The American College of Physicians (ACP) has published new guidelines for the clinical evaluation of patients with hematuria, as reported in the Annals of Internal Medicine.
Matthew Nielsen, MD, MS, of the University of North Carolina Lineberger Comprehensive Cancer Center, and Amir Qaseem, MD, PhD, of the ACP, performed a narrative literature review of published clinical guidelines and relevant peer-reviewed studies focused on the evaluation of hematuria as a marker for occult urinary tract cancer. To aid clinicians in their evaluation of hematuria, the following 7 High-Value Care Advice statements were developed:
- High-Value Care Advice 1: Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.
- High-Value Care Advice 2: Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults.
- High-Value Care Advice 3: Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults.
- High-Value Care Advice 4: Clinicians should refer for further urologic evaluations in all adults with gross hematuria, even if self-limited.
- High-Value Care Advice 5: Clinicians should consider urology referral for cystocopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause.
- High-Value Care Advice 6: Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.
- High-Value Care Advice 7: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.
“A review of current clinical practice suggests substantial unexplained variation in referral practices for patients with hematuria, highlighting opportunities to increase awareness and define a high-value strategy to evaluate hematuria,” wrote Drs Nielsen and Qaseem.
Current evidence-based guidelines recommend against screening healthy, asymptomatic via urinalysis for the purpose of cancer detection; in their review, the U.S. Preventive Services Task Force issued this practice an “I” recommendation based on insufficient evidence surrounding the potential benefits and harms. Little controversy exists regarding the practice of urologic evaluation for patients with gross hematuria, and a lack of clarity can confuse recommendations surrounding referral and evaluation for patients with asymptomatic microscopic hematuria (AMH). American Urology Association (AUA) guidelines suggest AMH evaluation in patients 35 years and older; Canadian Urological Association (CUA) and British Association of Urological Surgeons (BAUS) guidelines suggest this same evaluation in patients older than age 40. Patients with any risk factors for cancer should be screened, regardless of age.
Harms associated with hematuria screening include anxiety and discomfort associated with transurethral cystoscopy and complications, including urinary tract infection, sepsis, and urethral stricture. Harms associated with CT urography include nephropathy from intravenous contrast and a risk for life-threatening hypersensitivity to the contrast. In addition, costs associated with hematuria evaluation can be substantial.
“The proportion of patients undergoing urinalysis with the intent of hematuria screening is unknown,” wrote Dr Nielsen. “Survey data cited previously suggest that its routine use has decreased in primary care practice in recent decades. Nevertheless, data suggest that a substantial portion of patients continue to receive this testing.”
“The differing algorithms of existing recommendations for the evaluation of AMH reflect both current uncertainty in this area of practice and differences in opinion about the implicit tradeoffs among the harms, costs, and benefits of a given approach,” Dr Nielsen concluded. “Further research is needed to strengthen the evidence base supporting a high-value approach to the evaluation of the common finding of AMH.”
- Nielsen M, Qaseem A. Hematuria as a marker of occult urinary tract cancer: Advice for high-value care from the American College of Physicians. Ann Intern Med. 2016; doi: 10.7326/M15-1496