-grade NMIBC recurrence is superior to that of cytology, with ADXBLADDER able to exclude the presence of high-grade recurrence in 97.8% of cases compared to 97.1% with cytology. These results show that ADXBLADDER has promise as a more reliable alternative to urine cytology in the follow-up of NMIBC. Keywords biomarker, bladder cancer, follow-up, cytology MCM5, non-muscle-invasive bladder cancer, surveillance, #uroonc, #BladderCancer, #blcsm, #utuc © 2020 The Authors BJU International wileyonlinelibrary.com published by John Wiley & Sons Ltd on behalf of BJU International. www.bjui.org This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ADXBLADDER vs urine cytology in NMIBC follow up considered eligible for the study were those attending the Introduction urology clinic for a BCa follow-up cystoscopy, with a The cytological analysis of urine sediments has been used as a previous diagnosis of pathologically confirmed BCa in the tool to diagnose urinary tract malignancies for over 70 years [1]. preceding 24 months. Patients had to be over 18 years of age, Urine cytology in conjunction with cystoscopy is considered to able to understand the study and give informed consent, and be the ’gold standard’ and is recommended in the European capable of providing a full void urine sample of greater than Guidelines for high-risk non-muscle-invasive bladder cancer 10 mL. Patients unable to provide 10 mL of urine, and those (NMIBC). The excellent specificity of urine cytology is well who had urological instrumentation less than 2 weeks prior documented; however, the reported sensitivity has been to their appointment, or had active calculi or prostatitis were extremely variable [2]. Whilst, historically, cytology was thought excluded from the study. to have good sensitivity for high-grade disease, with reported All patients were required to undergo flexible cystoscopy as sensitivities of between 38% and 84% [3], recently, larger part of their BCa follow-up, the results of which were multicentric studies have demonstrated much lower sensitivities, recorded. If the cystoscopy was found to be normal the with a prospective study of 1016 patients demonstrating an patients were considered to be BCa recurrence-negative. If a overall sensitivity of 22%, 13% for low-grade tumours, 23% for lesion was detected on cystoscopy and was pathologically high-grade tumours and 25% for high-risk tumours [4,5]. One determined to be positive at biopsy/transurethral resection of of the potential reasons for the variability in the sensitivity for bladder tumours (TURBT), the patient was considered to be cytology is that the technique is highly subjective, requiring a BCa recurrence-positive. Other findings on cystoscopy (i.e. skilled uro-pathologist for interpretation, so adds variability, inflammation or erythema) were considered to be BCa particularly in multicentric studies. Despite a number of recurrence-negative unless a biopsy was clinically indicated classification systems being brought into practice, most recently which was pathologically determined to be positive. Cases in the Paris System for reporting Urine Cytology (Paris system) [6], which a lesion was detected but no pathological assessment the complication of equivocal results (such as those reported as was carried out, were excluded from final analysis (e.g. if the atypical), has resulted in the use of cytology in follow-up detected lesion was removed by diathermy, or the patient becoming increasingly questionable. There is therefore a underwent watchful waiting). growing need for alternative non-invasive diagnostic tools in bladder cancer (BCa). Cytology testing was carried out locally in a subset of patients and cases classified as per the Paris system were included [6]. For The field of urinary biomarker research is a very active area of the purposes of this study, a positive cytology result was research, with the focus being on developing non-invasive and recorded for those reported as ‘suspicious for high-grade cost-effective strategies to aid in the diagnosis of BCa. However, urothelial carcinoma’, ‘low-grade urothelial neoplasia’ or ‘high- despite this, no urinary biomarker has been successfully grade urothelial carcinoma’, whilst those reported as ‘atypical’, implemented into clinical practice due to low sensitivities and ‘negative for high-grade urothelial carcinoma’ and ‘non- specificities and a lack of high-quality prospective studies to diagnostic’ were considered to have a negative cytology result. support their use in clinical practice [7]. The method of detecting MCM5 in urine sediment has been Urine Collection and Processing shown to accurately diagnose BCa in a number of previous studies, with particularly high sensitivity for high-risk disease Each patient provided a full void urine sample of at least (high-grade, pT1 and above and carcinoma in situ [CIS] 10 mL, which was collected prior to their cystoscopy and tumours) [8–11]. processed within 48 h of collection. Sample processing involved centrifuging the samples at room temperature for In the present study, we report results from a large, 5 min at 1500 g. The resulting sediment pellet was then prospective, European multicentre study, conducted with the resuspended in ADXBLADDER lysis buffer (10 µL lysis objective of assessing the performance of ADXBLADDER buffer per 1 mL urine) for 30 min at room temperature to compared to that of cytology in the detection of NMIBC allow adequate lysis of cells, after which the lysate samples recurrence. were stored at ≤ 20oC until MCM5 testing was required. Patients and Methods MCM5 Testing: ADXBLADDER Study Population MCM5 is a protein essential for DNA replication present in Between August 2017 and July 2019, 1718 patients were all cells capable of dividing but lost in terminally enrolled prospectively to the study. Ethical approval was differentiated cells. In normal urothelium MCM5-expressing obtained locally at all sites (REC reference: 17/NE/0174), and cells are confined to the basal proliferative compartment, informed consent was sought from all patients. Patients however, in the presence of urothelial carcinoma, Ó 2020 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International 199 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Gontero et al. MCM5-positive cells are present throughout the urothelium previous diagnosis of high-grade pTa, CIS or pT1. A total of and exfoliated into the urine. ADXBLADDER is a diagnostic 99% of the patients underwent their previous TURBT more test that detects MCM5 in urine sediment. Patient samples than 3 months previously, with 49% undergoing TURBT were tested for the presence of MCM5 using ADXBLADDER 3 12 months previously and the remaining 50% (Arquer Diagnostics Ltd, Sunderland, UK) as per the 12 24 months previously. For 22% of the population, manufacturer’s instructions. All laboratory staff performing TURBT was the last treatment received; however, the the ADXBLADDER test were blinded to the results of the majority had received BCG after their last TURBT (57%), the cystoscopy and cytology, and clinicians were blinded to the remaining 21% had received another form of intravesical ADXBLADDER results. Briefly, two 100-µL replicates of each chemotherapy (primarily mitomycin C [18%]). All patient lysate sample and controls were added to the ELISA demographics are provided in Table 1. microtitre plate and incubated at room temperature for In the detection of recurrent bladder tumours, 60 min with shaking (700–1200 rpm). A wash step was ADXBLADDER outperformed cytology’s sensitivity for all performed, followed by a 30 min incubation of 100 µL of tumour types. The overall performance in this cohort of anti-MCM5 horseradish peroxidase conjugated antibody at matching cytology patients demonstrated that room temperature. Following a second wash step, 100 µL ADXBLADDER was able to correctly identify a BCa 3,3’,5,5’-Tetramethylbenzidine was added to the plate and recurrence in 28 of the 54 BCa recurrence-positive patients, incubated for 30 min at room temperature before yielding a sensitivity of 51.9% (95% CI 37.8–65.7%), whilst ADXBLADDER stop solution was added to terminate the 298 BCa recurrence-negative patients were correctly identified colorimetric reaction. Sample optical density was then by ADXBLADDER, giving a specificity of 66.4% (95% CI measured at 450 and 630 nm and normalized to the control 61.8–70.7), and a negative predictive value (NPV) of 92% values. Samples with a normalized optical density greater (95% CI 88.5–94.7; Table 2). than or equal to the assay threshold, as per the manufacturer’s instructions, were considered positive for In contrast, the ability of cytology to correctly identify BCa MCM5, and samples with an optical density below this were recurrences was significantly poorer, with cytology only regarded as MCM5-negative. detecting nine out of the 54 BCa-positive recurrences, yielding a sensitivity of 16.7% (95% CI 7.9–29.3), specificity Statistical Analysis remained high with only 9/449 BCa-negative patients giving a positive cytology result, thereby generating a specificity of Comparisons of diagnostic accuracy were calculated based on 98% (95% CI 96.2–99.1) and an overall NPV of 90.7% (95% the area under the receiver-operating characteristic curve CI 87.8–93.2; Table 3). (AUC). Significance for ADXBLADDER vs cytology sensitivities was calculated using McNemar’s exact test. All The sensitivity of ADXBLADDER was consistently higher statistical analyses were performed with STATA 12.1. Statistical than that of cytology regardless of the recurrent tumour type. significance was indicated if P values were < 0.05. For low-grade, CIS and high-grade recurrences the sensitivity of ADXBLADDER was 44.1% (95% CI 27.2–62.1), 60.0% (95% CI 26.2–87.8) and 58.8% (95% CI 32.9–81.6), Results respectively, and 65% (95% CI 40.8–84.6) for non-pTa low- Patients attending the urology clinic for NMIBC follow-up grade tumours, whilst for cytology the sensitivity for both cystoscopy were recruited between August 2017 and July low- and high-grade recurrences was 17.6% (95% CI 6.8– 2019. Patients provided informed consent and supplied a 34.5) and 30% (95% CI 6.7–65.3) for CIS, (Table 4, Fig. S2) urine sample. Of the 1718 patients recruited, 514 had and 15% (95% CI 3.2–37.9) for non-pTa low-grade tumours. matched cytology data, 11 of these patients had a bladder Whilst there was no significant difference in the AUC, as a lesion detected but no associated pathology of the tumour result of the very high specificity of cytology (Fig. S1), the and were therefore excluded from analysis. Therefore, 503 increased sensitivity of ADXBLADDER in comparison with patients with results for both ADXBLADDER and cytology cytology was statistically significant for all tumours (P < were included in the comparative analysis of performance 0.001), Low-grade tumours (P = 0.02), high-grade tumours (P characteristics for the two tests (Fig. 1). Of the remaining 503 = 0.04) and high-risk (non-pTa low-grade) tumours (P = eligible patients recruited with matching cytology data 373 0.006; Fig. 2). were men and 130 women, with a median (interquartile range) age of 72 (65–77) years. Fifty-four of the patients were diagnosed with a pathologically confirmed recurrent BCa Discussion tumour (11% prevalence, 95% CI 8.2 13.8). European Association of Urology guidelines currently Of the 503 patients, 203 (40%) had a previous diagnosis of a recommend cytology in the follow-up of NMIBC for high- low-grade pTa tumour, whilst the remaining patients had a risk patients as an adjunct to cystoscopy, as white-light Ó 2020 The Authors 200 BJU International published by John Wiley & Sons Ltd on behalf of BJU International 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ADXBLADDER vs urine cytology in NMIBC follow up Fig. 1 Standards for Reporting of Diagnostic Accuracy (STARD) patient recruitment and enrolment outline. MIBC, carcinoma invading bladder muscle. 1718 patients consented 108 patients ineligible • 58 >2 years since diagnosis • 50 Previous MIBC diagnosis 1610 patients provided urine sample 134 patients excluded • 15 <10mL urine provided • 12 No cytoscopy carried out • 71 urine sample processed incorrectly • 36 Samples lost in transit ADXBLADDER Cytology 45 patients excluded (1431) (514) 11 patients excluded • 43 No pathology of suspicious lesions (*) • 11 No pathology of suspicious lesions (*) • 2 Lost to follow-up 503 eligibile patients with matching cytology 449 54 No bladder cancer No bladder cancer recurrence recurrence cystoscopy alone is not considered to be sufficient [12]. (an optical density reading of greater than the predefined cut- However, concerns over the poor sensitivity of cytology to off being classed as positive), in addition the results from an detect recurrent tumours at high risk of progression have ADXBLADDER test can be available within 3 h. highlighted an unmet need within the follow-up of NMIBC Furthermore, using the currently recommended Paris system for a non-invasive, cost-effective adjunctive test to cystoscopy. for classifying cytology, a non-negligible number of samples in this study were categorized as non-diagnostic (14.9%), and In the present study, we establish that ADXBLADDER is a further 4.2% were classified as atypical. This latter subgroup significantly more sensitive than cytology at detecting was also regarded as negative in the present study since, in recurrent bladder tumours for all tumour sub-type spite of absence of a true consensus on the optimal recurrences (P < 0.001), detecting at least twice the number management of an atypical cytology result, it is generally of recurrences as cytology for low-grade, high-grade, CIS and accepted that it should be followed up akin to the ‘negative’ non-pTa low-grade tumours. The overall sensitivity of category [4]. In contrast, ADXBLADDER gave non-equivocal cytology in this study of 16.7% (17.6% for high-grade disease, results for all samples. 15% for non-pTa low-grade tumours) is consistent with the previously reported sensitivity of cytology in another large As a result of the study being blinded, one of the multicentric study [5], but is lower than other previous limitations is that there was no further testing carried out reports [13]. In contrast, ADXBLADDER demonstrated a in patients with a positive ADXBLADDER test, but much higher sensitivity of 51.9% (58.8% for high-grade negative cystoscopy and cytology; therefore, the presence of disease and 65% for non-pTa low-grade tumours). upper tract tumours cannot be excluded in these patients. Additionally, there was no follow-up available for this Whilst cytology requires the time of a skilled uro-pathologist, subset of patients to determine if there may have been a ADXBLADDER is a simple ELISA requiring no interpretation Ó 2020 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International 201 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Gontero et al. Table 1 Patient demographics at recruitment. sub-clinical recurrence, which was undetected by the other tests, which has been demonstrated with other Characteristic Total BCa population recurrence- biomarker tests [14]. Another limitation of the study is (N = 503) positive that all cytology was reviewed locally; therefore, the (n = 54) multicentric nature of the study may have introduced Men 373 (74) 45 (83) variability in the cytology reporting, which may explain Women 130 (26) 9 (17) the low sensitivity observed in comparison with some Age, years 72 (65–77) 73 (67–79) Stage and grade of last TURBT/biopsy, n (%) previous reports. Ta low-grade 203 (40) 28 (52) Ta high-grade 143 (28) 12 (22) The lack of a priori power analysis sample size calculation T1 136 (27) 12 (22) is also a potential limitation of the study. These CIS; all* 63 (13) 5 (9) calculations were provided only for the overall cohort of CIS: alone* 7 (1) 1 (2) EAU risk group 1718 patients, of which the current 514 cases with matched Low 72 (14) 9 (17) cytology data represent a sub-study. However, using the Intermediate 112 (22) 18 (33) McNemar two-sided test for paired comparisons, it is High 300 (60) 26 (48) Undetermined 19 (4) 1 (2) calculated that 31 patients with a recurrence are required Time between TURBT and ADXBLADDER test, n (%) to detect the observed difference in sensitivity, (51.9% vs <3 months 4 (0.8) – 16.7%), to be significant at a = 0.05 and power = 0.80. In 3–12 months 245 (49) 28 (52) >12 months 254 (50) 26 (48) all, 54 patients had a recurrence, which provides a post hoc Last treatment received, n (%) power of 97% to detect the observed difference to be BCG 288 (57) 19 (35) significant at a = 0.05. Intravesical chemotherapy 105 (21) 12 (22) Mitomycin-C 91 (18) 9 (17) While the overall sensitivity of ADXBLADDER is similar to Mitomycin-C + hyperthermia 1 (0.2) – Synergo 7 (1) 1 (2) that reported by other commercially available urinary Epirubicin 2 (0.4) 1 (2) biomarkers, such as NMP22, BTA Stat and UBC Rapid, Doxorubicin 1 (0.2) – there was a relatively high prevalence of pTa low-grade GemRIS 1 (0.2) 1 (2) None (TURBT only) 110 (22) 23 (43) recurrent tumours within this population. In high-grade or late-stage disease, the sensitivity of ADXBLADDER (65%) is BCa, bladder cancer; CIS, carcinoma in situ; EAU, European Association of Urology; higher than that previously observed by these markers TURBT, transurethral resection of bladder tumour. *Seven patients had CIS alone, 56 patients had co-occurring papillary lesions. (31% for NMP22 ELISA, 16% for NMP22 BladderChek) [5]. Although the observed specificity of cytology was higher than that of ADXBLADDER, the role of ADXBLADDER as a test Table 2 Two 3 two contingency table for ADXBLADDER. must be considered [15]. ADXBLADDER significantly ADXBLADDER BCa BCa Total outperformed urine cytology in the detection of both low- recurrence- recurrence- and high-grade BCa recurrences. Hence, it should be positive negative considered as a more reliable alternative to urine cytology, Positive 28 151 179 when indicated by current guidelines, as an adjunct to Negative 26 298 324 cystoscopy. Total 54 449 503 The present results clearly demonstrate that ADXBLADDER BCa, bladder cancer. has a superior sensitivity when compared to cytology, for the detection of recurrent bladder tumours, revealing a promising case for ADXBLADDER to replace cytology in the follow-up Table 3 Two 3 two contingency table for cytology. of NMIBC. Cytology BCa BCa Total recurrence- recurrence- positive negative Conflicts of Interest Positive (high-grade UC/ 9 9 18 This was a commercially sponsored study by Arquer suspicious for high-grade UC Diagnostics Ltd. M. Roupret, P. Gontero, S. R. C. and low-grade UN) McCracken, T. Dudderidge, M. Colombel, F. Longo, E. Negative (negative for high-grade 45 440 485 UC, atypia and non-diagnostic) Montanari and J. Palou are paid consultants to Arquer Total 54 449 503 Diagnostics. J. A. Witjes has received fees for lecture honorarium for Nucleix. None has any shareholding in BCa, bladder cancer; UC, urothelial carcinoma; UN, urothelial neoplasia. Arquer Diagnostics or any related company. J. Stockley and Ó 2020 The Authors 202 BJU International published by John Wiley & Sons Ltd on behalf of BJU International 1464410x, 2021, 2, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.15194 by Readcube (Labtiva Inc.), Wiley Online Library on [25/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ADXBLADDER vs urine cytology in NMIBC follow up Table 4 Comparison of performance characteristics of ADXBLADDER with cytology by recurrent tumour classification. Type of tumour ADXBLADDER Cytology Sensitivity, % (95% CI) NPV, % (95% CI) Sensitivity, % (95% CI) NPV, % (95% CI) All tumours ( n = 54) 51.9 (37.8–65.7) 92.0 (88.5–94.7) 16.7 (7.9–29.3) 90.7 (87.8–93.2) Stage pTa (n =42) 45.2 (29.8–61.3) 92.9 (89.5–95.4) 19 (8.6–34.1) 93 (90.3–95.1) pT1 (n = 8) 75 (34.9–96.8) 99.4 (97.8–99.9) 12.5 (0.3–52.7) 98.6 (97–99.4) CIS: all* (n =10) 60 (26.2–87.8) 98.8 (97.4–99.4) 30 (6.7–65.2) 98.6 (97–99.4) CIS: alone* (n = 3) 100 (29.2–100.0) 100 (n/a) 0 (0–70.8) 99.4 (99.37–99.39) Grade Low (n = 34) 44.1 (27.2–62.1) 94.1 (91–96.4) 17.6 (6.8–34.5) 94.2 (91.8–96.1) High (n = 17) 58.8 (32.9–81.6) 97.8 (95.6–99.1) 17.6 (3.8–43.4) 97.1 (95.2–98.4) Number of tumours Solitary (n = 29) 44.8 (26.5–64.3) 95.1 (93.2–96.4) 17.2 (5.9–35.8) 95.1 (94.2–95.8) Multiple (n = 21) 52.4 (29.8–74.3) 96.9 (95.2–98.0) 19.1 (5.5–41.9) 96.5 (95.7–97.1) Size of tumours <1 cm (n = 37) 43.2 (27.1–60.5) 93.5 (91.5–95.1) 18.9 (8–35.2) 93.8 (92.8–94.7) 1–3 cm (n = 11) 63.6 (30.8–89.1) 98.8 (97.3–99.4) 9.1 (0.2–41.3) 97.9 (97.5–98.3) Low-grade pTa (n = 34) 44.1 (27.2–62.1) 94.1 (91–96.4) 17.6 (6.8–34.5) 94.2 (91.8–96.1) Non-low-grade pTa (n = 20) 65 (40.8–84.6) 97.8 (95.6–99.1) 15 (3.2–37.9) 96.5 (94.4–97.9) CIS, carcinoma in situ; NPV, negative predictive value. *Three patients had CIS alone, seven patients had co-occurring papillary lesions. Fig. 2 Comparison of sensitivity (95% CI) of ADXBLADDER vs cytology by recurrent tumour classification: in all tumours (*P < 0.001), low-grade tumours (**P = 0.02), high-grade tumours (***P = 0.04) and Excl pTa low-grade (****P = 0.006). 51.9 Overall population (54) * 16.7 ADXBLADDER 44.1 CYTOLOGY Low-grade (34) 17.6 ** 58.8 High-grade (17) 17.6 *** 65 Excl pTa low-grade (20) 15 **** 0 20 40 60 80 100 Sensitivity (%) A. Kennedy are employees of Arquer Diagnostics holding References share options in the company. The funder of the study 1 Papanicolaou GN, Marshall VF. Urine sediment smears as a assisted the authors in study design, data collection, data diagnostic procedure in cancers of the urinary tract. Science 1945; analysis, data interpretation, writing of the report, and the 101: 519–20 decision to submit the paper for publication. P. Gontero, 2 Sathianathen NJ, Butaney M, Weight CJ, Kumar R, Konety BR. 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Eur Urol Oncol 2020; 3: 42–6. online version of this article: 12 Daneshmand S, Bazargani ST, Bivalacqua TJ et al. Blue light cystoscopy for the diagnosis of bladder cancer: results from the US prospective Fig. S1. Receiver-operating characteristic (ROC) curve (A) all multicenter registry. Urol Oncol Semin Orig Investig 2018; 36: 361.e1–6 tumours; (B) non pTaLG. 13 Pichler R, Tulchiner G, Fritz J, Schaefer G, Horninger W, Heidegger I. Fig. S2. Comparison of the detection of NMIBC recurrences Urinary UBC rapid and NMP22 test for bladder cancer surveillance in comparison to urinary cytology: Results from a prospective single-center by ADXBLADDER vs cytology in all tumours (A), low-grade study. Int J Med Sci 2017; 14: 811–9 tumours (B), CIS (C) and high-grade tumours (D). Ó 2020 The Authors 204 BJU International published by John Wiley & Sons Ltd on behalf of BJU International