Article Text

Download PDFPDF

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review
  1. Yin Zhou1,
  2. Marije van Melle1,
  3. Hardeep Singh2,3,
  4. Willie Hamilton4,
  5. Georgios Lyratzopoulos5,
  6. Fiona M Walter1
  1. 1 Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  2. 2 Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  3. 3 Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  4. 4 University of Exeter Medical School, Exeter, UK
  5. 5 Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
  1. Correspondence to Dr Yin Zhou; ykz21{at}


Objectives In urological cancers, sex disparity exists for survival, with women doing worse than men. Suboptimal evaluation of presenting symptoms may contribute.

Design We performed a systematic review examining factors affecting the quality of the diagnostic process of patients presenting with symptoms of bladder or kidney cancer.

Data sources We searched Medline, Embase and the Cochrane Library from 1 January 2000 to 13 June 2019.

Eligible criteria We focused on one of the six domains of quality of healthcare: timeliness, and examined the quality of the diagnostic process more broadly, by assessing whether guideline-concordant history, examination, tests and referrals were performed. Studies describing the factors that affect the timeliness or quality of the assessment of urinary tract infections, haematuria and lower urinary tract symptoms in the context of bladder or kidney cancer, were included.

Data extraction and synthesis Data extraction and quality assessment were independently performed by two authors. Due to the heterogeneity of study design and outcomes, the results could not be pooled. A narrative synthesis was performed.

Results 28 studies met review criteria, representing 583 636 people from 9 high-income countries. Studies were based in primary care (n=8), specialty care (n=12), or both (n=8). Up to two-thirds of patients with haematuria received no further evaluation in the 6 months after their initial visit. Urinary tract infections, nephrolithiasis and benign prostatic conditions before cancer diagnosis were associated with diagnostic delay. Women were more likely to experience diagnostic delay than men. Patients who first saw a urologist were less likely to experience delayed evaluation and cancer diagnosis.

Conclusions Women, and patients with non-cancerous urological diagnoses just prior to their cancer diagnosis, were more likely to experience lower quality diagnostic processes. Risk prediction tools, and improving guideline ambiguity, may improve outcomes and reduce sex disparity in survival for these cancers.

  • urological tumours
  • primary care
  • health and safety
  • quality in health care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

View Full Text

Statistics from


  • Contributors YZ, GL and FMW designed the study. YZ developed and performed the search. YZ and MvM performed the data extraction with MvM. YZ drafted the manuscript. MvM, HS, WH, GL and FMW critically revised the article.

  • Funding YZ is supported by a Wellcome Trust Primary Care Clinician PhD Fellowship (203921/Z/16/Z). The authors WH and FMW are coprincipal investigators and the authors. GL and HS are coinvestigators of the multi-institutional CanTest Research Collaborative funded by a Cancer Research UK Population Research Catalyst award (C8640/A23385). HS is additionally supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement There are no data in this work.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.