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ACP issues guidance for evaluating blood in urine as sign of cancer
Physicians should include gross hematuria in their routine patient history review due to its association with urinary tract cancer, according to a guidance issued by the American College of Physicians High Value Care Task Force.
The presence of blood in urine is common, but it can sometimes indicate occult cancer. Although there is agreement that a urologic assessment is indicated for patients with gross hematuria, there is no clear consensus on the indication for evaluation of microscopic hematuria, which occurs more commonly.
This guidance offered seven specific pieces of high-value care advice for clinicians regarding the best practices for evaluating patients who experience hematuria.
“Physicians should be aware of risk factors for cancer when considering the finding of hematuria,” Wayne J. Riley, MD, MPH, MBA, MACP, adjunct professor of health care management at Vanderbilt University and president of the American College of Physicians, said in a press release. “Doctors and patients need to know that visible blood in the urine, or gross hematuria, is strongly associated with cancer and other potentially serious underlying conditions.”
The highlighted suggestions in the guidance included:
- Gross hematuria should be included in the routine review of systems and all patients with microscopic hematuria should be asked about a potential history of gross hematuria;
- Screening urinalysis should not be used for cancer detection in asymptomatic adults;
- Heme-positive results of dipstick testing should be confirmed with microscopic urinalysis demonstrating three or more erythrocytes per high-powered field before the initiation of any further evaluation in asymptomatic adults;
- Further urologic evaluation referrals should be issued for all adults with gross hematuria;
- Referrals for cystoscopy and imaging should be considered for all adults with confirmed microscopic hematuria if there is no known benign cause;
- Evaluation of hematuria should still be pursued even if the patient is receiving antiplatelet or anticoagulant therapy; and
- Urinary cytology or other urine-based molecular biomarkers should not be obtained to detect bladder cancer in the initial hematuria evaluation.
The report also included the most common risk factors for urinary tract cancer in patients with microscopic hematuria. These included male sex, age 50 years or older, a history of smoking, a history of gross hematuria, urologic disease or disorders, pelvic irradiation and chronic urinary tract infection. Chimney sweeps; nurses; waiters; aluminum, ship, and oil/petroleum workers; workers in the tobacco, dye, rubber or leather industry; hairdressers and printers, may also be at increased risk due to exposure to chemicals or dyes.
Although the interventions outlined in these recommendations could lead to reduction in mortality and morbidity associated with possible cancer, the task force acknowledged there are harms associated with screening for occult urinary tract cancer. These include unnecessary testing; pain or infection as the result of cystoscopy; exposure to radiation, hypersensitivity reactions and contrast nephropathy; and the potential association with additional unnecessary, invasive and expensive procedures.
Still, increased awareness regarding the association between gross hematuria and cancer is necessary, according to the task force. Recent reports have suggested that a history of self-limited gross hematuria is a significantly underreported symptom. The task force included data from one study — published in Mayo Clinic Proceedings by Loo and colleagues — that showed 19.8% of patients referred to urologic evaluation for asymptomatic microscopic hematuria had visible hematuria in the preceding 6 months, which was associated with an increased risk for urologic cancer (OR = 7.2).
Amir Qaseem
“The differing algorithms of existing recommendations for the evaluation of asymptomatic microscopic hematuria reflect both current uncertainty in this area of practice and differences of opinion about the implicit tradeoffs among the harms, costs and benefits of a given approach,” Amir Qaseem, MD, PhD, MHA, FACP, director of the department of clinical policy at the American College of Physicians, and Matthew Nielsen, MD, MS, an associate professor of urology and the director of urologic oncology at University of North Carolina, wrote on behalf of the task force. “These tradeoffs include both the threshold for initiating evaluation in a given case and the appropriate components of evaluation in a given circumstance.” – by Anthony SanFilippo
Disclosure: The task force members report no relevant financial disclosures.