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ACP issues guidelines for evaluating blood in the urine as sign of cancer

The ACP has issued High Value Care advice regarding hematuria as a marker for occult cancer, including current practice and suggestions for evaluating patients with hematuria.

“Physicians should be aware of risk factors for cancer when considering the finding of hematuria,” Wayne J. Riley, MD, MPH, MBA, MACP, ACP president, said in a 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 guidelines, published in the Annals of Internal Medicine, address gross hematuria and the more common finding of asymptomatic microscopic hematuria (AMH). Matthew Nielsen, MD, MS, University of North Carolina Lineberger Comprehensive Cancer Center, in Chapel Hill, wrote that there is little controversy around evaluation of patients with gross hematuria, but evaluation of patients with AMH is less clear regarding evaluation and referral.

Researchers conducted a narrative review of published clinical guidelines and peer-reviewed literature to identify practical advice for physicians. As a result of the review, Nielsen and colleagues published seven specific clinical guidelines.

They advised that physicians include gross hematuria when reviewing patient history and ask patients with microscopic hematuria about history of gross hematuria. Physicians should not use screening urinalysis for cancer detection in asymptomatic adults, the researchers wrote, or collect urinary cytology or other urine-based molecular markers for bladder cancer detection in initial hematuria evaluation.

The guidelines also state that physicians should evaluate for hematuria even for patients who are receiving antiplatelet or anticoagulant therapy.

"Physicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates three or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults," Nielsen and colleagues continued.

Additionally, all adults with gross hematuria should be referred for further urologic assessment, even if it is self-limited. Nielsen and colleagues noted that evidence has demonstrated that history of self-limited gross hematuria "may be a common, important, and significantly underreported symptom."

Patients who have microscopically confirmed hematuria but no demonstrable benign cause should be considered for urology referral for cytoscopy and imaging.

"Health care practices associated with high costs, potentially avoidable harms, and limited or no benefits provide little value," the authors concluded. "The differing algorithms of existing recommendations for the evaluation of AMH 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. These tradeoffs include both the threshold for initiating evaluation in a given case and the appropriate components of evaluation in a given circumstance. Further research is needed to strengthen the evidence base supporting a high-value approach to the evaluation of the common finding of AMH." – by Chelsea Frajerman Pardes

Disclosures: Nielsen reports personal fees from the American College of Physicians during the conduct of the study, other from Grand Rounds and Urology Care Foundation/Astellas outside the submitted work, and grants from the American Cancer Society and National Institutes of Health outside the submitted work. Please see the full study for a list of all other authors' relevant financial disclosures.