Introduction

Bladder cancer affects over 20 000 people each year in the UK, when including Ta tumours not included in government statistics. This puts bladder cancer in the top 10 most common cancers in the UK (Action Bladder Cancer UK, 2025). 
 
It is estimated that over 100 000 people in the UK are currently living with bladder cancer, with men three times more likely to be affected than women (Action Bladder Cancer UK, 2025). This includes those with non-muscle invasive tumours, Ta, T1 and CIS to muscle invasive and advanced disease. For those with non-muscle invasive bladder cancer (NMIBC), treatment includes transurethral resection of bladder tumour (TURBT), ongoing endoscopic surveillance and intravesical treatment. For those with high-risk NMIBC or muscle-invasive bladder cancer (MIBC), radical cystectomy may be recommended. Radiotherapy can be offered to patients opting for a bladder-sparing treatment or those unsuitable for radical surgery. 
 
In the absence of a bladder cancer screening programme, and no significant improvement in prognosis and mortality rates for MIBC (Action Bladder Cancer UK, 2025), more needs to be done to improve the pathway, to ensure patients are diagnosed and receive treatment as soon as possible. The expensive and often invasive nature of investigations, combined with a lack of effective screening tests, indicates the emphasis must be on prompt investigation of symptoms, haematuria being the most common. With only 3–5% of patients presenting with non-visible haematuria diagnosed with bladder cancer, routine screening of asymptomatic patients would increase referrals, unnecessary investigations, and patient anxiety. Although the detection rate for those presenting with visible haematuria increases to around 20%, its sporadic and transient nature makes this unsuitable for routine screening (Jubber et al, 2020; Meeks, 2021; Rai et al, 2022).
 

Rationale

Early diagnosis and timely treatment of bladder cancer has numerous benefits including improved survival outcomes, increased treatment options, reduced risk of progression, and improved quality of life for those living with bladder cancer. It also benefits healthcare providers, as treating early bladder cancer is less resource intensive. However, the need for regular surveillance and repeated TURBTs for those with recurrent tumours make bladder cancer one of the most expensive cancers to treat (Action Bladder Cancer UK, 2025).
 
The Getting It Right First Time (GIRFT, 2023) academy recognises the complexities and challenges of the bladder cancer pathway because of the multiphase diagnostic and treatment pathways. Therefore, improving the bladder cancer pathway is essential to reduce delays and provide earlier diagnosis and treatment, which improves the patient experience and clinical outcomes. This article explores issues affecting this pathway, and improvements that the author and her team have made to overcome these. 

Presentation

Most patients present to primary care with visible or non-visible haematuria, and are referred to the haematuria clinic for further assessment. Those who meet the National Institute for Health and Care Excellence (NICE) (2015) NG12 guidelines (Table 1) should be referred on an urgent suspected cancer pathway, previously referred to as a 2-week wait referral. 

The faster diagnosis standard is part of the NHS Long Term Plan intended to reduce variation and inequalities in care, while improving patients’ experience and quality of life. This ensures that patients referred with suspected cancer are diagnosed or have cancer ruled out within 28 days, reducing delays and ensuring timely treatment (NHS England, 2019; NHS England, 2025a).

Table 1. National Institute for Health and Care Excellence guidelines for referral to an urgent suspected cancer pathway

Refer people using a suspected cancer pathway referral for bladder cancer if they are:

aged 45 and over and have: unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection or

aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test

From National Institute for Health and Care Excellence (2015)

Background

Over the past 10 years, there have been numerous changes to the haematuria clinic at the Newcastle upon Tyne Hospitals NHS Foundation Trust. Following an initial triage, patients were offered a face-to-face clinic appointment, where the clinical nurse specialist (CNS) would take a history from the patient, including presenting complaint, past medical history, medications and environmental history. This appointment allowed the CNS to obtain bloods and urine specimens that had not been arranged by the GP.  

During the COVID-19 pandemic, the haematuria clinic was converted to a telephone triage service, which Garrard et al (2022) suggested is a reasonable alternative, if it does not result in delays. The downside of a telephone triage service was being unable to obtain blood and urine samples, if required, so we had to ensure these results were available at the time of referral. 

Developments

Over the last 4 years, we have transformed our haematuria clinic into a straight-to-test service, which is designed to improve the pathway for patients referred with suspected cancer. With the development of electronic patient records, the background information required from patients is now readily available in the referral documentation (Wilson et al, 2022). However, as highlighted by Chew et al (2023), there is a lack of data from the patient perspective supporting the straight-to-test service. Therefore, we audited our service to ensure patients were satisfied with the process. The early results are shown in Table 2.  

Table 2. Key achievements of the haematuria straight-to-test pathway

75% of patients reported the referral reason was explained completely clearly

90% felt that they received all necessary information before their test(s)

95% said that information was explained in a way they understood

70% were given a clear point of contact

85% said appointments were at convenient times

89% had the opportunity to ask questions

Overall service rating: 3.6/4 (Good–Excellent)

Patient comments: ‘smooth’, ‘well explained’, ‘excellent service’

The audit reported that 75% of patients felt the reason for referral was explained clearly. This highlights the need to work more closely with primary care providers to ensure patients understand they are being referred to diagnose or rule out a urological malignancy. Reassuringly, 90% of patients felt they received all the necessary information before their investigations. This is supported by our process of sending a triage letter, which outlines the pathway and investigations in clear, accessible language, with all medical terms explained. As shown in Table 2, 95% of patients reported that they understood this information.
 
Alongside written communication, patients are contacted by the pathway navigator, who reiterates the process and arranges the imaging and cystoscopy appointments. Where possible, patients are offered convenient slots, reflected in the audit finding that 85% of patients felt their appointments were scheduled at a suitable time. Overall, the audit suggests patients are satisfied with the straight-to-test service, with the majority rating it as good or excellent. One area identified for improvement is clarity regarding the patient’s point of contact, as only 70% of patients knew who to approach with queries. The pathway navigator should be listed as the initial contact on the letter, with medical queries directed to the CNS.

The straight-to-test service was developed and refined through a plan–do–study–act  cycle, with SMART objectives set to ensure that 75% of patients had bladder cancer diagnosed or ruled out within 28 days, in line with the national standard (since increased to 80%). Figure 1 demonstrates the success of the service.
 

Figure 1. Percentage of patients receiving a diagnosis by 28 days (results of three plan-do-study-act cycles). a. Cycle 1 – on the haematuria pathway. b. Cycle 2 and (c) Cycle 3 – on the straight-to-test pathway.

The introduction of electronic triage has released over 10 hours of CNS time each week (Figure 2), improving pathway efficiency and reducing delays. The nursing time previously spent in clinics seeing or speaking to the patients has reduced due to nurses triaging referrals electronically and requesting imaging, which takes significantly less time. That time is now spent on extra clinic capacity for new diagnosis patients and service development.  In addition, moving away from printed referrals is cost-effective and enhances the environmental sustainability of the service.

Patients no longer need to wait for an initial appointment, instead the referral is sent via the referral assessment service on NHS e-referral. This is triaged by a CNS, who decides if the patient requires further assessment and if the required blood and results are available. Incomplete information at referral can delay the patient pathway, as essential investigations cannot be initiated, so in this situation the referral is deferred back to the referrer for further action (NHS England, 2025b). 

Any patients unsuitable for a straight-to-test appointment will be offered a telephone or face-to-face appointment. These are known as reasonable adjustments and might include a frail patient who is unsure whether they want to proceed with investigations, or someone with communication difficulties who might struggle to understand the process.

Figure 2. Nursing time spent in clinics. 

Required test results

It is essential for the referrer to rule out a urinary tract infection (UTI) before referral, as this is one of the most common causes of haematuria. Patients with a UTI should not be referred to the haematuria clinic, unless the haematuria persists despite appropriate treatment (British Association of Urological Surgeons, 2024).

Urea and electrolytes and full blood count are also important baseline tests, which should be arranged by the referrer. Urea and electrolyte levels are a key indicator of renal function. This must be within the normal range for a computed tomography intravenous urogram (CT IVU) to be requested as this uses intravenous iodinated contrast, which is nephrotoxic in patients with impaired renal function (Royal College of Radiologists, 2010). The full blood count ensures patients with non-visible haematuria are referred on the appropriate pathway. Asymptomatic non-visible haematuria is commonly assessed on a routine pathway, but those with a raised white cell count on full blood count or with dysuria should be referred on a suspected cancer pathway. 

In their suspected cancer referral documentation for men with haematuria, the Northern Cancer Alliance (2024) stipulates that prostate cancer must be excluded by undertaking a digital rectal exam and measurement of their prostate-specific antigen (PSA) level before the referral. This ensures the patient is referred on the most appropriate pathway. As patients will be offered a digital rectal exam at their flexible cystoscopy appointment, we do not mandate this before referral. 

Referring patients without an appropriate baseline assessment can result in unnecessary referrals, invasive investigations and increased pressure on suspected cancer diagnostic pathways. If the service is under-pressure as a result of inappropriate referrals, delays are inevitable, which increase patient anxiety and delays treatment for those diagnosed with cancer. 

Imaging 

Diagnostic imaging for initial investigation of haematuria is requested at the time of triage, so the imaging modality selected is based on the clinical information provided in the referral. This should include patient allergies as CT IVU is contraindicated for those with an iodine allergy. Therefore, comprehensive triage is essential to maintain a safe and effective straight-to-test service. 

Imaging modality must be selected based on clinical presentation, considering performance status and comorbidities, to ensure justified and responsible use of imaging resources. This minimises unnecessary exposure to radiation or contrast in frail patients, while ensuring those who will benefit most receive timely and appropriate investigations (iRefer, 2025).

Our local protocol is for those aged over 50 years old, with visible haematuria and a performance status of 0–2, to have a CT IVU. Patients with multiple comorbidities or a performance status of 3–4 are offered an ultrasound or face-to-face consultation to discuss the risks and benefits of invasive investigations. Patients with visible haematuria under 50 years old and those with non-visible haematuria require a renal tract ultrasound scan. 

There were significant delays for CT IVU appointments and the subsequent reports, so the team worked with radiology to allow 10 allocated CT slots per week for the haematuria clinic and agreed that reports would be available within 3 working days. We have explored same-day reporting, but the infrastructure of our radiology department means that this is currently unavailable. 

Flexible cystoscopy

The CNS will also request a flexible cystoscopy during triage. This procedure provides direct visualisation of the urethra and bladder to identify potential causes of haematuria, including bladder cancer. A good quality referral can ensure patients are allocated appropriate appointments as those with mobility or communication difficulties will be offered a double appointment.

As outlined by GIRFT (2023), risk stratification should begin in the haematuria clinic. A thorough triage of a high-quality referral will identify risk factors such as smoking history, recurrent UTIs or occupational chemical exposure (Macmillan Cancer Support, 2025a). Patients referred on a suspected cancer pathway via the GP are allocated a designated urgent appointment slot by the pathway navigator. The pathway navigator is an essential element of the straight-to-test haematuria clinic and is invaluable in facilitating the patient’s journey through the pathway within the 28-day faster diagnosis standard target. They are often the first contact the patient has with a member of the hospital team (NHS Health Education England, 2022).

The role of the clinical nurse specialist 

In the flexible cystoscopy appointment, the doctor performs the procedure and reviews any imaging results. If bladder cancer is suspected, the patient is listed for a TURBT. During or straight after this appointment, the CNS then meets with the patient to explain the procedure, provide contact details, answer questions, and outline the next steps. Immediately after this, the patient is taken straight to pre-assessment for the TURBT – this has had an impact on TURBT performance, as we have been able to offer earlier surgery dates. 

Risk stratification allows patients with suspected high-risk NMIBC or MIBC to be prioritised for surgery. Dedicated surgical slots are being developed for high-risk cases to support timely diagnosis and treatment. The cancer care coordinator monitors these patients on a central spreadsheet, which is reviewed at a weekly meeting to identify and promptly address any potential delays.

Recognising and prioritising high-risk patients is a key focus of the GIRFT (2023) bladder cancer pathway improvement recommendations, as this has a direct impact on patient outcomes. We have a well-established process whereby the histopathologists email the consultant, CNS and cancer care coordinator when MIBC is suspected or confirmed following TURBT. This ensures patients are allocated an urgent outpatient appointment in the new diagnosis clinic. 

Nurse-led clinic 

Our diagnostic clinic is a well-established nurse-led service in which the CNS discusses histopathology results and outlines the ongoing management. Each consultation is tailored to the individual, with the CNS using clear, patient-friendly language to ensure that patients and their families or carers fully understand the information. This approach helps build trust and confidence, encouraging patients to ask questions and empowering them through greater understanding of their diagnosis.

Nurse-led follow-up clinics provide significant benefits for both patients and the service. For patients, they ensure timely appointments and reduce delays, with most seen within a week of their results becoming available. Continuity of care is maintained, as patients are often reviewed by the same CNS they met during their cystoscopy appointment.

From a service perspective, nurse-led clinics increase capacity and reduce pressure on consultant-led clinics, which are both more costly and limited in availability. This model therefore provides a cost-effective solution that ensures consistent, standardised care across the pathway.

Holistic needs assessment 

During a new diagnosis consultation, patients are provided with an information pack including a NMIBC or MIBC booklet, CNS contact information and a holistic needs assessment. The holistic needs assessment is a document to help the patients identify any needs or concerns they may have (Northern Cancer Alliance, 2025). This is relatively new development within our service and there was apprehension about the time this would take to complete; however, this has been beneficial to our patients and has had little impact on CNS capacity. All patients are offered a holistic needs assessment at diagnosis, followed by a telephone call from the cancer care coordinator around 2 weeks later. This allows the patient time to absorb their diagnosis and look through the document. The assessment can also be delayed if the patient is not ready. 
The cancer care coordinator will ask if the patient has identified any concerns. If they have, they will be signposted to the appropriate services, or to the CNS for a follow-up call to complete a personalised care and support plan. Between June 2024 and July 2025, we have offered 171 holistic needs assessments, with 26 patients requiring further support. This has included benefits advice and signposting patients for help obtaining blue badges to improve their independence. 

Starting conversations about holistic needs demonstrates that we as health professionals care about their whole wellbeing and we have found patients to be responsive to the process, even though only a small proportion required a care plan. Identifying issues early, by asking questions, can improve the patient’s quality of life and allow patients to feel listened to and that their opinions are valued. Of 171 patients, only 5% (nine patients) declined a holistic needs assessment (Macmillan Cancer Support, 2025b). 

Conclusions

The complexities of the bladder cancer pathway need to be actively addressed to improve the experience and outcomes for patients. The development of a straight-to-test haematuria clinic with improved triage, risk stratification before TURBT and nurse-led diagnosis clinics have demonstrated measurable improvement in the pathway. These changes have allowed us to ensure high-risk patients receive a diagnosis and treatment earlier, while maintaining a high level of care for all patients.