A 9-month delay in diagnosis of bladder cancer after a first hematuria diagnosis significantly increases mortality risk.
Diagnosis within 3 months of a first hematuria episode increased survival by almost 2 years compared with diagnosis delayed beyond 9 months. Delay in diagnosis also was associated with increased need for major surgical interventions, including surgery, said Ryan Hedgepeth, MD, a clinical lecturer in urology at the University of Michigan.
The differences could not be explained by more advanced disease stage or grade.
About 10% of patients with hematuria have an underlying life-threatening disease. However, hematuria is not specific for bladder cancer and can be associated with several neoplastic and non-neoplastic diseases, including urinary tract infection. This lack of specificity may lead some physicians to delay further evaluation of hematuria, said Dr. Hedgepeth.
Cancer stage, grade are not factors
To determine potential hazards of delayed follow-up of hematuria, Dr. Hedgepeth and colleagues queried the National Cancer Institute's Medicare-linked Surveillance, Epidemiology, and End Results database. They identified 29,740 patients who had hematuria within the year preceding cancer diagnosis during 1992-2002 and then grouped the patients according to the time interval between hematuria and diagnosis.
Dr. Hedgepeth reported that 2,084 patients had a delay of 9 months from first claim for hematuria and diagnosis of bladder cancer. Compared with patients whose delay was 3 months or less, a delay of 9 months or longer increased mortality risk by a third (HR 1.34, 95% CI 1.20-1.50). After adjustment for disease stage and grade at diagnosis, a 30% increased mortality risk persisted (HR 1.29, 95% CI 1.14-1.45), he reported at the AUA annual meeting in Chicago.
Median survival was 70.9 months in patients whose diagnosis occurred within 3 months of a first hematuria, declining to 50.9 months for patients whose bladder cancer diagnosis was delayed for 9 months or longer. Longer delays in diagnosis were associated with older age and increased comorbidity.
Cancer stage and grade at diagnosis were similar across the range of intervals from less than 3 months to 9 months or longer. In fact, patients with low-grade disease and a diagnosis interval of 9 months or more had a twofold increase in the risk of bladder cancer mortality compared with patients whose low-grade disease was diagnosed within 3 months of hematuria (HR 2.11, 95% CI 1.69-2.64). In contrast, delayed diagnosis was associated with a 10% increased risk of bladder cancer mortality in patients who had high-grade cancer.
Delayed diagnosis significantly increased the likelihood of major interventions (10.1% vs. 8.6%, p=.04), including the likelihood of radical cystectomy (6.2% vs. 5.8%, p=.04).
Nearly 25% of the patients in the study had a delay in diagnosis of 3 months or more after the first Medicare claim for hematuria. Both bladder cancer mortality and overall mortality began to increase when the delay reached 3 months.