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American College of Physicians Issues Advice for Evaluating Hematuria as a Marker of Urinary Tract Cancer

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Key Points

  • A review of available clinical guidelines on the evaluation of hematuria has found substantial variation in urologic referral practices for patients with hematuria.
  • The study’s findings highlight opportunities to increase awareness and define a high-value strategy to evaluate hematuria as a sign of urinary tract cancer.
  • Further research is needed to strengthen the evidence base supporting a high-value approach to the common finding of asymptomatic microscopic hematuria.

Although little controversy exists regarding the indication for urologic evaluation for patients with gross hematuria, the evaluation of patients with the much more common finding of microscopic hematuria is complicated by a lack of clarity regarding indications for clinical referral, according to a review of current clinical practice by the American College of Physicians’ High Value Care Task Force by Nielsen et al published in Annals of Internal Medicine. The Task Force findings highlight opportunities to increase awareness and define a high-value strategy to evaluate hematuria as a sign of urinary tract cancer. 

Study Methodology and Findings

The study authors conducted a narrative literature review of published clinical guidelines that addressed the evaluation of hematuria as a marker of occult urinary tract cancer and other relevant studies from peer-reviewed literature.

To avoid unnecessary, invasive, and expensive testing and procedures in patients with hematuria, the American College of Physicians offers the following advice to clinicians for high-value care on the evaluation of hematuria as a marker of occult urinary tract cancer:

  1. Include gross hematuria in the routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.
  2. Do not use screening urinalysis for cancer detection in asymptomatic adults.
  3. 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.
  4. Refer all adults with gross hematuria, even if self-limited, for further urologic evaluation.
  5. Consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause.
  6. Pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.
  7. Do not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.

“Further research is needed to strengthen the evidence base supporting a high-value approach to the common finding of AMH [asymptomatic microscopic hematuria],” concluded the study’s authors.

Amir Qaseem, MD, PhD, MHA, of the American College of Physicians, is the corresponding author of this article in the Annals of Internal Medicine.

Matthew Nielsen, MD, MS, reported personal fees from the American College of Physicians during the conduct of this study, other fees from Grand Rounds and Urology Care Foundation/Astellas outside the submitted work, and grants from the American Cancer Society and the National Institute of Health outside the submitted work. The other authors reported no potential conflicts of interest.

Funding for this study was provided by the American College of Physicians.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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