Follow-up on Hematuria

Even though hematuria, or blood in the urine, is the most frequent presenting sign of bladder cancer, patients may not be getting complete evaluations, say researchers from Vanderbilt University in Nashville, Tennessee.

In a retrospective study of 2,455 primary care patients aged ≥ 40 years diagnosed with hematuria in the absence of other explanatory diagnosis, only 13.7% underwent cystoscopy within 180 days, and only 13.9% had radiographic evaluation. Moreover, only 5.7% underwent both cystoscopic and radiologic evaluation, although the American Urological Association Best Practice Guidelines recommend this as standard practice for patients aged > 35 years.

The findings indicate that health care providers are, to an extent, using clinical information to risk-stratify patients, the researchers say. Older patients and men were most likely to undergo cystoscopy; both increasing age and male gender are known risk factors for urothelial carcinoma. White patients were more likely than black patients to have cystoscopy (14.6% of 1,949 patients vs 11.2% of 312 patients), but black patients were more likely to have imaging studies (16.7% vs 13.9%) and cystoscopy plus imaging (6.7% vs 5.9%). Also, men were about twice as likely as were women to have any type of follow-up diagnostic testing, although women made up > 70% of the studied patients.

Of the study patients, 66 (2.7%) were diagnosed with a genitourinary neoplasm within 180 days of the hematuria diagnosis, with bladder cancer being the most common diagnosis. Other patients (4.6%) were found to have stone disease; 2.5% had benign prostatic hyperplasia; and 2.4% had infection.

Receipt of cystoscopy or imaging was associated with higher rates of diagnosis. Ultrasound yielded a lower diagnosis of neoplasm compared with that of computed tomography (CT). Similarly, cystoscopy plus ultrasound yielded a lower count of neoplasms compared with that of cystoscopy plus CT.

Patients who underwent follow-up testing were “far more likely” than those who did not to be diagnosed with malignancy (12.8% vs 1.1% for cystoscopy, 12% vs 1.2% for imaging, and 18.4% vs 1.7% for both) and other urologic/nephrologic conditions within 6 months. That finding was expected, the researchers say, but they add that it is an important observation because a measurable proportion of patients presenting with hematuria will have a genitourinary malignancy. Delays in diagnosis can lead to later stage at diagnosis, higher treatment burden, and less favorable cancer-control outcomes.

The researchers were troubled by the statistically significant variation across practice sites for receipt of cystoscopy, imaging, and both cystoscopy and imaging (P < .001 for each). They note that there is “legitimate debate” about the widespread application of diagnostic testing for hematuria, because the yield of such testing is low in some settings. Perhaps this uncertainty about appropriate candidates, they suggest, underlies the low rates of testing and variability across practice sites. They also note that, although all sites were in various locations at Vanderbilt University Medical Center, there may have been structural differences between practice sites that facilitated or impeded appropriate evaluation, such as the availability of onsite urology or imaging services. In fact, the researchers say, they found that the site with the highest proportion of patients undergoing complete evaluation was the main hospital campus, which had both urology and imaging services.

Better understanding of the barriers to guideline adherence for the evaluation of hematuria, the researchers say, is the first step toward improving guideline implementation.

Source
Friedlander DF, Resnick MJ, You C, et al. Am J Med. 2014;127(7):633-640.
doi: 10.1016/j.amjmed.2014.01.010.