Women's Urinary Symptoms May Mask Cancer

Nick Mulcahy

June 27, 2013

Primary care physicians are more likely to attribute initial symptoms associated with urinary and kidney cancers in women — as opposed to men — to relatively benign causes, such as bacterial infections, according to a new study conducted in the United Kingdom.

Researchers found that women with urinary tract cancers were around twice as likely as men to have visited their general practitioner 3 or more times before they were referred to a specialist.

Specifically, more women than men made 3 or more visits before referral for bladder cancer (27% vs 10%) or kidney cancer (30% vs 18%), report the study authors, led by Georgios Lyratzopoulos, MD, from the Department of Public Health and Primary Care at the University of Cambridge in United Kingdom.

"The findings indicate that generalists are less likely to suspect the diagnosis of urinary tract cancers in women," write the authors.

The findings from this study, published online June 24 in BMJ Open, offer "compelling evidence" of gender-based delays in the diagnosis of these cancers, and "amplify previous limited evidence" on gender inequalities in the diagnosis of urinary tract cancers in both England and the United States, the authors write.

Dr. Lyratzopoulos and colleagues place their findings in a larger context, and suggest that the gender-based delays can have serious consequences. They report that previous research conducted in England found that the 5-year survival rate for bladder cancer is better for men than for women (57% vs 44%) (Lancet Oncol. 2009;10:351-369).

The authors analyzed data from the National Audit of Cancer Diagnosis in Primary Care, which covered 1170 representative general practices — around 14% of the national total — in 2009 and 2010 in England.

On multivariable analysis, after adjustment for age, hematuria status, and the use of primary-care-led investigations, being a woman was independently associated with 3 or more prereferral consultations for bladder cancer (odds ratio [OR], 3.29; P <.001) and for renal cancer (OR, 1.90; P = .031).

Hematuria status is important both as a finding and as a potential opportunity for improvement in diagnostic efficiency, the authors explain.

In general, presentation with hematuria, which is the most common symptom of bladder cancer, was associated with the more timely diagnosis of bladder cancer in the study. However, gender inequalities persisted for both cancers in the men and women who presented with hematuria.

Specifically, on multivariable analysis, "there was no evidence that gender differences in the proportion of patients with 3 or more prereferral consultations varied between patients with and without hematuria" for bladder cancer (P = .18) or renal cancer (P = .27), the authors report.

Improving Diagnosis

These findings "signal a large potential for improving the timeliness of diagnosis of urinary tract cancer in women." In part, this can be achieved with "more rigorous adherence" to existing clinical guidelines on the investigation and management of hematuria, the authors note.

They explain that all patients who present with painless macroscopic hematuria should be referred to specialists, according to clinical guidelines, including those in the United Kingdom.

The problem of lax referral for hematuria is not limited to general practitioners in the United Kingdom. Previous research conducted in the United States indicates that primary care physicians "often do not adhere to guidelines for prompt investigation of patients presenting with hematuria," write Dr. Lyratzopoulos and colleagues.

Nevertheless, "many patients" with urinary tract cancers present without hematuria, and the positive predictive value of hematuria for urologic cancer is generally lower than 15% (depending on age). This leaves a lot of room for improvement in diagnosis, and signals a need for the development of new diagnostic tools, the authors conclude.

The study was funded by a Post-Doctoral Fellowship award to Dr. Lyratzopoulos from the National Institute for Health Research. The authors have disclosed no relevant financial relationships.

BMJ Open. Published online June 24, 2013. Abstract

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