Cases corner – 65 years old with haematuria
8th November 2018
Mrs B, a 65 year old woman, present to you with a 2 week history of
visible haemturia. She denies any other symptoms. Examination is unremarkable. Blood tests are requested which shows an iron deficiency anaemia. A urine sample confirms visible haemturia and a culture is negative for infection.
The patient’s presentation is classic for a urological carcinoma. Mrs B should be sent
on a 2-week-wait urology referral to look for renal or bladder malignancy. However,
it is important to recognise that other cancers can also cause anaemia or
If we apply the NICE NG12 Guidelines to this patient’s presentation, Mrs B would be
at risk of the following cancers: bladder, colorectal, endometrial and renal.
It can be difficult to know how to investigate or refer these patients. Mrs B should receive the following:
- A colorectal 2 week-wait cancer referral, because she is over 60 with iron-deficiency anaemia
- A urological 2-week-wait cancer referral, because she is over 45 with unexplained visible haematuria without a urinary tract infection
- A trans-vaginal ultrasound scan, because she is over 55 with visible haematuria and anaemia (in London, the age criteria is women over 45).
This list may seem exhaustive, especially to request at one time. There is no formal guidance on how to investigate the patient, whether to refer one after the other, until the cause of her symptoms is found, or, equally appropriate to refer to patient for multiple referrals at the same time. Of course for the patient it would be ideal for all of their investigations and reviews to be consolidated and done together.
Because hospital pathways are site specific, it can be challenging when patients trigger multiple pathways or present with vague symptoms that could cross tumour sites. Systems would be better suited to ruling out cancer in the patient, rather than a single tumour site or organ. This could be achieved in a Multi-disciplinary Centre, which are new pathways currently being trialled by NHS England.
The key here is to appropriately safety net patients and, to be aware, that if the urology referral rules out cancer, to ensure there is plan in place to rule out cancer from the other tumour sites the patient is at risk of.