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Brown TA, Tse JR. Discrepant guidelines in the evaluation of hematuria. Abdom Radiol (NY) 2024; 49:202-208. [PMID: 37971572 DOI: 10.1007/s00261-023-04091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 08/24/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To assess discrepancies in current imaging recommendations for hematuria among North American societies: American College of Radiology (ACR), American Urological Association (AUA), and Canadian Urological Association (CUA). METHODS The latest available ACR Appropriateness Recommendations, AUA guidelines, and CUA guidelines were reviewed. AUA and CUA guidelines imaging recommendations by variants and level of appropriateness were converted to match the style of ACR. Imaging recommendations including modality, anatomy, and requirement for contrast were recorded. RESULTS Clinical variants included microhematuria without risk factors, microhematuria with risk factors, gross hematuria, and microhematuria during pregnancy. CUA recommends ultrasound kidneys as the first-line imaging study in the first 3 variants; pregnancy is not explicitly addressed. For hematuria without risk factors, ACR does not routinely recommend imaging, while AUA recommends shared decision-making to decide repeat urinalysis versus cystoscopy with ultrasound kidneys. For hematuria with risk factors and gross hematuria, ACR recommends CT urography; MR urography can also be considered in gross hematuria. AUA further stratifies intermediate- and high-risk patients, for which ultrasound kidneys and CT urography are recommended, respectively. For pregnancy, ACR and AUA both recommend ultrasound kidneys, though AUA additionally recommends consideration of CT or MR urography after delivery. CONCLUSION There is no universally agreed upon algorithm for diagnostic evaluation. Discrepancies centered on the role of upper tract imaging with ultrasound versus CT. Prospective studies and/or repeat simulation studies that apply newly updated guidelines are needed to further clarify the role of imaging, particularly for patients with microhematuria with no and intermediate risk factors.
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Affiliation(s)
- Terrell A Brown
- School of Medicine, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, USA
| | - Justin R Tse
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Lin OM, Paine D, Gramling E, Menon M. Disparities in Time to Diagnosis Among Patients With Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e379-e385. [PMID: 37612207 DOI: 10.1016/j.clml.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Multiple myeloma (MM) is one of the most diagnosed hematologic malignancies in the United States. Despite improvements in therapy, health disparities persist among patients with MM. Here, we aim to determine whether there are disparities in time to diagnosis (TTD) among MM patients with regard to income, race/ethnicity, and gender. PATIENTS Patients with a monoclonal protein detected in the serum and/or urine and a subsequent bone marrow biopsy confirmed diagnosis of MM were included in the study. METHODS We extracted data on patients with MM and assessed whether the predictor variables were associated with the primary outcome of TTD, which we define as the time between detection of a monoclonal protein in the serum or urine and bone marrow biopsy diagnosis of MM. RESULTS Compared to patients with commercial insurance, patients receiving Medicaid (HR: 0.408, 95% CI: 0.206-0.808; P = .010) and patients without insurance (HR: 0.428, 95% CI: 0.207-0.885; P = .022) were significantly more likely to have delayed TTD. TTD was also prolonged if the provider who ordered the testing for the detection of a monoclonal protein was not a hematologist (HR: 0.435, 95% CI: 0.284-0.668; P < .0001). No disparities were found with regard to race/ethnicity or gender. CONCLUSION This study suggests there may be socioeconomic disparities in TTD among patients with MM. Interventions such as patient navigation may be useful to reduce TTD among socioeconomically disadvantaged patient populations. Further studies need to be conducted to elucidate reasons for delays.
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Affiliation(s)
- Olivia M Lin
- Department of Medicine, University of Washington, Seattle, WA.
| | - Dana Paine
- Department of Medicine, University of Washington, Seattle, WA
| | - Esther Gramling
- Department of Medicine, University of Washington, Seattle, WA
| | - Manoj Menon
- Department of Medicine, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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Estevez A, Kaul S, Fleishman A, Korets R, Chang P, Wagner A, Bellmunt J, Olumi AF, Rayala H, Gershman B. Disparities in the prevalence and management of high-risk non-muscle invasive bladder cancer. Urol Oncol 2022; 41:255.e15-255.e21. [PMID: 36456453 DOI: 10.1016/j.urolonc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/05/2022] [Accepted: 11/03/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the associations of socioeconomic characteristics with the management of non-muscle invasive bladder cancer (NMIBC). METHODS We identified adult patients aged 18 to 89 years with Ta, T1, or Tis NMIBC in the NCDB. We then examined the associations of patient and socioeconomic characteristics with the guidelines-based management of high-risk NMIBC using multivariable logistic regression. RESULTS 163,949 patients were included in the study cohort, including 64% with Ta, 32% with T1, and 4% with Tis disease. Among those diagnosed with bladder cancer, male (OR 1.24, 95%CI 1.21-1.27), uninsured (OR 1.10, 95%CI 1.01-1.19 vs. private), and non-White (OR 1.34, 95%CI 1.28-1.41 for Black; OR 1.10; 95%CI 1.03-1.18 for Other vs. White) patients were more likely to be diagnosed with high-risk disease, as well as patients from lower education level areas. Among those with high-risk NMIBC, patients who were older, non-White, Hispanic, uninsured or insured with Medicaid were less likely to receive guideline recommended intravesical BCG, while those residing in rural and higher education level areas were more likely to receive BCG. When examining non-guidelines based use of radiotherapy for HGT1 disease, older age (OR 1.06; 95% CI 1.04-1.07) and VA/Military insurance (OR 2.73; 95%CI 1.07, 6.98 vs. private) were associated with radiotherapy use. CONCLUSION There are strong disparities in the prevalence and management of high-risk NMIBC. These observations highlight important targets for future strategies to reduce such healthcare disparities and provide more equitable bladder cancer treatment to patients.
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Rai BP, Luis Dominguez Escrig J, Vale L, Kuusk T, Capoun O, Soukup V, Bruins HM, Yuan Y, Violette PD, Santesso N, van Rhijn BWG, Hugh Mostafid A, Imran Omar M. Systematic Review of the Incidence of and Risk Factors for Urothelial Cancers and Renal Cell Carcinoma Among Patients with Haematuria. Eur Urol 2022; 82:182-192. [PMID: 35393159 DOI: 10.1016/j.eururo.2022.03.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/12/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022]
Abstract
CONTEXT The current impact of haematuria investigations on health care organisations is significant. There is currently no consensus on how to investigate patients with haematuria. OBJECTIVE To evaluate the incidence of bladder cancer, upper tract urothelial carcinoma (UTUC), and renal cell carcinoma (RCC) among patients undergoing investigation for haematuria and identify any risk factors for bladder cancer, UTUC, and RCC (BUR). EVIDENCE ACQUISITION Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov were searched for all relevant publications from January 1, 2000 to June 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Prospective, retrospective, and cross-sectional studies with a minimum population of 50 patients with haematuria were considered for the review. EVIDENCE SYNTHESIS A total of 44 studies were included. The total number of participants was 229701. The pooled incidence rate for urothelial bladder cancer was 17% (95% confidence interval [CI] 14-20%) for visible haematuria (VH) and 3.3% (95% CI 2.45-4.3%) for nonvisible haematuria (NVH). The pooled incidence rate for RCC was 2% (95% CI 1-2%) for VH and 0.58% (95% CI 0.42-0.77%) for NVH. The pooled incidence rate for UTUC was 0.75% (95% CI 0.4-1.2%) for VH and 0.17% (95% CI 0.081-0.299%) for NVH. On sensitivity analysis, the proportions of males (risk ratio [RR] 1.14, 95% CI 1.10-1.17 for VH; 1.54, 95% CI 1.34-1.78 for NVH; p < 0.00001; moderate certainty evidence) and individuals with a smoking history (RR 1.41, 95% CI 1.24-1.61 for VH; 1.53, 95% CI 1.36-1.72 for NVH; p < 0.00001; moderate certainty evidence) appeared to be higher in BUR than in non-BUR groups. CONCLUSIONS Male gender and smoking history are risk factors for BUR cancer in haematuria, with bladder cancer being the commonest cancer. The incidence of RCC and UTUC in NVH is low. The review serves as a reference standard for future policy-making on investigation of haematuria by global organisations. PATIENT SUMMARY Our review shows that male gender and smoking history are risk factors for cancers of the bladder, kidney, and ureter. The review also provides information on the proportion of patients who have cancer when they have blood in their urine (haematuria) and will allow policy-makers to decide on the most appropriate method for investigating haematuria in patients.
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Affiliation(s)
- Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | | | - Luís Vale
- Department of Urology, Centro Hospital Universitário S. João, Porto, University of Porto, Porto, Portugal
| | - Teele Kuusk
- Department of Urology, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, UK
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Harman M Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Cochrane Canada Centre, McMaster University, Hamilton, ON, Canada
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
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Bladder Cancer Screening, Signs and Symptoms, and Workup. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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A simplified nomogram to assess risk of bladder cancer in patients with a new diagnosis of microscopic hematuria. Urol Oncol 2020; 38:240-246. [PMID: 31952999 DOI: 10.1016/j.urolonc.2019.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/04/2019] [Accepted: 12/08/2019] [Indexed: 01/11/2023]
Abstract
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.
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Zhou Y, van Melle M, Singh H, Hamilton W, Lyratzopoulos G, Walter FM. Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review. BMJ Open 2019; 9:e029143. [PMID: 31585970 PMCID: PMC6797416 DOI: 10.1136/bmjopen-2019-029143] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/27/2019] [Accepted: 07/24/2019] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Marije van Melle
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Georgios Lyratzopoulos
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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