Neil Osterweil

May 18, 2014

ORLANDO, Florida — Worse outcomes for women with bladder cancer than for men may be due in part to the under-recognition by general practice clinicians that hematuria — blood in the urine — is a likely sign of cancer, say the authors of a retrospective study.

"Women are less likely than men to go undergo a complete, timely evaluation [for hematuria], and this might be relevant to women's more advanced stage of bladder cancer at diagnosis," said Daniel Barocas, MD, MPH, assistant professor of urologic surgery at Vanderbilt University Medical Center in Nashville, Tennessee.

Dr. Barocas presented the results of the study here at the American Urological Association (AUA) 2014 Annual Scientific Meeting.

Disparities Unmasked

Dr. Barocas and colleagues reviewed data for 9211 Part A and B Medicare beneficiaries treated in a fee-for-service setting who had been diagnosed with hematuria by a primary care provider during an outpatient visit. They excluded patients with a pre-existing condition and those who had undergone a procedure that might cause hematuria. Of the study population, 2542 were men and 6669 were women.

Hematuria evaluations were classified as "complete" if both cytoscopy and abdominopelvic imaging were performed, "incomplete" if only 1 of the tests was performed, and "absent" if neither was performed.

Only 14% of the beneficiaries who met the study criteria had a complete hematuria evaluation; 21% had incomplete examinations and 65% had none at all.

The overall rates of referrals to urologists for evaluation of hematuria for both men and women were low. More than half of all patients of both sexes did not receive a urology workup within 6 months of a finding of hematuria, Dr. Barocas reported.

When they looked at the components of evaluation by sex, study investigators discovered that men had significantly more diagnostic procedures (26% vs 12%, P < .001) and more imaging studies (41% vs 30%, P < .001) than women.

Men were also more likely than women to have a complete evaluation (22% vs 12%) and less likely to have an incomplete evaluation (55% vs 69%, P < .001).

The study authors also found that although patients who are not white historically present with higher-stage disease and have worse survival than whites with bladder cancer, race/ethnicity was not an independent predictor of whether a patient would undergo evaluation for hematuria.

In multivariate analyses controlling for sex and race, they found that 39% of men were referred to a urologist by their primary care practitioners, compared with 17% of women (P < .001), but once they got to a urologist, men and women were equally likely to undergo a diagnostic procedure (67% vs 65%, respectively).

Dr. Barocas and colleagues speculate that some primary care practitioners may assume a woman presenting with new or recurrent hematuria has a urinary tract infection and treat her empirically with antibiotics, and that this process may be repeated over several visits until the woman develops other, more serious symptoms that lead to a diagnosis of later-stage bladder cancer.

They are hesitant, however, to lay the blame at the door of their colleagues in primary care. Instead, they say, all clinicians need better tools for risk-stratifying patients for hematuria evaluations. They also urge development of collaborative efforts between urologists and primary care practitioners that emphasize the need for earlier detection of bladder cancer in women and address sex-based disparities in bladder cancer survival.

"We need to be sure that our primary care providers or ER physicians, who are the frontline of our referrals, understand that hematuria is a problem — it needs to be worked up," said Moben Mirza, MD, assistant professor urology at the University of Kansas Medical Center in Kansas City, who was not involved in the study.

In our minds, it's cancer until proven otherwise. Dr. Moben Mirza

"In our minds, it's cancer until proven otherwise. I don't think the rest of the community thinks or believes that, because if they did, they would be referring hematuria to us more often," Dr. Mirza told Medscape Medical News.

The study was supported by the National Institutes of Health. Dr. Barocas disclosed serving on the AUA committee on guidelines for the diagnosis of bladder cancer. Dr. Mirza reported no relevant financial relationships.

American Urological Association (AUA) 2014 Annual Scientific Meeting. Abstract MP6-16. Presented May 17, 2014.

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