Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey

Sexual dimorphism in bladder cancer: a review of etiology, biology, diagnosis, and outcomes

Bladder carcinoma represents a prevalent malignancy, wherein the influence of sex extends across its incidence, biological attributes, and clinical outcomes. This scholarly exposition meticulously examines pertinent investigations, elucidating the nuanced impact of sex on bladder cancer, and posits cogent avenues for future research and intervention modalities. In the initial discourse, an exhaustive scrutiny is undertaken of the etiological underpinnings of bladder cancer, encompassing variables such as tobacco consumption, occupational exposures, and genetic aberrations. Subsequently, a comprehensive dissection unfolds, delving into the intricate biological disparities inherent in sex vis-à-vis the initiation and progression of bladder cancer. This analytical framework embraces multifaceted considerations, spanning sex hormones, sex chromosomal dynamics, metabolic enzymatic cascades, and the intricate interplay with the microbiome. Lastly, a synthesized exposition encapsulates the ramifications of gender differentials on the diagnostic and prognostic landscapes of bladder cancer, underscoring the imperative for intensified investigative endeavors directed towards elucidating gender-specific variances and the formulation of tailored therapeutic strategies.

Gender and cystectomy for bladder cancer: A high-volume tertiary urologic care center experience

BACKGROUND

Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender.

OBJECTIVE

This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes.

MATERIALS AND METHODS

Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed.

RESULTS

The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS.

CONCLUSIONS

After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.

The Impact of the Initial Clinical Presentation of Bladder Cancer on Histopathological and Morphological Tumor Characteristics

This study investigated the impact of the initial clinical presentation of bladder cancer on tumor characteristics. A cross-sectional, retrospective study was performed, and it involved 515 patients who underwent transurethral bladder cancer resection at the University Hospital Center Split between April 2019 and April 2023, excluding recurrent cases. The association between symptomatic versus asymptomatic presentation and bladder cancer characteristics was analyzed. A subgroup analysis compared tumor characteristics between patients with gross and microscopic hematuria. Multiple regression analyses revealed a significant association between symptomatic presentation and the detection of high-grade bladder cancer (OR 3.43, 95% CI 2.22-5.29, p < 0.001), concomitant CIS (OR 3.41, 95% CI 1.31-8.88, p = 0.012), T2 stage bladder cancer (OR 5.79, 95% CI 2.45-13.71, p < 0.001), a higher number of tumors (IRR 1.24, 95% CI 1.07-1.45, p = 0.005), and larger tumor size (B 1.68, 95% CI 1.19-2.18, p < 0.001). In the subgroup analysis, gross hematuria was associated with the detection of high-grade bladder cancer (OR 2.07, 95% CI 1.12-3.84, p = 0.020), T2 stage bladder cancer (OR 6.03, 95% CI 1.42-25.49, p = 0.015), and larger tumor size (B 1.8, 95% CI 0.99-2.6, p < 0.001). The identified associations between symptomatic presentation and unfavorable bladder cancer characteristics, likely attributed to early detection in asymptomatic cases, underscore the importance of additional research in the development of bladder cancer screening strategies.

Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria

BACKGROUND & OBJECTIVE

Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations.

MATERIAL & METHODS

Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included.

RESULTS

The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup.

CONCLUSIONS

Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.

Free Ferrous Protoporphyrin and Reactive Oxygen Species Status of Voided Urine Predicts Higher Stage in Urothelial Carcinoma

Purpose

This study was conducted to evaluate the correlation between the free ferrous protoporphyrin and reactive oxygen species (FH and ROS) combined test and the tumor grade and stage in a pathologically confirmed uroepithelial carcinoma (UC) patient population.

Patients and Methods

In this retrospective study, we enrolled patients newly diagnosed with UC between May 2020 and June 2021. All patients were classified as FH(+) and ROS(+), FH(+) and ROS(-), or FH(-) and ROS(-), based on the FH and ROS combined test of voided urine. Demographic information, pathological results, and status of the FH and ROS combined test were reviewed retrospectively. The relationship between FH and ROS combined test status and tumor stage and grade was evaluated using logistic regression.

Results

This study included 120 UC patients with a median age of 69 years (interquartile range [IQR] 62–77 years). Eighteen patients (15%) were diagnosed with upper tract urothelial carcinoma, and the others (85%) were diagnosed with bladder cancer. The pathological stages for those with FH(+) and ROS(+) at diagnosis were 25.0% Ta, 45.8% T1, and 29.2% ≥T2. The pathological stages for those with FH(+) and ROS(-) at diagnosis were 23.5% Ta, 35.3% T1, and 41.2% ≥T2. The pathological stages for those with FH(-) and ROS(-) at diagnosis were 52.6% Ta, 26.3% T1, and 21.1% ≥T2. After adjusting for clinical factors, including age, sex, and smoking history, FH(+) and ROS(-) were independent risk factors for muscle-invasive UC (≥T2 stage) at diagnosis (odds ratio [OR] 3.379; 95% confidence interval [CI] 1.103–10.355; P=0.033) in the univariate and multivariate logistic regression analyses.

Conclusion

Among patients with newly diagnosed UC, FH(+) and ROS(-) might have an association with a more advanced pathological stage. This finding may help differentiate between patients with aggressive diseases and those who may benefit from organ-sparing surgery.

Does neoadjuvant chemotherapy diminish the sex disparity in bladder cancer survival after radical cystectomy?

INTRODUCTION

Sex-specific survival disparities for bladder cancer outcomes after radical cystectomy (RC) have been demonstrated in several studies. However, these studies predate the widespread adoption of neoadjuvant chemotherapy (NAC). We evaluated the differences in sex-specific survival between patients who received NAC with those who did not, using a contemporary national outcomes database.

METHODS

The National Cancer Data Base was queried from 2004 to 2015 to identify subjects who underwent RC. Kaplan-Meier method with log-rank test was performed to compare all-cause mortality between men and women at each pathologic (p) TNM stage group: T1-4N0, N+ and M+ disease. Associations for all-cause mortality were identified using an adjusted Cox regression analysis, and our findings were confirmed with a subgroup analysis.

RESULTS

A total of 9,835 subjects (7,483 men and 2,532 women) were included in the analysis. Kaplan-Meier survival curves and Cox regression analysis demonstrated female sex was not associated with worse overall survival compared to males (HR 0.947, 95%CI 0.852-1.053, P = 0.947) in the overall cohort. Stratified by pT stage and node positivity, worse overall survival was seen in women with pT4 disease who did not receive NAC compared to men (5-year OS 9.6% women vs. 15.2% men, P < 0.001), but no sex-specific difference was seen across all groups in patients who received NAC. Subgroup multivariable analysis showed that female sex conferred a survival disadvantage for pT4 (HR 1.369, P = 0.026) disease only in patients who did not receive NAC.

CONCLUSIONS

In a contemporary cohort of subjects who underwent RC, administration of NAC narrows the sex survival-gap in advanced stage bladder cancer. Strategies to improve NAC usage in women should be adopted to overcome potential sex-specific differences such as delayed diagnosis, anatomic differences in higher stage disease, or altered tumor biology which may contribute to differences in oncologic outcomes.

Recent Advances in the Management of Patients with Non-Muscle-Invasive Bladder Cancer Using a Multidisciplinary Approach: Practical Recommendations from the Spanish Oncology Genitourinary (SOGUG) Working Group

Simple Summary

This report presents clinically relevant advances in the management of non-muscle-invasive bladder cancer, which have been the focus of discussion of expert members of the Spanish Oncology Genitourinary (SOGUG) Multidisciplinary Working Group in the framework of the Genitourinary Alliance project (12GU), designed as a space for the integration of novel information in the care of bladder cancer patients. The present study is focused on different aspects regarding the evaluation of hematuria, assessment of second (or repeated) transurethral resection of bladder cancer, histopathological diagnosis and problems with tumor grading, importance of histological variants, shortage of drug supply, and the current role and influence of immunotherapy and biological markers on the oncological outcome of patients. All proposals and recommendations have a multidisciplinary practical approach and are intended to help clinicians in shared decision making for patients with non-muscle-invasive urothelial cancer.

Abstract

On the basis of the discussion of the current state of research on relevant topics of non-muscle-invasive bladder cancer (NMIBC) among a group of experts of the Spanish Oncology Genitourinary (SOGUG) Working Group, recommendations were proposed to overcome the challenges posed by the management of NMIBC in clinical practice. A unified definition of the term ‘microhematuria’ and the profile of the patient at risk are needed. Establishing a ‘hematuria clinic’ would contribute to a centralized and more efficient evaluation of patients with this clinical sign. Second or repeated transurethral resection (re-TUR) needs to be defined, including the time window after the first procedure within which re-TUR should be performed. Complete tumor resection is mandatory when feasible, with specification of the presence or absence of muscle. Budding should be used as a classification system, and stratification of T1 tumors especially in extensive and deep tumors, is advisable. The percentage of the high-grade component should always be reported, and, in multiple tumors, grades should be reported separately. Luminal and basal subtypes can be identified because of possibly different clinical outcomes. Molecular subtypes and immunotherapy are incorporated in the management of muscle-invasive bladder cancer but data on NMIBC are still preliminary.

A Fact-Finding Procedure Integrating Machine Learning and AHP Technique to Predict Delayed Diagnosis of Bladder Patients with Hematuria

Bladder cancer, the ninth most common cancer worldwide, requires fast diagnosis and treatment to prevent disease progression and improve patient survival. However, patients with bladder cancer often experience considerable delays in diagnosis. One reason for such delays is that hematuria, a major symptom of bladder cancer, has a high probability of also being a warning sign for urinary tract diseases. Another reason is that the sensitivity of the body parts affected by bladder cancer deters patients from undergoing cystoscopy and influences patients' “physician shopping” behavior. In this study, the analytic hierarchy process was used to determine critical variables influencing delayed diagnosis; moreover, the variables were used to construct models for predicting delayed diagnosis in patients with hematuria by using several machine learning techniques. Furthermore, the critical variables associated with delayed diagnosis of bladder cancer in patients with hematuria were evaluated using GainRatio technology. The study sample was selected from a population-based database. The model evaluation results indicated that the prediction model established using decision tree algorithms outperformed the other models. The critical risk factors for delayed diagnosis of bladder cancer were as follows: (1) cystoscopy performed 6 months after hematuria diagnosis and (2) physician shopping.

Sex Differences in Bladder Cancer Immunobiology and Outcomes: A Collaborative Review with Implications for Treatment

CONTEXT

Urothelial carcinoma of the bladder (UCB) exhibits significant sexual dimorphism in the incidence, etiology, and response to intravesical immunotherapy. Environmental factors such as tobacco use and clinical management issues such as delayed presentation have widely been associated with sex differences in UCB outcomes. Emerging findings from immune checkpoint blockade trials are suggestive of differential outcomes in females compared with males. Sex-specific differences in the way immune system functions and responds to pathogenic insults are well established. As such, an in-depth understanding of the genetic and epigenetic factors contributing to sex-associated differences in response to immunomodulatory therapies is needed urgently for improved management of UCB.

OBJECTIVE

To review the associations between patient sex and clinical outcomes, with a focus on the incidence, host intrinsic features, and response to therapies in UCB.

EVIDENCE ACQUISITION

Using the PubMed database, this narrative review evaluates published findings from mouse model-based and clinical cohort studies to identify factors associated with sex and clinical outcomes in bladder cancer. A scoping review of the key findings on epidemiology, genetic, hormonal, immune physiology, and clinical outcomes was performed to explore potential factors that could have implications in immunomodulatory therapy design.

EVIDENCE SYNTHESIS

Sex-associated differences in UCB incidence and clinical outcomes are influenced by sex hormones, local bladder resident immune populations, tumor genetics, and bladder microbiome. In the context of therapeutic outcomes, sex differences are prominent in response to bacillus Calmette-Guérin immunotherapy used in the treatment of non-muscle-invasive bladder cancer. Similarly, with respect to tumor molecular profiles in muscle-invasive bladder cancer, tumors from females show enrichment of the basal subtype.

CONCLUSIONS

Among proposed tumor/host intrinsic factors that may influence response to immune-based therapies, patient sex remains a challenging consideration that deserves further attention. Evidence to date supports a multifactorial origin of sexual dimorphism in the incidence and outcomes of UCB.

PATIENT SUMMARY

In this review, we highlight the sex-associated host and tumor intrinsic features that may potentially drive differential disease progression and therapeutic response in urothelial carcinoma of the bladder.

Diagnostic and treatment delays among patients with primary bladder cancer in Poland: a survey study

Introduction

The aim of this study was to determine and quantify the mechanisms responsible for the delays in bladder cancer diagnosis and initial treatment.

Material and methods

Patients referred to two academic hospitals in Poland with a primary bladder tumor were prospectively identified and structurally interviewed. For all patients, time intervals between symptom onset, diagnostic and therapeutic interventions were assessed.

Results

A total of 144 patients diagnosed with bladder cancer were included in the analysis. The median time from symptom onset to treatment was 112 days. This comprised of the following median waiting times: 1) patient waiting time of 13 days, 2) assessment waiting time of 14 days and 3) treatment waiting time of 42 days. In the multivariate analysis, large city residence (OR 0.2, 95% CI 0.1-0.6) and comorbidity (OR 0.3, 95% CI 0.1-0.8) reduced the risk of delay, whereas medium-sized city residence (OR 1.4, 95% CI 0.4-5.1) and general practitioner as the first medical professional contact (OR 5.3, 95% CI 0.6-50.0) increased the risk of delay.

Conclusions

Diagnostic and treatment waiting times for bladder cancer in Poland are unsatisfactory. Potential solutions for shortening these delays include healthcare policy changes such as utilization of the oncological priority programs, primary care education and public health campaigns.

A simplified nomogram to assess risk of bladder cancer in patients with a new diagnosis of microscopic hematuria

INTRODUCTION

The vast majority of patients who undergo a diagnostic evaluation for microscopic hematuria (MH) do not have occult bladder cancer. Identifying patients with MH at high risk of harboring bladder cancer can allow for a risk adjusted approach to diagnostic interventions with the goal of safely reducing unnecessary evaluations.

METHODS

Patients with a new diagnosis of microhematuria during an 8.5 year period were retrospectively identified. All patients who had a complete MH evaluation were randomized to a training or a validation cohort. Logistic regression analysis was performed in the training cohort to identify factors related to a bladder cancer diagnosis and to develop our model. Receiver operating curves to identify bladder cancer were constructed for the training and validation cohort and tested for their ability to discriminate true cases. A nomogram to predict a bladder cancer diagnosis was created.

RESULTS

In 4,178 patients split into training and validation cohorts, those diagnosed with bladder cancer were shown to be older, have a greater degree of MH (more RBC/hpf), and were former or current smokers. A nomogram created using this model was able to predict risk of a bladder cancer diagnosis with good discrimination (areas under the curve 0.79, 95% CI 0.75-0.83). A cutoff of 0.01 probability demonstrated a sensitivity of 99.1% and a negative predictive value of 99.7%.

CONCLUSION

A nomogram can accurately predict the risk of bladder cancer diagnosed during the evaluation of MH and can potentially be used avoid a significant number of work ups in those at the lowest risk.

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review

OBJECTIVES

In urological cancers, sex disparity exists for survival, with women doing worse than men. Suboptimal evaluation of presenting symptoms may contribute.

DESIGN

We performed a systematic review examining factors affecting the quality of the diagnostic process of patients presenting with symptoms of bladder or kidney cancer.

DATA SOURCES

We searched Medline, Embase and the Cochrane Library from 1 January 2000 to 13 June 2019.

ELIGIBLE CRITERIA

We focused on one of the six domains of quality of healthcare: timeliness, and examined the quality of the diagnostic process more broadly, by assessing whether guideline-concordant history, examination, tests and referrals were performed. Studies describing the factors that affect the timeliness or quality of the assessment of urinary tract infections, haematuria and lower urinary tract symptoms in the context of bladder or kidney cancer, were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by two authors. Due to the heterogeneity of study design and outcomes, the results could not be pooled. A narrative synthesis was performed.

RESULTS

28 studies met review criteria, representing 583 636 people from 9 high-income countries. Studies were based in primary care (n=8), specialty care (n=12), or both (n=8). Up to two-thirds of patients with haematuria received no further evaluation in the 6 months after their initial visit. Urinary tract infections, nephrolithiasis and benign prostatic conditions before cancer diagnosis were associated with diagnostic delay. Women were more likely to experience diagnostic delay than men. Patients who first saw a urologist were less likely to experience delayed evaluation and cancer diagnosis.

CONCLUSIONS

Women, and patients with non-cancerous urological diagnoses just prior to their cancer diagnosis, were more likely to experience lower quality diagnostic processes. Risk prediction tools, and improving guideline ambiguity, may improve outcomes and reduce sex disparity in survival for these cancers.

Comparison of the Harms, Advantages, and Costs Associated With Alternative Guidelines for the Evaluation of Hematuria

IMPORTANCE

Existing recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure.

OBJECTIVE

To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation.

DESIGN, SETTING, AND PARTICIPANTS

A microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018.

EXPOSURES

Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography.

MAIN OUTCOMES AND MEASURES

Urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected.

RESULTS

The simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines.

CONCLUSIONS AND RELEVANCE

In this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.

Evaluation of Hematuria in a Large Public Health Care System

Background:

Hematuria is the most common presenting symptom in bladder cancer, but many patients are not adequately evaluated.

Objectives:

To evaluate the type and frequency of hematuria evaluation in a large public health care system.

Patients and Methods:

Electronic medical records of adult patients with urinalysis positive for hematuria (≥3 RBCs/HPF) from January 2015 to April 2018 in an outpatient setting were reviewed. Logistic regression was performed to determine factors associated with urology referral and complete evaluation.

Results:

11,422 patients met the inclusion criteria; the majority were females (72%) and white race (60%). There were an additional 3,221 patient’s with initial diagnosis of UTI. Median age was 49.0 years. Testing included repeat urinalysis (50%), imaging (26%), urology referral (11.4%), cystoscopy (4.4%) and complete evaluation defined as cystoscopy and US/CT/MRI (4%). In the multivariable analysis, factors independently associated with higher referral to urology were age >35, male gender, hypertension, RBCs ≥20. African American race was associated with less referral to urology. Smoking was a significant variable on univariable analysis only. 37 patients (0.25%) were diagnosed with urological malignancies, with bladder cancer in 33, 12 of whom are missed by excluding UTI patients.

Conclusions:

In the outpatient setting of a public health care system, the vast majority of patients with hematuria are not referred and evaluated properly across all age categories and regardless of smoking status. This might result in missed cancer diagnoses and requires quality improvement measures.

Microscopic hematuria predicts lower stage in patients with upper tract urothelial carcinoma

Background

The aim of this study was to assess the association between the severity of hema-turia (microscopic or gross) and the tumor stage and grade in a population of histopathologically confirmed upper tract urothelial carcinoma (UTUC) patients.

Patients and methods

We conducted a multicenter, observational study of patients who were newly diagnosed with UTUC between January 2011 and December 2016. Demographic information, pathology, and the status of hematuria were retrospectively reviewed. The association between the severity of hematuria and the tumor stage and grade was evaluated using logistic regression.

Results

The UTUC patients presented with gross hematuria (GH, 76.7%), microscopic hematuria (MH, 11.1%), and no hematuria (12.2%) at the time of diagnosis. The pathological stages at diagnosis for those with MH were Ta in 5.1%, T1 in 47.5%, and ≥T2 in 47.5%. The stages at diagnosis for those with GH were Ta in 1.7%, T1 in 35.5%, and ≥T2 in 62.7%. On univariate and multivariate logistic regression analyses, after adjusting for clinical factors such as age, gender, and smoking history, GH was an independent risk factor for muscle-invasive UTUC (≥T2 disease) at diagnosis (OR 1.89, 95% CI 1.073–3.329; P=0.027). High-grade tumor was found in 47.8% of patients with GH and 39.0% of those with MH. The severity of hematuria was not associated with tumor grade.

Conclusion

We are the first to report evidence that microscopic hematuria at presentation accurately predicts lower pathological stage in patients with newly diagnosed UTUC. Earlier detection of disease, before the development of GH, may influence the treatment decision and survival. The type of hematuria at the time of diagnosis does not impact the tumor grade.

Implementation science theories to inform efforts for de-implementation of urologic oncology care practices resulting in overuse and misuse

The field of implementation science has been conventionally applied in the context of increasing the application of evidence-based practices into clinical care, given evidence of underusage of appropriate interventions in many settings. Increasingly, however, there is recognition of the potential for similar frameworks to inform efforts to reduce the application of ineffective or potentially harmful practices. In this article, we provide some examples of clinical scenarios in which the quality problem may be overuse and misuse, and review relevant theories and frameworks that may inform improvement activities.

Diagnostic evaluation of patients presenting with hematuria: An electronic health record-based study

BACKGROUND

To gain new insights into the origin and prevention of diagnostic delays in the evaluation of hematuria in an electronic health record (EHR)-based integrated care setting.

METHODS

We performed a retrospective review of 298 consecutive patients with new-onset hematuria at a Veterans Affairs facility from January 1, 2011 to December 31, 2013 excluding those where diagnostic evaluation was unnecessary (i.e., cystoscopy within 3 years prior). We collected data on presentation, such as red flags of painless gross hematuria (PGH) or asymptomatic microhematuria (AMH) and subsequent evaluation (imaging, urologic referral, and cystoscopy). Delay was defined when evaluation was not completed within 60 days. Logistic regression was performed to identify predictors of delay.

RESULTS

Of 201 patients, 149 had delays. PGH was present in 99 patients. These patients had a higher rate of urology referral within 1 year than patients with AMH (86.7% vs. 64.7%; P<0.01) and were more likely to undergo cystoscopy (75.8% vs. 52%; P<0.01). Delays occurred in 67% of PGH patients vs. 81% of AMH patients (OR 0.46; P = 0.02), and roughly a third were related to scheduling/coordination, patient-related issues, or delay in primary care referral. Bladder neoplasms were detected in 18% of patients with PGH and 2% of those with AMH.

CONCLUSION

Delays in evaluation for hematuria occur commonly, regardless of strength of the red-flag. Many delays were preventable and could be targeted with interventions including EHR-based tracking systems or reformed scheduling practices.

An Inexpensive, Point-of-Care Urine Test for Bladder Cancer in Patients Undergoing Hematuria Evaluation

Although hematuria (blood in urine) is the most common symptom of bladder cancer, 70-98% of hematuria cases are benign. These hematuria patients unnecessarily undergo costly, invasive, and expensive evaluation for bladder cancer. Therefore, there remains a need for noninvasive office-based tests that can rapidly and reliably rule out bladder cancer in patients undergoing hematuria evaluation. Herein, a clinical assay for matrix metalloproteinases ("Ammps") is presented, which generates a visual signal based on the collagenase activity (in urine of patients) on the Ammps substrates. Ammps substrates are generated by crosslinking gelatin with Fe(II) chelated alginate nanoparticles, which precipitate in urine samples. The cleavage of gelatin-conjugated alginate (Fe(II)) nanoparticles by collagenases generates free-floating alginate (Fe(II)) nanoparticles that participate in Fenton's reaction to generate a visual signal. In a pilot study of 88 patients, Ammps had 100% sensitivity, 85% specificity, and a negative predictive value (NPV) of 100% for diagnosing bladder cancer. This high NPV can be useful in ruling out bladder cancer in patients referred for hematuria evaluation.

Review of the Clinical Approaches to the Use of Urine-based Tumor Markers in Bladder Cancer

Bladder cancer is a common disease with a stable incidence for the past few decades despite advancements in molecular and genetic determinants of cancer development and progression. Cystoscopy remains the standard for detection and surveillance of bladder cancer, but it is an invasive and potentially costly procedure. With the knowledge of molecular alterations associated with bladder cancer numerous urine-based tumor markers have become commercially available. These urine markers have been evaluated in all clinical scenarios for the detection of bladder cancer including screening, hematuria, atypical cytology evaluation, and surveillance, but given the relative lack of impactful trials they are not routinely utilized. The efforts to develop markers with increased sensitivity to replace cystoscopy for the detection of bladder cancer have thus far been unsuccessful as well. This review addresses role of urine markers for screening, detection, and surveillance of bladder cancer.

Predictors of genitourinary malignancy in patients with asymptomatic microscopic hematuria

OBJECTIVES

To report the incidence of genitourinary malignancy and identify associated risk factors in patients undergoing urologic evaluation for asymptomatic microscopic hematuria (AMH) according to the 2012 American Urologic Association guidelines.

SUBJECTS/PATIENTS AND METHODS

A retrospective institutional review of patients who underwent evaluation for AMH between 2012 and 2015 was conducted. Covariates analyzed included age, sex, smoking status, history of other malignancy, history of pelvic irradiation, presence of irritative voiding symptoms, use of anticoagulation, number of red blood cells on microscopic urinalysis, and guideline adherence. Univariate analysis was performed to explore the association between these risk factors and the presence of genitourinary malignancy.

RESULTS

Of the 1,049 patients analyzed with AMH, urologic malignancy was diagnosed in 12 patients (1.1%), including 1 upper-tract urothelial cancer, 5 renal tumors, and 6 bladder tumors. All patients with malignancy were over 50 years old. Older age, male sex, smoking history, and irritative voiding symptoms were associated with malignancy on univariate analysis.

CONCLUSIONS

Our data adds to the growing evidence that the incidence of malignancy among patients with AMH is low. Risk factors associated with urinary tract cancer are male sex, age>50 years, smoking history, and irritative voiding symptoms. Further prospective, randomized trials would be useful for developing a more tailored screening protocol for low-risk patients.

Haematuria work-up in general care-A German observational study

BACKGROUND

Haematuria is a common finding in the population and the diagnostic workflow of this symptom represents a large proportion of "work-load" in the urological outpatient clinic.

AIMS

The intention of this study was to verify if the intensive diagnostic procedures of haematuria patients is justified by detection of a significant proportion of genito-urinary tract cancers.

MATERIALS AND METHODS

In a retrospective design 1049 consecutive patients, who presented themselves with macro- or microhaematuria in the outpatient clinic PURR in the time from 2011 to 2012, were included in the study and the diagnostic procedures including ultrasound, intravenous urography, computed tomography of the abdomen and urethrocystoscopy as well as therapeutic consequences with its results were analysed.

RESULTS

The study group comprised 570 women (54.3%) and 479 men (45.7%) with a median age of 58 years and macrohaematuria occurred in 89 patients. Diagnostics revealed seven patients with renal cell cancer, six patients with urothelial cell cancer of the renal pelvis, four patients with urothelial cell cancer of the ureter, 65 patients with urothelial cell cancer of the lower urinary tract and 17 patients with prostate cancer. Age, male gender and macrohaematuria were associated with a higher risk of cancer.

CONCLUSIONS

The high incidence of urinary tract cancer in the data presented here support the rationale for diagnostic work-up of patients with micro- or macrohaematuria. Prospective randomised trials are necessary to identify index patients for second work-up after a primarily negative investigation as well as the role of molecular markers, which possibly enable to omit invasive work-up.

Application of Electronic Algorithms to Improve Diagnostic Evaluation for Bladder Cancer

BACKGROUND

Strategies to ensure timely diagnostic evaluation of hematuria are needed to reduce delays in bladder cancer diagnosis.

OBJECTIVE

To evaluate the performance of electronic trigger algorithms to detect delays in hematuria follow-up.

METHODS

We developed a computerized trigger to detect delayed follow-up action on a urinalysis result with high-grade hematuria (>50 red blood cells/high powered field). The trigger scanned clinical data within a Department of Veterans Affairs (VA) national data repository to identify all patient records with hematuria, then excluded those where follow-up was unnecessary (e.g., terminal illness) or where typical follow-up action was detected (e.g., cystoscopy). We manually reviewed a randomly-selected sample of flagged records to confirm delays. We performed a similar analysis of records with hematuria that were marked as not delayed (non-triggered). We used review findings to calculate trigger performance.

RESULTS

Of 310,331 patients seen between 1/1/2012-12/31/2014, the trigger identified 5,857 patients who experienced high-grade hematuria, of which 495 experienced a delay. On manual review of 400 randomly-selected triggered records and 100 non-triggered records, the trigger achieved positive and negative predictive values of 58% and 97%, respectively.

CONCLUSIONS

Triggers offer a promising method to detect delays in care of patients with high-grade hematuria and warrant further evaluation in clinical practice as a means to reduce delays in bladder cancer diagnosis.

Evaluation of microscopic hematuria and risk of urologic cancer in female patients

BACKGROUND

Urologic cancer has a lower prevalence in women compared with men; however, there are no differences in the recommended evaluation for women and men with microscopic hematuria.

OBJECTIVES

The purpose of this study was to identify risk factors that are associated with urologic cancer in women with microscopic hematuria and to determine the applicability of a hematuria risk score for women.

STUDY DESIGN

We conducted a retrospective cohort study within an integrated healthcare system in Southern California. All urinalyses with microscopic hematuria (>3 red blood cells per high-power field) that were performed from 2009-2015 were identified. Women who were referred for urologic evaluation were entered into a prospective database. Clinical and demographic variables that included the presence of gross hematuria in the preceding 6 months were recorded. The cause of the hematuria, benign or malignant, was entered into the database. Cancer rates were compared with the use of chi-square and logistic regression models. Adjusted risk ratios of urologic cancer were estimated with the use of multivariate regression analysis. We also explored the applicability of a previously developed, gender nonspecific, hematuria risk score in this female cohort.

RESULTS

A total of 2,705,696 urinalyses were performed in women during the study period, of which 552,119 revealed microscopic hematuria. Of these, 14,539 women were referred for urologic evaluation; clinical data for 3573 women were entered into the database. The overall rate of urologic cancer was 1.3% (47/3573). In women <60 years old, the rate of urologic cancer was 0.6% (13/2053) compared with 2.2% (34/1520) in women ≥60 years old (P<.01). In women who reported a history of gross hematuria, the rate of urologic cancer was 5.8% (20/346) compared with a 0.8% (27/3227) in women with no history of gross hematuria (P<.01). In multivariate analysis, > 60 years old (odds ratio, 3.1; 95% confidence interval, 1.6-5.9), a history of smoking (odds ratio, 3.2; 95% confidence interval, 1.8-5.9), and a history of gross hematuria in the previous 6 months (odds ratio, 6.2; 95% confidence interval, 3.4-11.5) were associated with urologic cancers. A higher microscopic hematuria risk score was associated with an increased risk of cancer in this test cohort (P<.01). Women in the highest risk group had a urologic cancer rate of 10.8% compared with a rate of 0.5% in the lowest risk group.

CONCLUSIONS

In this female population, >60 years old and a history of smoking and/or gross hematuria were the strongest predictors of urologic cancer. Absent these risk factors, the rate of urologic cancer did not exceed 0.6%. A higher hematuria risk score correlated significantly with the risk of urologic cancer in this female test cohort.

Assessing Bladder Cancer Risk in Type 2 Diabetes Clinical Trials: the Dapagliflozin Drug Development Program as a 'Case Study'

INTRODUCTION

Dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, decreases plasma glucose levels by suppressing renal glucose reabsorption and increasing urinary glucose excretion. Previously published pre-clinical data suggest that dapagliflozin lacks carcinogenic potential. This article reviews data on bladder cancer with dapagliflozin to illustrate the challenges in assessing bladder cancer in drug development programs in patients with type 2 diabetes mellitus (T2DM).

METHODS

Clinical cases of bladder cancer were analyzed in a pooled population of >9000 patients in 21 phase 2b/3 dapagliflozin clinical trials of up to 208 weeks' duration.

RESULTS

In the 21-study pool, demographic and baseline characteristics were generally consistent between dapagliflozin and comparator groups. The overall incidence of malignancies was also balanced between the treatment groups, with an incidence rate ratio (IRR) of 1.035 [95% confidence interval (CI): 0.724, 1.481]. Nine of 5936 dapagliflozin-treated patients and 1 of 3403 comparator-treated patients reported bladder cancer, with an IRR of 5.168 (95% CI: 0.677, 233.55). All of these patients had clinical attributes typical of bladder cancer in the general population (≥60-year-old males; 8 of the 10 patients were current/former smokers). All cases of bladder cancer were reported within 2 years of starting study treatment. There was an absence of detailed workup of hematuria prior to randomization, and no hematuria workup data were collected proactively in the dapagliflozin trials, which is typical of clinical practice. Failure to exclude bladder cancer prior to randomization increases the chance of recruiting patients with pre-existing bladder cancer in clinical trials and may delay the final diagnosis. Of the nine dapagliflozin-treated patients with bladder cancer, eight had microscopic hematuria prior to start of treatment or within 6 months of initiating study treatment.

CONCLUSION

The assessment of bladder cancer data illustrates the challenges of characterizing cancer risk in T2DM drug development programs. The totality of evidence to date does not suggest a causal relationship between dapagliflozin and bladder cancer.

FUNDING

AstraZeneca.

Evaluation of microscopic hematuria: a critical review and proposed algorithm

Microscopic hematuria (MH), often discovered incidentally, has many causes, including benign processes, kidney disease, and genitourinary malignancy. The clinician, therefore, must decide how intensively to investigate the source of MH and select which tests to order and referrals to make, aiming not to overlook serious conditions while simultaneously avoiding unnecessary tests. Existing professional guidelines for the evaluation of MH are largely based on expert opinion and have weak evidence bases. Existing data demonstrate associations between isolated MH and various diseases in certain populations, and these associations serve as the basis for our proposed approach to the evaluation of MH. Various areas of ongoing uncertainty regarding the appropriate evaluation should be the basis for ongoing research.

Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink

Background

Time from symptomatic presentation to cancer diagnosis (diagnostic interval) is an important, and modifiable, part of the patient’s cancer pathway, and can be affected by various factors such as age, gender and type of presenting symptoms. The aim of this study was to quantify the relationships of diagnostic interval with these variables in 15 cancers diagnosed between 2007 and 2010 using routinely collected data from the Clinical Practice Research Datalink (CPRD) in the UK.

Methods

Symptom lists for each cancer were prepared from the literature and by consensus amongst the clinician researchers, which were then categorised into either NICE qualifying (NICE) or not (non-NICE) based on NICE Urgent Referral Guidelines for Suspected Cancer criteria. Multivariable linear regression models were fitted to examine the relationship between diagnostic interval (outcome) and the predictors: age, gender and symptom type.

Results

18,618 newly diagnosed cancer patients aged ≥40 who had a recorded symptom in the preceding year were included in the analysis. Mean diagnostic interval was greater for older patients in four disease sites (difference in days per 10 year increase in age; 95% CI): bladder (10.3; 5.5 to 15.1; P<0.001), kidney (11.0; 3.4 to 18.6; P=0.004), leukaemia (18.5; 8.8 to 28.1; P<0.001) and lung (10.1; 6.7 to 13.4; P<0.001). There was also evidence of longer diagnostic interval in older patients with colorectal cancer (P<0.001). However, we found that mean diagnostic interval was shorter with increasing age in two cancers: gastric (-5.9; -11.7 to -0.2; P=0.04) and pancreatic (-6.0; -11.2 to -0.7; P=0.03). Diagnostic interval was longer for females in six of the gender non-specific cancers (mean difference in days; 95% CI): bladder (12.2; 0.8 to 23.6; P=0.04), colorectal (10.4; 4.3 to 16.5; P=0.001), gastric (14.3; 1.1 to 27.6; P=0.03), head and neck (31.3; 6.2 to 56.5; P=0.02), lung (8.0; 1.2 to 14.9; P=0.02), and lymphoma (19.2; 3.8 to 34.7; P=0.01). Evidence of longer diagnostic interval was found for patients presenting with non-NICE symptoms in 10 of 15 cancers (mean difference in days; 95% CI): bladder (62.9; 48.7 to 77.2; P<0.001), breast (115.1; 105.9 to 124.3; P<0.001), cervical (60.3; 31.6 to 89.0; P<0.001), colorectal (25.8; 19.6 to 31.9; P<0.001), gastric (24.1; 3.4 to 44.8; P=0.02), kidney (22.1; 4.5 to 39.7; P=0.01), oesophageal (67.0; 42.1 to 92.0; P<0.001), pancreatic (48.6; 28.1 to 69.1; P<0.001), testicular (36.7; 17.0 to 56.4; P< 0.001), and endometrial (73.8; 60.3 to 87.3; P<0.001). Pooled analysis across all cancers demonstrated highly significant evidence of differences overall showing longer diagnostic intervals with increasing age (7.8 days; 6.4 to 9.1; P<0.001); for females (8.9 days; 5.5 to 12.2; P<0.001); and in non-NICE symptoms (27.7 days; 23.9 to 31.5; P<0.001).

Conclusions

We found age and gender-specific inequalities in time to diagnosis for some but not all cancer sites studied. Whilst these need further explanation, these findings can inform the development and evaluation of interventions intended to achieve timely diagnosis and improved cancer outcomes, such as to provide equity across all age and gender groupings.

Urologist referral delay and its impact on survival after radical cystectomy for bladder cancer

BACKGROUND

Evidence shows that wait times before bladder cancer surgery have been increasing, and wait time can negatively affect survival. We aimed to determine if a long delay caused by an indirect referral before a first urologist visit affects the survival of patients undergoing radical cystectomy for bladder cancer.

METHODS

We analyzed data from 1271 patients who underwent surgery for bladder cancer during the decade 2000-2009. The cohort was obtained by linking two administrative databases in the province of Quebec. Patients were considered to have been directly referred to a urologist if they had 5 or fewer visits with a general practitioner before their first urologist visit; otherwise, they were considered to have been indirectly referred. The effect on survival after surgery of a longer delay before a first urologist visit was assessed using Cox regression models.

RESULTS

Median referral delay for the study population was 30 days (56 days for women, 23 days for men; p < 0.0001). Indirect referral was observed for 49% of women and 33% of men. Compared with patients who were directly referred, those who were indirectly referred after first symptoms of bladder cancer experienced poorer survival (hazard ratio: 1.29; 95% confidence interval: 1.10 to 1.52). Women who were indirectly referred had a significant 47% greater risk of death after radical cystectomy. Men who were indirectly referred also experienced decreased survival (adjusted hazard ratio: 1.25; 95% confidence interval: 1.03 to 1.51).

CONCLUSIONS

Patients indirectly referred to a urologist had an increased risk of mortality after surgery. Compared with men, women had longer wait times and poorer survival.

Comparative Analysis of Gender-Related Differences in Symptoms and Referral Patterns prior to Initial Diagnosis of Urothelial Carcinoma of the Bladder: A Prospective Cohort Study

Objective: To analyze gender-specific differences regarding clinical symptoms, referral patterns and tumor biology prior to initial diagnosis of urothelial carcinoma of the bladder (UCB). Methods: A consecutive series of patients with an initial diagnosis of UCB was included. All patients completed a questionnaire on demographics, clinical symptoms and referral patterns. Results: In total, 68 patients (50 men, 18 women) with newly diagnosed UCB at admission for transurethral resection of bladder tumors were recruited. Dysuria was more often observed in women (55.6 vs. 38.0%, p = 0.001). Direct consultation of the urologist was conducted by 84.0% of males and 66.7% of females (p = 0.120). One third of the women saw their general practitioner and/or gynecologist once or twice (p = 0.120) before referral to the urologist. Furthermore, women were significantly more often treated for urinary tract infections than men (61.1 vs. 20.0%, p = 0.005). Cystoscopy at first presentation to the urologist was more often performed in men than women (88.0 vs. 66.7%, p = 0.068), with a more favorable tumor detection rate at first cystoscopy in men (96.0 vs. 50.0%, p < 0.001). Conclusions: Delayed referral patterns might lead to deferred diagnosis of UCB and consequently to adverse outcome. Thus, primary care physicians might consider referring patients with bladder complaints to specialized care earlier.

Variation in the intensity of hematuria evaluation: a target for primary care quality improvement

BACKGROUND

Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria.

METHODS

We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation.

RESULTS

We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis.

CONCLUSIONS

Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.

Gender disparities in hematuria evaluation and bladder cancer diagnosis: a population based analysis

PURPOSE

Men are diagnosed with bladder cancer at 3 times the rate of women. However, women present with advanced disease and have poorer survival, suggesting delays in bladder cancer diagnosis. Hematuria is the presenting symptom in most cases. We assessed gender differences in hematuria evaluation in older adults with bladder cancer.

MATERIALS AND METHODS

Using the SEER (Surveillance, Epidemiology and End Results) cancer registry linked with Medicare claims we identified Medicare beneficiaries 66 years old or older diagnosed with bladder cancer between 2000 and 2007 with a claim for hematuria in the year before diagnosis. We examined the impact of gender, and demographic and clinical factors on time from initial hematuria claim to urology visit and on time from initial hematuria claim to hematuria evaluation, including cystoscopy, upper urinary tract imaging and urine cytology.

RESULTS

Of 35,646 patients with a hematuria claim in the year preceding bladder cancer diagnosis 97% had a urology visit claim. Mean time to urology visit was 27 days (range 0 to 377). Time to urology visit was longer for women than for men (adjusted HR 0.9, 95% CI 0.87-0.92). Women were more likely to undergo delayed (after greater than 30 days) hematuria evaluation (adjusted OR 1.13, 95% CI 1.07-1.21).

CONCLUSIONS

We observed longer time to a urology visit for women than for men presenting with hematuria. These findings may explain stage differences in bladder cancer diagnosis and inform efforts to decrease gender disparities in bladder cancer stage and outcomes.

Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: a nationwide claims-based investigation

BACKGROUND

Women have disproportionately higher mortality rates relative to incidence for bladder cancer. Multiple etiologies have been proposed, including delayed diagnosis and treatment. Guidelines recommend ruling out malignancy in men and women presenting with hematuria. This study sought to determine the difference in timing from presentation with hematuria to diagnosis of bladder cancer in women versus men.

METHODS

This is a retrospective population-based study examining the timing from presentation with hematuria to diagnosis of bladder cancer, based on data from the MarketScan databases, which include enrollees of more than 100 health insurance plans of approximately 40 large US employers from 2004 through 2010. All study patients presented with hematuria and were subsequently diagnosed with bladder cancer. The primary outcome measure was number of days between initial presentation with hematuria and diagnosis of bladder cancer by sex.

RESULTS

A total of 5416 men and 2233 women met inclusion criteria. Mean days from initial hematuria claim to bladder cancer claim was significantly longer in women (85.4 versus 73.6 days, P < .001), and the proportion of women with >6 month delay in bladder cancer diagnosis was significantly higher (17.3% versus 14.1%, P < .001). Women were more likely to be diagnosed with urinary tract infection (odds ratio = 2.32, 95% confidence interval = 2.07-2.59) and less likely to undergo abdominal or pelvic imaging (odds ratio = 0.80, 95% confidence interval = 0.71-0.89).

CONCLUSIONS

Both men and women experience significant delays between presentation with hematuria and diagnosis of bladder cancer, with longer delays for women. This may be partly responsible for the sex-based discrepancy in outcomes associated with bladder cancer.

Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey

OBJECTIVES

To explore whether women experience greater delays in the diagnosis of bladder and renal cancer when first presenting to a general practitioner with symptoms caused by those cancers and potential reasons for such gender inequalities.

DESIGN

Prospective national audit survey of cancer diagnosis.

SETTING

English primary care (2009-2010).

PARTICIPANTS

920 patients with bladder and 398 patients with renal cancer (252 (27%) and 165 (42%), respectively, were women).

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients with three or more pre-referral consultations; number of days from first presentation to referral; proportion of patients who presented with haematuria and proportion of patients investigated in primary care.

RESULTS

Women required three or more prereferral consultations more often than men (27% (95% CI 21% to 33%) vs 11% (9% to 14%) for bladder (p<0.001); and 30% (22% to 39%) vs 18% (13% to 25%) for renal cancer (p=0.025)) and had a greater number of days from presentation to referral. In multivariable analysis (adjusting for age, haematuria status and use of primary care-led investigations), being a woman was independently associated with higher odds of three or more pre-referral consultations (OR=3.29 (2.06 to 5.25, p<0.001) for bladder cancer; and OR=1.90 (1.06 to 3.42, p=0.031) for renal cancer). Although presentation with haematuria was associated with more timely diagnosis of bladder cancer, gender inequalities did not vary by haematuria status for either cancer (p=0.18 for bladder and p=0.27 for renal). Each year in the UK, approximately 700 women with either bladder or renal cancer experience a delayed diagnosis because of their gender, of whom more than a quarter (197, or 28%) present with haematuria.

CONCLUSIONS

There are notable gender inequalities in the timeliness of diagnosis of urological cancers. There is a need to both reinforce existing guidelines on haematuria investigation and develop new diagnostic decision aids and tests for patients who present without haematuria.