May 22, 2014

Urologic cancer studies point to need for referral education

Women with blood in their urine (hematuria) were less than half as likely as men with the same issue to be referred to a urologist for further tests, according to a new VUMC study.

Women with blood in their urine (hematuria) were less than half as likely as men with the same issue to be referred to a urologist for further tests, according to a new VUMC study.

The findings may help explain why women with bladder cancer are often diagnosed at a later stage in the disease and have worse mortality than men.

The study, presented by Jeffrey Bassett, M.D., MPH, fellow in Urologic Oncology, and Daniel Barocas, M.D., MPH, principal investigator and assistant professor of Urologic Surgery, was shared during the American Urological Association (AUA) annual conference held May 16-21 in Orlando, Florida, and was one of two VUMC studies selected for the AUA press program.

Blood in the urine is often the first sign of bladder cancer. The AUA recommends that everyone over the age of 35 with hematuria not due to a benign cause receive an evaluation that includes looking inside the bladder (called cystoscopy) as well as imaging of the urinary tract.

For this study, investigators reviewed the records of a random sample of 9,211 Medicare beneficiaries diagnosed with hematuria between January 2009 and June 2010. Only 17 percent of females with a diagnosis of hematuria from their primary care provider were referred to a urologist for a diagnostic workup within 180 days, compared to 39 percent of men.

“The data in the literature suggest that the misdiagnosis and treatment of hematuria in women as urinary tract infection is one of the main reasons why they present with more advanced stage bladder cancer at diagnosis,” said Bassett.

Some of the difference may be clinical decision-making by physicians who know that women are less likely to have bladder cancer than men. But Barocas said the disparities suggest physicians may need to be more vigilant.

“We are missing opportunities to diagnose these cancers early enough. Because we see such advanced disease in women and they are worked up for hematuria so much less frequently, there may be a need to figure out how to risk stratify women to know whether or not they need a workup,” said Barocas.

This study was funded by a grant from the National Cancer Institute, a division of the National Institutes of Health (1R03CA173807-01).

The second study involved a review of 6,462 National Cancer Database records from patients who underwent surgery for testicular cancer between 2004-2011. Testis cancer is the most common cancer among men under 35, and testing for blood markers is recommended for those suspected of having the disease.

The study presented by C.J. Stimson, M.D., J.D., resident in Urologic Surgery, and Sam Chang, M.D., Patricia and Rodes Hart Professor of Urologic Surgery, found that 25 percent of men suspected of having testis cancer did not have blood drawn to test for cancer biomarkers.

Patients treated at academic medical centers or in certain geographic regions were more likely to receive these tests.

“Those blood markers are elevated about 60 to 80 percent of the time in men with testis cancer,” said Chang. “They at times can help with the diagnosis regarding the type of testis cancer but also are important for the staging. The higher the markers then the more concerned we are about more aggressive or advanced disease.”

Chang said the disparities in testing indicate that clinicians may need more education about when to refer men for further evaluation.