Predictive value of the official cancer alarm symptoms in general practice: a systematic review

TY - JOUR

T1 - Predictive value of the official cancer alarm symptoms in general practice

T2 - a systematic review

AU - Krasnik Huggenberger, Ivan

AU - Andersen, John Sahl

PY - 2015/5

Y1 - 2015/5

N2 - INTRODUCTION: The objective of this study was to investigate the evidence for positive predictive value (PPV) of alarm symptoms and combinations of symptoms for colorectal cancer, breast cancer, prostate cancer and lung cancer in general practice. METHODS: This study is based on a literature search performed in PubMed, Embase, the Cochrane database and at ClinicalTrials.gov in accordance with the PRISMA guidelines. The main outcome measure used was PPV. RESULTS: A total of 16 eligible studies were identified. The intervals in the brackets refer to the variation of the results in the studies. Colorectal cancer: The PPV of “rectal bleeding” was high for patients > 60 years (6.6-21.2%), but much lower in younger age groups. For “change in bowel habits” and “significant general symptoms”, the PPV was 3.5-8.5%. Breast cancer: “Palpable suspected tumour” was well supported (8.1-24%). No studies on the predictive value of “pitting of the skin”, “papil-areola eczema/ulceration” and “suspect axillary lymph nodes” were found. Prostate cancer: One study showed a high PPV for positive rectal examination (12%). The value for “lower urinary tract symptoms” was low (1.0-3.0%). PPV for “perianal pain” and “haemospermia” were not found. Lung cancer: For “haemoptysis” the PPV increased from 8.4 in patients aged 55 years to 20.4 at the age of > 85 years. PPV for “cough”, “pain in the thorax”, “dyspnoea” and “general symptoms” were low (0.4- 1.1%). Using a new algorithm that estimates the PPV of combinations of symptoms and risk factors, a higher PPV may be achieved. CONCLUSION: A few of the alarm symptoms show a high PPV, whereas the PPV for some symptoms currently remains unknown. To improve the GPs’ diagnostic judgment, a new algorithm for calculating the PPV for combinations of symptoms and risk factors seems promising. Waiting a long time for a diagnosis is associated with a poorer prognosis for cancer patients [1, 2]. In Denmark 2008 saw the introduction of accelerated, well-planned, fast-track diagnostic and treatment pathways, coined cancer packages, for patients suspected of having cancer. For each cancer type, the Danish Health and Medicines Authority developed a manual for general practitioners (GPs) describing the symptoms that should engender a reasonable suspicion of malignancy (alarm symptoms) and trigger the initiation of the diagnostic pathway. Naturally, the relevance of the manual depends on the ability of the alarm symptoms to predict cancer in a general practice population. Low predictive values may imply a waste of resources and unnecessary anxiety for patients. The aim of this review was to examine the evidence for PPV of the alarm symptoms described by the Danish Health and Medicines Authority in relation to the four most commonly occurring cancers in Denmark: colorectal cancer, lung cancer, prostate cancer and breast cancer. Furthermore, tools for calculation of PPV using combinations of symptoms and risk factors were examined.

AB - INTRODUCTION: The objective of this study was to investigate the evidence for positive predictive value (PPV) of alarm symptoms and combinations of symptoms for colorectal cancer, breast cancer, prostate cancer and lung cancer in general practice. METHODS: This study is based on a literature search performed in PubMed, Embase, the Cochrane database and at ClinicalTrials.gov in accordance with the PRISMA guidelines. The main outcome measure used was PPV. RESULTS: A total of 16 eligible studies were identified. The intervals in the brackets refer to the variation of the results in the studies. Colorectal cancer: The PPV of “rectal bleeding” was high for patients > 60 years (6.6-21.2%), but much lower in younger age groups. For “change in bowel habits” and “significant general symptoms”, the PPV was 3.5-8.5%. Breast cancer: “Palpable suspected tumour” was well supported (8.1-24%). No studies on the predictive value of “pitting of the skin”, “papil-areola eczema/ulceration” and “suspect axillary lymph nodes” were found. Prostate cancer: One study showed a high PPV for positive rectal examination (12%). The value for “lower urinary tract symptoms” was low (1.0-3.0%). PPV for “perianal pain” and “haemospermia” were not found. Lung cancer: For “haemoptysis” the PPV increased from 8.4 in patients aged 55 years to 20.4 at the age of > 85 years. PPV for “cough”, “pain in the thorax”, “dyspnoea” and “general symptoms” were low (0.4- 1.1%). Using a new algorithm that estimates the PPV of combinations of symptoms and risk factors, a higher PPV may be achieved. CONCLUSION: A few of the alarm symptoms show a high PPV, whereas the PPV for some symptoms currently remains unknown. To improve the GPs’ diagnostic judgment, a new algorithm for calculating the PPV for combinations of symptoms and risk factors seems promising. Waiting a long time for a diagnosis is associated with a poorer prognosis for cancer patients [1, 2]. In Denmark 2008 saw the introduction of accelerated, well-planned, fast-track diagnostic and treatment pathways, coined cancer packages, for patients suspected of having cancer. For each cancer type, the Danish Health and Medicines Authority developed a manual for general practitioners (GPs) describing the symptoms that should engender a reasonable suspicion of malignancy (alarm symptoms) and trigger the initiation of the diagnostic pathway. Naturally, the relevance of the manual depends on the ability of the alarm symptoms to predict cancer in a general practice population. Low predictive values may imply a waste of resources and unnecessary anxiety for patients. The aim of this review was to examine the evidence for PPV of the alarm symptoms described by the Danish Health and Medicines Authority in relation to the four most commonly occurring cancers in Denmark: colorectal cancer, lung cancer, prostate cancer and breast cancer. Furthermore, tools for calculation of PPV using combinations of symptoms and risk factors were examined.

KW - Faculty of Health and Medical Sciences

KW - cancer, symptoms, predective value

M3 - Review

SN - 2245-1919

VL - 62

JO - Danish Medical Journal

JF - Danish Medical Journal

IS - 5

M1 - A5034

ER -