Reviewed by Dr. Allexa Hammond
Halpern et al., JAMA Intern Med 2017 Jun 1;177(6):800-807

Halpern and colleagues compare the relative cost effectiveness of four diagnostic strategies for work-up in patients with asymptomatic hematuria for possible genitourinary malignancies: CT with cystoscopy (the current guideline recommendation of the American Urological Association), renal ultrasound with cystoscopy, cystoscopy alone, and CT alone. These four diagnostic approaches were each compared with a reference case of no evaluation using simulation modeling to calculate the expected number of GU cancers found. In comparison to the reference case, CT with cystoscopy was expected to detect 246 cancers per 10,000 individuals with asymptomatic microscopic hematuria at a cost of $11.5 million, renal ultrasound with cystoscopy to detect 245 at a cost of $3.5 million, cystoscopy alone to detect 222 at a cost of $2.3 million, and CT alone to detect 221 a cost of $9.3 million.

Since cystoscopy alone or with ultrasound was expected to detect more cancers at a lower cost than CT alone, CT alone was said to be “dominated.” Adding renal ultrasound to cystoscopy was expected to detect 23 additional cancers at a cost of $1.2 million, a net increase of approximately $54,000 per additional cancer detected. Adding CT to cystoscopy was expected to detect 24 additional cancers at a cost of $9.2 million, or approximately $380,000 per additional cancer detected. Replacing ultrasound and cystoscopy with CT and cystoscopy was expected to diagnose 1 additional cancer at a cost of $6.5 million.

Based on their estimate that $100,000 to diagnose a cancer was a reasonable standard, the authors conclude that renal ultrasound combined with cystoscopy was the most cost-effective diagnostic approach for detecting GU malignancy, particularly in high-risk populations. Further discussion is warranted regarding whether renal ultrasound with cystoscopy should replace CT with cystoscopy in national guidelines.

Asymptomatic microscopic hematuria is a common finding in internal medicine practice. Although there are many different causes of asymptomatic microscopic hematuria, one of the most concerning is genitourinary malignancy. This holds particularly true for high-risk populations, such as male smokers over 50 years of age.

Clinicians can influence health care costs in a clinically rational way by finding diagnostic strategies that are clinically acceptable and more cost-effective. In the present study, the authors suggest forgoing CT and instead using ultrasound, which offers substantial cost savings with similar effectiveness. The ultimate purpose of this study was not only to offer an alternative diagnostic approach to the evaluation of possible GU malignancy in the setting of asymptomatic microscopic hematuria, but also to provide a message to the reader to continue to question current medical practice with the hopes of preventing wasteful healthcare spending and needless complications arising from tests that may not have been necessary.