Multicentre real‐world evaluation of the Haematuria Cancer Risk Score to risk‐stratify the detection of bladder cancer in patients referred from primary care

Objectives
To investigate the potential of the Haematuria Cancer Risk Score (HCRS) to improve the real-world investigation pathway for suspected bladder cancer.

Materials and methods
Data were retrospectively analysed for all consecutive patients referred with suspected urinary tract cancer on a faster diagnostic pathway to five UK institutions between January and April 2025. The HCRS cut-off score of ≥82 was used to define a ‘HCRS high risk’ population. The co-primary outcomes were the ability to calculate HCRS in the referred population from the information provided by primary care and the cancer detection rate.

Results
In total, 1944 referrals were received, median age of 71 years (IQR 61–78), 1186/1944 (61%) were male, and 1586/1944 (82%) had sufficient information to calculate the HCRS. Of the cohort with HCRS scores, overall 165/1586 (10%) had bladder cancer. The HCRS was ≥82 in 176/437 (40%) of those with non-visible haematuria (NVH); in total, 6/176 (3%) had bladder cancer; and using HCRS in the NVH group alone, no case of muscle-invasive bladder cancer (MIBC) would have been missed. The HCRS was ≥82 in 1062/1149 (92%) with visible haematuria (VH), of whom 150/1062 (14%) had bladder cancer. Adopting a strategy of using HCRS and upper tract imaging in combination for the whole cohort would have resulted in two cases of NMIBC being missed for the NVH cohort and one case of NMIBC being missed for the VH cohort. No cases of MIBC or upper tract urothelial cancer would have been missed.

Conclusion
HCRS is a simple innovation, which demonstrates clear potential when combined with upper tract imaging to improve current UK risk stratification to determine which patients referred with haematuria need flexible cystoscopy.