ACP advice for evaluating blood in the urine as a sign of cancer
1. ACP issues advice for evaluating blood in the urine as a sign of cancer
Blood in the urine is a common finding in adults during primary care visits
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-1496
In a paper published in Annals of Internal Medicine, the American College of Physicians (ACP) issued advice for the evaluation of blood in the urine, or hematuria, as a sign of urinary tract cancer and to help physicians make decisions about referral of patients for urological assessment.
While there is little controversy regarding the indication for urologic evaluation for patients with gross hematuria, ACP explains in the paper, the evaluation of patients with the much more common finding of microscopic hematuria is complicated by a lack of clarity regarding indications for referral and optimal components of the evaluation. ACP offers physicians the following advice:
- Include gross hematuria in their routine patient history review and specifically ask all patients with microscopic hematuria about any history of gross hematuria. Adults with gross hematuria, even if self-limited (ceases with or without specific treatment) should be referred for further urologic evaluation.
- Confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes/HPF (high-powered field) before initiating further evaluation in all asymptomatic adults.
- Consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of demonstrable benign cause. Physicians should pursue a full evaluation of hematuria even if the patient is on antiplatelet or anticoagulant therapy.
- Do not use screening urinalysis for cancer detection in asymptomatic adults or obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.
Media Contact: For embargoed PDFs of the full paper and press release, please contact Cara Graeff. To interview someone from ACP, please contact Steve Majewski at [email protected] or 215-351-2514.
2. Fecal immunochemical test effective for annual colon cancer screening
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According to a study published in Annals of Internal Medicine, the fecal immunochemical test (FIT) is highly sensitive for detecting colorectal cancer, and adherence to annual follow-up screening among initial participants is high, making the non-invasive test feasible and effective for annual colorectal cancer screening programs.
Colorectal cancer is the second leading cause of cancer death in the United States. Evidence shows that highly sensitive guaiac-based fecal occult blood tests (FOBT), which are recommended for annual screening of average risk patients between the ages of 50 and 75, can reduce morbidity and mortality from colorectal cancer. But community screening programs can only be successful if people participate. FIT screening is another noninvasive option that can be delivered by mail and does not require any dietary or medication restrictions, making it easy for people to comply. FIT also has higher detection rates for CRC and advanced adenomas than FOBT, but little is known about how well FIT works over several rounds of annual screening.
Researchers collected data on a large cohort of patients from Kaiser Permanente Northern and Southern California over four rounds of annual screening with FIT. Sensitivity was highest during the first round of testing (84.5 percent) and became lower but stable over subsequent years (73.4 to 78.0 percent). Over 4 years of repeated testing, patients continued to use the test and it continued to identify colorectal cancer, suggesting that he FIT is acceptable and effective for community colorectal cancer screening programs.
Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, please contact Janet Byron at [email protected] or 510-891-3115.
3. More may be better when sharing genetic testing results with patients
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Being told they were at also at risk for coronary artery disease did not increase depression or anxiety among patients undergoing a genetic test for Alzheimer disease. Providing information about how to reduce risk for coronary artery disease also helped patients improve health behaviors. The results are published in Annals of Internal Medicine.
Genetic testing is being increasingly used to identify risks for certain diseases. These tests often identify incidental or secondary findings that are important but unrelated to the original purpose of testing. This topic is controversial because revealing secondary risks to patients may increase psychological risks.
Pleiotropy is the association between genetic variants and multiple disease traits. The apolipoprotein E (APOE) gene is associated with increased risk for both Alzheimer disease and coronary artery disease. Researchers sought to determine the behavioral effects of revealing modest associations between the APOE genotype and coronary artery disease risk during APOE-based genetic risk assessments for Alzheimer disease. More than 250 participants were randomly assigned to receive risk information on either Alzheimer disease only or Alzheimer disease and coronary artery disease. The research examined measures of anxiety and depression over a year following provision of genomic risk information.
The researchers found that patients who were informed of increased risk for both Alzheimer disease and coronary artery disease had a decrease in distress and an increase in healthy behaviors compared with those who received information about Alzheimer disease risk alone. These finding suggest that receiving information about increased long-term risk for a debilitating disease for which no specific clinical action can be undertaken to decrease risk (Alzheimer's) was more distressing than when this bad news was coupled with information about risk for a second debilitating disease for which clinical action can decrease risk (coronary artery disease).
Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, please contact Haley Bridger at [email protected] or 617-525-6383.
Also in this issue:
The Future Ecology of Care
Jacob West, MPP, and Ateev Mehrotra, MD, MPH
Ideas and Opinions
Two Ways of Knowing: Big Data and Evidence-Based Medicine
Ida Sim, MD, PhD
Ideas and Opinions