Progress towards a Nordic standard for the investigation of hematuria: 2019

Abstract

Objective: To describe the management of patients with hematuria in the Nordic countries in relation to bladder cancer epidemiology, especially in the context of introducing fast track pathways with the aim of proposing a common guideline. Materials and methods: Epidemiological data on bladder cancer from each country, and the combined cancer registry, Nordcan, were analyzed. The evolution of the different national recommendations and the introduction of fast track pathways were assessed. Patients' demographics, type of hematuria and cancer detection rates were analysed if available. Results: The crude incidence of bladder cancer has increased substantially since the 1960s, while the age standardized incidence has been stable during recent decades. The relative survival has increased in all countries, while the mortality has been stable. For those with microscopic hematuria there has been a clear trend towards less rigorous investigations. In the fast track pathways, introduced in three of five countries, about one in five patients with macroscopic hematuria had a cancer diagnosis. Data show that time to diagnosis has been reduced. Conclusions: The number of patients with bladder cancer is increasing in the Nordic region. The introduction of fast track pathways has been important in improving the management of patients with suspicion of the disease. Our recommendation is to focus on macroscopic hematuria in the fast track pathways. Microhematuria without any symptoms should not be an indication for cystoscopy. However, urinary tract symptoms accompanied by microhematuria can still be investigated according to respective guidelines but not necessarily within fast track pathways.

Diagnostic accuracy of ultrasonography, computed tomography, cystoscopy and cytology to detect urinary tract malignancies in patients with asymptomatic hematuria

“…For example Scandinavian guidelines argue against any investigation in patients with NVH(Skaaheim Haug et al 2019) whereas the American Urology Association (AUA) recommends cystoscopy and computed tomography (CT) in all patients >35 years and specify that in patients <35 years work-up is recommended "according to the treating physician's discretion" (Davis et al 2012).…”

Observational study on time on treatment with abiraterone and enzalutamide

“…There has been concern that use of ART drugs in clinical practice is continued too long and given that these drugs are expensive and are used by a large number of men with mCRPC, this could have large financial implications. A wide range in time on treatment for these drugs has been reported in previous observational studies, ranging from 3 to 20 months (S1 Table) [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25].…”

“…treatment for ART with a range from 3 up to more than 20 months, likely due to differences in study design, study population, and definition of drug stop [13][14][15][17][18][19][20][21][22][23][24][25].…”

Assessment of Diagnostic Yield of Cystoscopy and Computed Tomographic Urography for Urinary Tract Cancers in Patients Evaluated for Microhematuria

“…The National Board of Health and Welfare of Sweden (Socialstyrelsen) endorses no evaluation of patients with MH. 5 …”

“…The National Board of Health and Welfare of Sweden (Socialstyrelsen) endorses no evaluation of patients with MH. 5 More than 10 years ago, intravenous urography was replaced by CT urography as the preferred imaging modality for the upper urinary tract because of its higher accuracy in detecting upper tract urothelial carcinoma (UTUC) and kidney cell carcinoma (KCC). Nevertheless, some studies have questioned the use of CT urography as first-line imaging given the low prevalence of UTUC and concerns about radiation exposure (especially among young patients with MH) as well as the possible consequences of false-positive findings.…”