SAN DIEGO—Women who report irritative voiding symptoms should have their risk for bladder cancer assessed, even if they do not have hematuria, according to data presented here at the joint meeting of the American Urogynecologic Society and the Society for Gynecologic Surgeons.
“We found that most patients with bladder cancer did not present with hematuria,” said Roger P. Goldberg, MD, MPH, Director of Urogynecology Research at the Evanston Continence Center of Northwestern University Medical School and a clinical instructor in obstetrics and gynecology at the Feinberg School of Medicine there, in presenting the findings.
“The absence of hematuria, therefore, does not determine whether or not cystoscopy is necessary.”
“This was a large-scale series where we could identify the prevalence of bladder cancer in women with irritative voiding symptoms,” he said in a follow-up telephone interview.
“The question is: Who should we be worried about? There's been a general thought that if there's no microscopic hematuria, the patient is at low risk, but 60% of our bladder cancer patients lacked such findings.”
Dr. Goldberg and his co-investigators conducted the study because they wanted to know whether hematuria predicted the risk of bladder cancer in women who were being evaluated for irritative voiding symptoms. They also wanted to know whether the presence or absence of this finding could be used to determine whether cystoscopy was necessary in the setting of a tertiary urogynecology practice.
The study included all 1,582 women who had been evaluated by office cystourethroscopy for irritative voiding symptoms at the center from 1991 to 2001.
All of the patients had undergone urethroscopy and cystoscopy with the bladder distended to maximum cystometric capacity. In cases that involved hematuria, bladder lesions or other factors that would cause physicians to suspect occult malignancy, the staff had sent washings for cytologic evaluation.
The presence of suspicious gross lesions prompted a referral to a urological oncologist.
The patients were an average of 60 years old and ranged from 17 to 95. Among them, 8.2% were active smokers, 47.5% had had prior pelvic surgery, and 10.8% had had a prior non-urologic malignancy.
The attending physicians diagnosed bladder cancer in 10 patients, including nine cases of transitional cell carcinoma and one of superficial squamous cell cancer.
Among the nine transitional cell carcinoma lesions, the biopsy showed that eight were superficial and one was invasive. No patients had adenocarcinoma or metastatic lesions from other primary sites.
Among women with hematuria the rate of cancer was 1.7%, compared with 0.45% among those without hematuria. Among the 10 bladder cancer cases, six had no hematuria.
Only Independent Predictive Risk Factor: Age
The analysis showed that age was the only independently predictive risk factor. The women with cancer were an average of 71.2 years old, compared with age 51.6 for those without cancer. The youngest woman with bladder cancer was 59 years old.
A total of 30% of bladder cancer patients had prior non-urologic malignancy, vs 11% of those without bladder cancer. Among patients with bladder cancer, 40% had microscopic or frank hematuria, vs 14% of those who did not.
The vast majority of bladder cancer patients—90%—had dysuria, compared with 34% of those without. More bladder cancer patients (40%) had bladder tenderness by transvaginal palpation than did those without cancer (15%).
Similar Rates among Smokers & Non-smokers
Individuals with bladder cancer and those without had similar rates of smoking, Dr. Goldberg said. “Smoking was not predictive, but we only had information on current status,” with no data on former smokers.
“Therefore, a nonsmoker with nonspecific symptoms and no blood is not someone we should rule out. The absolute risk was relatively low, but in 60% of cancers, you won't have a specific symptom” like hematuria, he said.
Although cystourethroscopy is a comprehensive way to diagnose bladder cancer in such patients, physicians will still need to weigh its expense against the potential yield, Dr. Goldberg reported. However, other factors other than the presence or absence of hematuria may be more helpful.
“Risk factors in the past have been blood in the urine and age over 50,” he continued.
“This study argues for a low threshold of concern if a woman has unexplained lower urinary tract symptoms, and we can't be overly reassured by the presence of a normal urinalysis. It argues for being more aggressive.”
“Although patients with bladder cancer are more likely to have blood in their urine, the findings show that this is not often the case,” James Montie, MD, Chair of Urology at the University of Michigan Comprehensive Cancer Center, commented in a phone interview.
“We need to be concerned about patients with irritative bladder symptoms. If a patient has persistent urgency, frequency, and pain, she needs to be evaluated. We need to know that the absence of hematuria does not rule out bladder cancer.”