Delay in haematuria management – how can we improve?

In this issue, Nilbert and colleagues present an evaluation of the standard pathway of care for haematuria introduced in Sweden in 2015 (1). Compared to patients diagnosed by conventional referral, they found that the diagnostic delay – time from occurrence of haematuria to diagnosis – was reduced with median 10 days, from 35 to 25. The prevalence of cancer was 19% in patients with macroscopic haematuria, similar to other studies (2, 3). Unfortunately, however, time from diagnosis to TURB referral was not significantly reduced. A similar experience was published by Somov and Irwin in 2013. Their evaluation of a maximum two-week wait rule from general practitioner (GP) referral to first specialist appointment showed little effect on diagnosis and management of bladder cancer (4). The authors accordingly proposed to abandon the two-week rule and instead focus on the 18-week standard for commencement of treatment.

Denmark became the first Scandinavian country to implement a public financed and organized standard Cancer Care Pathway in 2007 (5). An evaluation in 2012 showed that the median time to diagnosis was reduced by 4 days from 2002. A new audit in 2017 estimated that for all cancers 12.9% of the improved survival over the period might be attributable to reduced lead time (6, 7). For bladder cancer, the attribution of lead time to improved absolute survival was 5%. Although it seems generally accepted that lead time has an inverse effect on bladder cancer survival, there are studies that have not been able to reproduce this association (8, 9). One can therefore assume that the effect of fast-track diagnostics on survival from bladder cancer in Sweden will be modest.

Most GPs are well aware that visible haematuria is an alarm symptom requiring immediate investigation. The potential for quicker referral may therefore be small, and the shortened delay from symptom to referral shown from Sweden is also modest, with persistent wide variation.

Another aim for the standardized pathways was to increase patient satisfaction by ensuring shorter diagnostic times. Unfortunately, this has not been assessed in the present study. However, a Danish group noted that the introduction of the standard Cancer Care Pathway increased patient satisfaction with waiting times for first consultation in hospital. However, more patients reported longer waiting times for appointments with their GP (10). Whether this delay is a consequence of the Cancer Care Pathways stealing capacity from GPs or simply due to increased public awareness and expectations introduced by the Cancer Care Pathway, is unknown.

Most concerning, however, is that the waiting time until TURB and further to final treatment is longer than recommended and seems not to have been affected by the implementation of a standardized care pathway. Good and efficient clinical practice cannot be solved by governmental decrees alone, but demands willingness of professionals to scrutinize their own practice in order to improve. As urologists, we cannot influence the delay before a patient with macroscopic haematuria sees his GP. However, as clinicians we should be able clinically to discriminate between a stage cTa low-grade papillomatous mass and a solid obviously high-grade tumour by use of cystoscopy and CT scans. Thereafter we must organize individual clinical pathways with the appropriate urgency. By thoroughly mapping their own patient pathway for diagnosis and treatment for muscle-invasive bladder cancer, colleagues at Freeman hospital in the U.K. managed to reduce the time spent before radical treatment (11). This is an exercise all urological departments should perform regularly to minimize delaying factors, reduce patients’ anxiety and ensure a high standard of care.

Erik Skaaheim HaugDepartment of Urology, Vestfold Hospital Trust, Tønsberg, Norway[email protected]