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Cystoscopy with ultrasound effective for diagnosing asymptomatic microscopic hematuria

For evaluation of asymptomatic microscopic hematuria, a screening strategy that combines cystoscopy and renal ultrasound optimizes cancer detection and reduces costs, according to findings published in JAMA Internal Medicine.

“Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary malignant abnormality,” Joshua A. Halpern, MD, MS, from the department of urology at Weill Cornell Medicine, and colleagues wrote. “Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of [genitourinary] malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach.”

Halpern and colleagues evaluated the effectiveness, cost and incremental cost per cancer detected (ICCD) per 10,000 patients of four common diagnostic approaches for AMH including CT alone, cystoscopy alone, CT and cystoscopy combined, and renal ultrasound and cystoscopy combined, in relation to no evaluation. They used a decision-analytic model based on essential model inputs from clinical studies that analyzed adult patients with AMH on routine urinalysis with subgroups of high-risk patients, including males, smokers and those aged 50 years or older, seen in the primary care or urologic referral setting.

Data indicated that CT alone detected the fewest cancers — 221 cancers per 10,000 patients — and was dominated by all other strategies in cost-effectiveness. Compared with cystoscopy alone which detected 222 cancers, the combination of cystoscopy and renal ultrasound detected an additional 23 for a total of 245 cancers, with an ICCD of $53,820, making this strategy the most cost-effective, as well. CT and cystoscopy combined detected just one additional cancer compared with the combination of cystoscopy and ultrasound, but at a significantly higher ICCD of $6,480,484. Probabilistic sensitivity analysis revealed that in 100% of simulations, cystoscopy and ultrasound combine was the optimal approach.

“The combination of ultrasound and cystoscopy is the most cost-effective among four diagnostic approaches for the initial evaluation of AMH,” Halpern and colleagues concluded. “The use of ultrasound in lieu of CT as the first-line diagnostic strategy will reduce the cost, morbidity, and national expenditures associated with evaluation of AMH. Clinicians and policy makers should consider changing future guidelines in accordance with this finding.”

In a related commentary, Leslee L. Subak, MD, and Deborah Grady, MD, MPH, both from the University of California, San Francisco wrote that this study contains important findings and provides useful data for guideline associations reconsidering recommendations, as well as for clinicians determining on which approach to use for the evaluation of AMH.

“While cystoscopy plus renal ultrasound should be the preferred approach for initial evaluation, testing should be individualized based on shared decision making, patient characteristics, such as risk factors for genitourinary cancer, the results of prior evaluations, and patient preferences,” they concluded. “The results of this cost-effectiveness analysis provide helpful data to improve high-value care.” – by Alaina Tedesco

Disclosure: Grady and Halpern and colleagues report no relevant financial disclosures. Subak reports receiving investigator-initiated trial funding from Astellas Inc. and a grant from NIH.