Hematuria guidelines boost bladder Ca survival rate

Honolulu-A standardized hematuria evaluation that follows recommendations of the AUA Best Practice Guidelines appears to improve survival in patients with transitional cell carcinoma of the bladder, results of a retrospective analysis of a longitudinal database suggest.

Patients with bladder cancer diagnosed after detection of hematuria had significantly better 5-year survival compared with a contemporary cohort of bladder TCC patients in an observational study.

"To our knowledge, these are the first bladder cancer survival data derived from evaluation of hematuria," said Albert J. Mariani, MD, a urologist and chief of surgery at Hawaii Permanente Medical Group in Honolulu. "At a time when the threshold for evaluating hematuria was poorly established, we used the threshold that has been adopted by the AUA hematuria guidelines, and there was a significant difference in 5-year survival."

Between 1976 and 1985, Dr. Mariani and colleagues at Kaiser Permanente evaluated 1,000 consecutive patients with hematuria diagnosed by the current AUA criteria of three red blood cells per high-power field on two or more urinalyses or a single episode of gross hematuria (Urology 2001; 57:604-10). Results of that study showed that asymptomatic hematuria, whether gross or microscopic, is a clinically significant finding (J Urol 1989; 141:350-5).

In the current study, presented at the AUA annual meeting, bladder cancer survival among the 1,000 Kaiser patients with hematuria was compared with survival among a contemporary cohort of 771 Hawaii bladder cancer patients included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. All of the Kaiser patients underwent a standard evaluation that included intravenous urography or renal ultrasound, cystoscopy, urine culture and cytology, and other tests as indicated.

Overall, 90 cases of TCC were diagnosed among 145,000 Kaiser members in Hawaii, including 62 of the 1,000 patients evaluated for hematuria. The patients whose cancer was diagnosed subsequent to hematuria evaluation had a 5-year survival of 90%, compared with 78% for the SEER cohort (p=.038). Ten-year survival was 87% in the hematuria patients and 72% in the SEER group, a difference that did not quite reach statistical significance (p=.059).

Survival among all 90 Kaiser patients with bladder TCC was significantly better at both 5 years (88% vs. 79%, p=.049) and 10 years (84% vs. 74%, p=.045) than among the SEER cohort. Analysis of the subset of patients with grade III bladder cancer also demonstrated a significant survival advantage for Kaiser patients. Five-year survival was 70% for the Kaiser cohort and 54% for the SEER patients (p<.01), and the difference at 10 years was 56% versus 46% (p<.01). Survival did not differ among patients with localized tumors.

The data do not prove that a standardized approach to hematuria evaluation can improve survival in patients diagnosed with TCC of the bladder, Dr. Mariani acknowledged. However, the fact remains that Kaiser did have a standardized hematuria evaluation between 1976 and 1985, when the 1,000 patients had their workups, and the evaluation adhered to the principles subsequently adopted by AUA.

"Our results do support the AUA Best Practice Guidelines for evaluation of hematuria," Dr. Mariani told Urology Times.