Diagnostic pathway efficacy for urinary tract cancer: population-based outcome of standardized evaluation for macroscopic haematuria

Abstract

Objective: This study assessed a national healthcare intervention launched in Sweden in 2015 to reduce the time between macroscopic haematuria, diagnosis and treatment of urinary tract cancer. Methods: The outcome of the first 11 months was evaluated in 1697 individuals referred to a standardized care pathway for urinary tract cancer compared with 174 patients with conventionally diagnosed urothelial carcinoma. Results: Among the referred individuals, 317 (19%) were diagnosed with cancer, 1034 (61%) had a benign diagnosis and 345 (20%) had a negative evaluation. Bladder cancer was the most common malignant diagnosis [262/317 (83%)]. Cancers were diagnosed in 23% of males and 13% of females, and showed a strong correlation with age: cancer diagnosis in 2% aged <50 years and in 44% aged 90 years. Results were affected by bacteriuria but not by anticoagulant medication, with 12%/22% and 19%/19% cancer detection, respectively. The standardized care pathway shortened the diagnostic delay to a median of 25 days compared to 35 days for regular referral (p ¼ .01). However, median time to treatment was unchanged: 39 days from referral to transurethral resection, 42 days from primary resection to re-resection for stage TaG3/T1 disease and 100 days from referral to curative treatment for muscle-invasive disease. Conclusions: Macroscopic haematuria had a cancer capture rate of 19%, with higher predictive values in men and at older age, whereas anticoagulant therapy did not influence the diagnostic yield. The demonstrated lack of effect on time to treatment underscores the need to consider the entire patient process when initiating healthcare reforms to improve outcome. ARTICLE HISTORY

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

“…The main bias and applicability concerns related to the suboptimal identification and/or adjustment for confounders in 18 of the studies, 6 of which were studies using questionnaires,14–19 10 were retrospective cohort studies providing descriptive statistics mainly, using record reviews (n=5)20–24 and electronic health records (n=5),25–29 1 was a case–control study30 and 1 an ecological study 31…”

“…Ten of the 20 studies which extracted symptom information used coded information from routine or claims data,21 25 28 29 31 34 35 37–39 5 used self-reported symptoms from questionnaire and audit data,14–16 19 40 6 studies performed direct record review22 24 25 30 33 41 and 1 used coded information and record review 17…”

“…Eleven studies examined the direct association between the type of presenting symptoms and quality of the diagnostic process, the majority focusing on haematuria18 19 22 24 27 28 30 39–41 and one on UTI 42. No other presenting symptoms were examined.…”

“…Three studies examined the impact of interventions in the diagnostic pathways on diagnostic intervals in the UK and Sweden 16 20 30. A single institution UK study found that the time from GP referral to first hospital visit shortened from 42.9 to 21.3 days (p<0.001) after the introduction of the fast-track pathway, in which patients with alarm symptoms are typically seen or investigated by a specialist within 2 weeks of a GP referral 20.…”

Delay in haematuria management – how can we improve?

“…In this issue, Nilbert and colleagues present an evaluation of the standard pathway of care for haematuria introduced in Sweden in 2015 (1). Compared to patients diagnosed by conventional referral, they found that the diagnostic delay time from occurrence of haematuria to diagnosiswas reduced with median 10 days, from 35 to 25.…”