Hematuria, or blood in the urine, is commonly encountered in clinical practice, with over 2 million American patients referred to urologists annually. The association of this finding with occult urinary tract cancer led to the development of several guidelines, with differing recommendations for evaluation. A study led by investigators at UNC published in this week’s print edition of JAMA Internal Medicine explores the tradeoffs of these different approaches.

Matthew Nielsen, Associate Professor of Urology and Adjunct Associate Professor of Epidemiology and Health Policy & Management, was the corresponding author for the study. Other UNC-affiliated investigators include Mihaela Georgieva, Stephanie Wheeler, and Daniel Erim, from the Department of Health Policy and Management, and Mathew Raynor from the Department of Urology.

About The Study

The authors synthesized information from the published literature to create a computer-based microsimulation model of 100,000 patients presenting with hematuria. This study design permitted estimation of urinary cancer detection rates, costs, and harms, in particular, the risk of radiation-induced future cancer associated with exposure to CT imaging, across the recommendations from five current guidelines.

The most intensive recommendation, recommending CT and cystoscopy for all adults, was associated with marginally higher cancer detection rates, though this cost twice as much per patient evaluated and was associated with an estimated risk of radiation-induced future cancer in more than one out of 200 patients evaluated, more than 10 times higher than the additional number of cancers detected. The authors conclude, “The balance of harms, advantages, and costs of hematuria evaluation may be optimized by risk stratification and more selective application of diagnostic testing in general and computed tomography imaging in particular.”

An accompanying editorial notes that “this study sets a good example for future guidelines development,” involving CT imaging, to the extent that the “morbidity and mortality associated with these radiation-induced cancers cannot be ignored.” More information about the study can be found in a New England Journal of Medicine Journal Watch podcast interview with Dr. Nielsen (found below).

Hematuria — should the workup include imaging?

August 8th, 2019
From: Clinical Conversations |
Audio podcasts featuring the week’s news, plus your comments and pertinent interviews.

 

Matthew Nielsen and colleagues found almost 80 diagnostic algorithms for working up a finding of hematuria. From these, they chose five representative approaches, ranging from those based on the patients’ risk factors to more aggressive ones that stress CT imaging for all.

Using a 100,000-patient simulated cohort, Nielsen’s group found that more intensive imaging found more cancers than the other approaches. However, radiation-induced cancers from CT wiped out that advantage.

Join us as Dr. Nielsen walks through his findings and their clinical implications. The work appeared in JAMA Internal Medicine.