Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians

BACKGROUND: The presence of blood in the urine, or hematuria, is a common finding in clinical practice and can sometimes be a sign of occult cancer. This article describes the clinical epidemiology of hematuria and the current state of practice and science in this context and provides suggestions for clinicians evaluating patients with hematuria. METHODS: A narrative review of available clinical guidelines and other relevant studies on the evaluation of hematuria was conducted, with particular emphasis on considerations for urologic referral. HIGH-VALUE CARE ADVICE 1: Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria. HIGH-VALUE CARE ADVICE 2: Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults. HIGH-VALUE CARE ADVICE 3: Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults. HIGH-VALUE CARE ADVICE 4: Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited. HIGH-VALUE CARE ADVICE 5: Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause. HIGH-VALUE CARE ADVICE 6: Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy. HIGH-VALUE CARE ADVICE 7: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria