- Design
- Retrospective national cohort (VA and Medicare-linked)
- Population
- 267,133 adults with new microhaematuria, 2015–2024
- Primary outcome
- New bladder cancer diagnosis within 2 years
- Effect
- Incidence 1.5%; model AUC 0.63 vs AUA categories 0.52
This Veterans Health Administration and Medicare-linked cohort, published 16 September in the Journal of Urology, followed 267,133 adults with new microhaematuria between 2015 and 2024 for bladder cancer diagnosis within two years.
Only 11.9% had cystoscopy within two years, and 1.5% (95% CI 1.4% to 1.5%) were diagnosed with bladder cancer. Older age, male sex, smoking history and 25 or more red cells per high-power field were associated with cancer after accounting for competing risk of death. A model based on these factors discriminated better than the American Urological Association risk categories (AUC 0.63 vs 0.52), and further separated patients the guideline calls high risk.
Most people with microhaematuria do not have bladder cancer, and most are never scoped. The AUA tiers performed little better than chance in this cohort. Weighting the individual risk factors helps target cystoscopy to those most likely to benefit — and makes the case for urgent evaluation in an older male smoker with heavy haematuria stronger.
- Prioritise cystoscopy for older men with a smoking history and 25 or more red cells per high-power field.
- Do not rely on guideline risk tier alone; weigh each risk factor.
- Confirm microhaematuria on microscopy before referral.
- Remember that most patients with microhaematuria do not have bladder cancer.
Why it matters
Challenges the assumption that current guideline tiers reliably separate who needs cystoscopy.
Don't overread it
A mostly male, older US veteran population; the model needs validation elsewhere, including in women and in India.
The statistics, in plain English
An AUC of 0.52 is barely better than a coin toss; 0.63 is modestly better. Neither model is precise, but weighting risk factors outperformed the current tiers.
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