In a paper published in Annals of Internal Medicine, the American College of Physicians (ACP) issued High Value Care advice for the evaluation of blood in the urine, or hematuria, as a sign of urinary tract cancer and to help physicians make decisions about referral of patients for urological assessment.
“Physicians should be aware of risk factors for cancer when considering the finding of hematuria,” said ACP President Dr. Wayne J. Riley. “Doctors and patients need to know that visible blood in the urine, or gross hematuria, is strongly associated with cancer and other potentially serious underlying conditions.”
While there is little controversy regarding the indication for urologic evaluation for patients with gross hematuria, ACP explains in the paper, the evaluation of patients with the much more common finding of microscopic hematuria is complicated by a lack of clarity regarding indications for referral and optimal components of the evaluation.
ACP advises that physicians should include gross hematuria in their routine patient history review and specifically ask all patients with microscopic hematuria about any history of gross hematuria. Physicians should refer for further urologic evaluation all adults with gross hematuria, even if self-limited (ceases with or without specific treatment). Emerging evidence suggests that a history of self-limited gross hematuria may be a common, important, and significantly underreported symptom.
Physicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes/HPF (high-powered field) before initiating further evaluation in all asymptomatic adults.
Physicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of demonstrable benign cause. Physicians should pursue a full evaluation of hematuria even if the patient is on antiplatelet or anticoagulant therapy.
Physicians should not use screening urinalysis for cancer detection in asymptomatic adults or obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.
About ACP’s High Value Care Task Force
ACP’s High Value Care initiative is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices. ACP defines High Value Care as the delivery of services providing benefits that make their harms and costs worthwhile. ACP’s High Value Care Task Force papers focus on value by evaluating the benefits, harms, and costs of a test or intervention. Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit to justify even their low costs and might even be harmful.
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 143,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
Source: ACP
