- Design
- Retrospective cohort, competing-risk analysis
- Population
- 267,133 adults with new microhaematuria in US Veterans Health data
- Primary outcome
- Bladder cancer diagnosis within 2 years
- Effect
- Cumulative incidence 1.5%; cystoscopy 11.9%; model AUC 0.63 vs AUA categories 0.52
Using US Veterans Health Administration and Medicare data from 2015 to 2024, this study followed 267,133 adults with new microhaematuria for two years. Only 11.9% had a cystoscopy in that time, and 1.5% were diagnosed with bladder cancer.
After accounting for the competing risk of death, older age, male sex, a smoking history and 25 or more red cells per high-power field were associated with bladder cancer. A model using these factors discriminated better than the American Urological Association risk categories (AUC 0.63 vs 0.52), particularly within the guideline's high-risk group.
The population is mostly older men, so absolute risks will be lower in many Indian clinics. An AUC of 0.63 is still modest: no simple tool sorts patients reliably.
The practical point is that the degree of haematuria and smoking history matter, and that a patient in a high-risk group who has not been investigated is common. Confirm microhaematuria on repeat testing, exclude infection, and prioritise cystoscopy for older male smokers with heavier haematuria.
- Confirm microhaematuria on microscopy and exclude infection before referring
- Prioritise cystoscopy and upper tract imaging in older men, smokers and those with 25 or more red cells per high-power field
- Record smoking history and red cell count on the referral
- Follow up patients whose evaluation was never completed
- Visible haematuria still warrants urgent referral regardless of these factors
Why it matters
It shows that guideline risk categories do little to separate who has cancer, and most patients are never evaluated.
Don't overread it
The study population was largely older male veterans; risks may differ in younger or female patients.
The statistics, in plain English
An AUC of 0.63 means the model ranks a patient with cancer above one without only 63% of the time, against 52% for the guideline categories, which is barely better than chance. Both are weak, but the model is less weak.
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