Miriam E. Tucker

October 25, 2013

WASHINGTON, DC — Less than 10% of patients with hematuria are referred for bladder cancer screening, even though this is recommended in American Urological Association guidelines. A new retrospective study suggests that clinical factors and practice site play a role in this lack of adherence.

"Individuals diagnosed with an incident case of hematuria oftentimes did not receive subsequent workup with bladder cystoscopy or imaging. There were certain clinically relevant risk factors, such as age and gender, that predicted whether or not an individual subsequently got evaluated," said David Friedlander, MD, now a first-year urology resident at Brigham and Women's Hospital in Boston. "However, there was also significant nonclinical variation, as demonstrated by variation across practice sites."

Dr. Friedlander presented the findings here at the American College of Surgeons 2013 Annual Clinical Congress. When the research was conducted, he was a fourth-year medical student at Vanderbilt University Medical Center in Nashville, Tennessee.

Hematuria is the most common presenting sign of bladder cancer, and about 1 in 10 patients who present with hematuria will have a malignancy or other treatable condition. Updated guidelines issued by the American Urological Association (AUA) call for both cystoscopy and upper urinary tract imaging for anyone older than 35 years with hematuria, as reported by Medscape Medical News.

Unfortunately this is one area that is too often overlooked and attributed to a benign condition like a urinary tract infection or some other issue without fully verifying the problem.

Compliance with guidelines is often low across medical specialties, said session moderator Craig Derkay, MD, from the Eastern Virginia Medical School in Norfolk. "We really spend a lot of time trying to put these guidelines together, and it's disappointing how few are complied with across the board," he said.

"This is an opportunity to go back to the primary care providers in the area and ask why," he told Medscape Medical News.

"Unfortunately this is one area that is too often overlooked and attributed to a benign condition like a urinary tract infection or some other issue without fully verifying the problem," said lead investigator Daniel Barocas, MD, from Vanderbilt University Medical Center. "Consequently, we find patients diagnosed later in their disease than they ought to be."

The researchers obtained claims and clinical data from a large regional health system with 8 distinct primary care practice locations. To be included, patients had to be 40 years or older, have no previous hematuria diagnosis and no explanatory diagnosis in the previous year, and have 18 months of data available.

The primary outcome was cystoscopy, imaging, or both within 180 days of presentation with hematuria.

Of the 6585 patients identified with hematuria, 2455 met the inclusion criteria.

The median age of study participants was 58 years, 70.5% were female, 64.3% were married, 30.1% were current or former smokers, and 4.6% were receiving anticoagulant therapy.

Within 180 days of presentation for hematuria, just 5.7% of patients underwent bladder cystoscopy and imaging, in accordance with the AUA recommendation. In addition, 13.7% underwent cystoscopy and 13.9% underwent imaging.

On multivariate analysis, referral for both tests was significantly more likely in older patients (odds ratio [OR], 1.03) and in patients receiving anticoagulant therapy (OR, 1.44). Referral for both tests was significantly less likely in female patients (OR, 0.31). Race, smoking, marital status, insurance type, and distance to provider were not significant.

Practice site was also a significant predictor of referral. Several sites had markedly lower rates of diagnostic testing for patients with hematuria (P < .001 for all sites).

"Variability based on nonclinical factors, such as practice site, is undesirable and may be amenable to quality-improvement initiatives, process improvement for coordination of care, and a reduction in logistical barriers for providers and patients," Dr. Friedlander said.

Not surprisingly, evaluation was associated with higher rates of diagnosis. More bladder cancer was found in patients who underwent cystoscopy than in those who did not (10.0% vs 0.1%).

Table. Rates of Explanatory Diagnosis

Diagnostic Procedure Percent
No workup 7
Cystoscopy 40
Imaging 46
Cystoscopy plus imaging 60


Dr. Barocas noted that primary care physicians were involved in the study and provided oversight, so "you would expect some variation. There is no guideline to which one should adhere 100%," he acknowledged.

He noted that a recent study suggested that further risk stratification for cancer might be possible in patients with hematuria (Mayo Clin Proc. 2013;88:129-138).

For example, "a young healthy woman who doesn't smoke probably doesn't have bladder cancer and may not need to be scoped, whereas an older man who's a lifetime smoker should definitely get a thorough evaluation. There is some reasonable judgment involved," said Dr. Barocas, who was one of the authors of the AUA guidelines.

Nonetheless, "when you find variability that's independent of known risk factors, it makes you suspect there's some opportunity to intervene and change that, either by educating the providers or by improving whatever processes impede an appropriate workup," he explained.

Dr. Barocas reports financial relationships with Bayer, Dendreon, GE Healthcare, and Janssen. Dr. Friedlander and Dr. Derkay have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 2013 Annual Clinical Congress. Presented October 8, 2013.


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