A MODEL-BASED COMPARISON OF EVALUATION STRATEGIES FOR URINARY TRACT MALIGNANT TUMORS IN PATIENTS WITH ASYMPTOMATIC MICROSCOPIC HEMATURIA

Purpose: Asymptomatic microscopic hematuria (AMH) is common in the general adult population. AMH is considered a risk factor for urinary tract malignant tumors and its presence is a frequent reason for urologic referral. The recommendations for evaluation and management of patients with asymptomatic microscopic hematuria vary among different clinical practice guidelines, with approaches ranging from extensive evaluations of the majority of patients to patient risk-stratification to avoid unnecessary workup. The purpose of this study was to compare the US guidelines with international guidelines and alternative evaluation strategies for urinary tract malignant tumors in adult patients with asymptomatic microscopic hematuria. 

Method: We used a patient-level microsimulation model from the perspective of a US public insurance payer to assess different initial evaluation strategies for urinary tract cancers in a hypothetical cohort of 100,000 adult AMH patients. The analytic horizon was one urology clinic visit. We compared the benefits and trade-offs in terms of costs per patient, cancer detection rates (including missed cancer cases), secondary cancers and related mortality from radiation exposure as well as the burden of procedural complications and incidental findings. We also calculated the incremental cost effectiveness ratios (ICERs) for the different evaluation strategies as incremental cost per additional cancer case detected.

Result: The American Urological Association (AUA) guidelines recommending extensive evaluations for all AMH patients, including multi-phasic computed tomography (CT), were associated with a greater number of detected cancer cases at a higher cost than the alternative risk-stratification evaluation strategies. The AUA strategy had an ICER of over $200,000 per additional cancer case detected compared to an evaluation strategy stratifying patients in three risk groups using a Hematuria Risk Index. In addition, the AUA guidelines were associated with a higher number of radiation-induced cancer cases, deaths from radiation-induced cancer, short-term procedural complications, and incidental findings than the alternative evaluation strategies using patient risk-stratification.

Conclusion: Risk-stratification of AMH patients is an important way to avoid unnecessary workup and complications by tailoring initial evaluation based on patients’ risk for developing urinary tract malignancies. The results from this study suggest that low-risk AMH patients can avoid extensive workup altogether while medium-risk AMH patients can undergo a less intensive initial evaluation than that recommended by the AUA.