Should National Institute for Clinical Excellence (NICE) Guidelines Remove Urine Cytology as a Suggested Adjunct in Suspected Bladder Cancer (haematuria) Investigations?
Main Article Content
Despite National Institute for Clinical Excellence (NICE) guidelines suggesting the use of urine cytology (UC) for the diagnosis of bladder cancer, its use is variable. Reasons for this include sub-optimal sensitivity, financial cost, availability of alternative tests, and uncertainty over interpretation of results. Anecdotally, however, suspicious or malignant UC when other investigations are normal, occasionally leads to a cancer diagnosis. Therefore, we retrospectively assessed a cohort of our haematuria patients to determine the value of UC in cancer diagnosis and the clinical significance of atypical UC (graded as C3).
Patients and methods
We identified 3018 patients with haematuria referred on the suspected cancer pathway (“two-week wait”) in 2015. We retrospectively analysed clinical, demographic, and follow-up/outcome data in a random cohort of 500 cases.
Median follow up was 58 months. Urological malignancy was diagnosed in 61/500 patients; all were identified by cystoscopy or imaging, i.e., irrespective of UC result. No cases of atypical UC re-presented with a ‘missed’ cancer diagnosis within the five-year follow-up period. However, suspicious and malignant cytology was associated with high-grade/aggressive tumours and subsequent tumour recurrence.
Urine cytology did not identify any cancers that were not already found by imaging or cystoscopy. Atypical UC in the presence of negative haematuria investigations does not appear to be associated with malignancy, and therefore should not alter patient management nor prompt further investigation. Suspicious and malignant UC was associated with higher risk cancers and could therefore be used to prioritise waiting lists for transurethral resection of bladder tumour (TURBT), however, it is unclear whether this might benefit patient outcomes. We conclude therefore that UC has no role in haematuria investigations.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright of articles published in all DPG titles is retained by the author(s). The author(s) grants DPG the rights to publish the article and identify itself as the original publisher. The author grants DPG exclusive commercial rights to the article. The author grants any party the rights to use the article freely for non-commercial purposes provided that the original work is properly cited.
2. Tan WS et al. Does urinary cytology have a role in haematuria investigations? BJU Int. 2019 Jan;123(1): 74–81.
3. Babjuk M et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017 Mar;71(3):447–61.
4. Yafi FA, Brimo F, Steinberg J, et al. Prospective analysis of sensitivity and specificity of urinary cytology and other urinary biomarkers for bladder cancer. Urol Oncol 2015 Feb;33(2):66.e25-31.
5. Maas M, Bedke J, Stenzl A, Todenhöfer T. Can urinary biomarkers replace cystoscopy? World J Urol 2019; (37):1741–49.
6. IARC Working Group on the Evaluation of Carcino-genic Risks to Humans. Chemical Agents and Related Occupations. Lyon (FR): International Agency for Research on Cancer; 2012. (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, No. 100F.) OCCUPATIONAL EXPOSURES IN THE RUBBER-MANUFACTURING INDUSTRY. Available from: https://www.ncbi.nlm.nih.gov/books/NBK304412/.
7. Barkan GA et al. The Paris System for Reporting Urinary Cytology: The quest to develop a standardized terminology. Acta Cytol 2016;60(3):185–97.
8. MedCalc Software Ltd. Diagnostic test evaluation calculator and multiple regression. https://www.medcalc. org/calc/diagnostic_test.php and https://www.medcalc.org/manual/multiple-regression.php (Version 20.009; accessed June 22, 2021).
9. Nurminen P, Ettala O, Seppänen M, Taimen P, Boström PJ, Kaipia A. Urine cytology is a feasible tool for assessing erythematous bladder lesions after bacille Calmette-Guérin (BCG) treatment. BJU Internat 2019; 123(2):246–51.
10. Hofland CA, Mariani AJ. Is cytology required for a hematuria evaluation? J Urol 2004;171:324–6
11. Mishriki SF, Aboumarzouk O, Vint R, Grimsley SJ, Lam T, Somani B. Routine urine cytology has no role in hematuria investigations. J Urol 2013;189:1255–8.
12. Cancer in the West Midlands, Public Health England. 2017 [PDF file]. Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/639592/Cancer_in_theWest_Midlands.pdf.
13. Owens CL, Vandenbussche CJ, Burroughs FH, Rosenthal DL. A review of reporting systems and terminology for urine cytology. Cancer Cytopathol 2013;121:9–14.
14. Brimo F, Vollmer RT, Case B, Aprikian A, Kassouf W, Auger M. Accuracy of urine cytology and the significance of an atypical category. Am J Clin Pathol 2009;132:785–93.
15. Muus Ubago J, Mehta V, Wojcik EM, Barkan GA. Evaluation of atypical urine cytology progression to malignancy. Cancer Cytopathol 2013;121:387–91.
16. The Royal College of Pathologists. Meeting pathology demand: histopathology workforce census. 2018; Available at https://www.rcpath.org/uploads/assets/952a934d-2ec3-48c9-a8e6e00fcdca700f/Meeting-Pathology-Demand-Histopathology-Workforce-Census-2018.pdf (accessed June 22, 2021).