Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis.

BACKGROUND Selection of primary care patients for investigation of potential oesophagogastric cancer is difficult, as the symptoms may represent benign conditions, which are also more common. AIM To review systematically the presenting features of oesophagogastric cancers in primary care, including open-access endoscopy clinics. DESIGN AND SETTING Systematic review and meta-analysis. METHOD MEDLINE®, Embase, the Cochrane Library, and CINAHL were searched for studies of adults who were symptomatic and presented in primary care or open-access endoscopy clinics. Exclusions were being asymptomatic, screening, or recurrent cancers. Data were extracted to estimate the diagnostic performance of features of oesophagogastric cancers and summarised in a meta-analysis. RESULTS Fourteen studies were identified. The strongest summary sensitivity and specificity estimates were for: dyspepsia 0.42 (95% confidence interval [CI] 0.29 to 0.56) and 0.48 (95% CI = 0.31 to 0.65); pain 0.41 (95% CI = 0.24 to 0.62) and 0.75 (95% CI = 0.51 to 0.89); and dysphagia 0.32 (95% CI = 0.17 to 0.52) and 0.92 (95% CI = 0.81 to 0.97). Summary positive likelihood ratios (LR+) and diagnostic odds ratios were: dyspepsia 0.79 (95% CI = 0.55 to 1.15) and 0.65 (95% CI = 0.32 to 1.33); pain 1.64 (95% CI = 1.20 to 2.24) and 2.09 (95% CI = 1.57 to 2.77); and dysphagia 4.32 (95% CI = 2.46 to 7.58) and 5.91 (95% CI = 3.56 to 9.82). Sensitivity was lower for: anaemia 0.12 [95% Cl = 0.08 to 0.19] with specificity 0.97 [95% Cl = 0.94 to 0.99]; nausea/vomiting/bloating 0.17 [95% Cl = 0.05 to 0.46] and 0.84 [95% Cl = 0.60 to 0.94] respectively; reflux 0.23 [95% Cl = 0.10 to 0.46] and 0.70 [95% Cl = 0.59 to 0.80]; weight loss 0.25 [95% Cl = 0.12 to 0.43] and 0.96 [95% Cl = 0.88 to 0.98]. [corrected]. Corresponding LR+ were: anaemia 4.32 (95% CI = 2.64 to 7.08); nausea/vomiting/bloating 1.07 (95% CI = 0.52 to 2.19); reflux 0.78 (95% CI = 0.47 to 1.78) and; weight loss 5.46 (95% CI = 3.47 to 8.60). CONCLUSION Dysphagia, weight loss, and anaemia show the strongest association but with relatively low sensitivity and high specificity. The findings support the value of investigation of these symptoms, but also suggest that, in a population of patients who are low risk but not no-risk, investigation is not currently recommended.

[1]  S. Vernon,et al.  Emergency presentation of cancer and short-term mortality , 2013, British Journal of Cancer.

[2]  G. Collins,et al.  Identifying patients with undetected gastro-oesophageal cancer in primary care: External validation of QCancer® (Gastro-Oesophageal). , 2013, European journal of cancer.

[3]  K. Bodger,et al.  Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics , 2013, Gut.

[4]  G. Lyratzopoulos,et al.  Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers , 2013, British Journal of Cancer.

[5]  T. Peters,et al.  The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case–control study using electronic records , 2012, British Journal of Cancer.

[6]  S. Hiom,et al.  Routes to diagnosis for cancer – determining the patient journey using multiple routine data sets , 2012, British Journal of Cancer.

[7]  T. Peters,et al.  The risk of pancreatic cancer in symptomatic patients in primary care: a large case–control study using electronic records , 2012, British Journal of Cancer.

[8]  G. Lyratzopoulos,et al.  Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. , 2012, The Lancet. Oncology.

[9]  J. Hippisley-Cox,et al.  Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm. , 2011, The British journal of general practice : the journal of the Royal College of General Practitioners.

[10]  W. Hamilton.  Cancer diagnosis in primary care. , 2010, The British journal of general practice : the journal of the Royal College of General Practitioners.

[11]  J. V. van Lanschot,et al.  Delay in Diagnostic Workup and Treatment of Esophageal Cancer , 2009, Journal of Gastrointestinal Surgery.

[12]  B Rachet,et al.  What if cancer survival in Britain were the same as in Europe: how many deaths are avoidable? , 2009, British Journal of Cancer.

[13]  K. Kaukinen,et al.  Age, symptoms and upper gastrointestinal malignancy in primary care endoscopy , 2008, Scandinavian journal of gastroenterology.

[14]  R. Laheij,et al.  Is there any association between referral indications for open-access upper gastrointestinal endoscopy and endoscopic findings? , 2007, Endoscopy.

[15]  P. Moayyedi,et al.  Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. , 2006, Gastroenterology.

[16]  Johannes B Reitsma,et al.  Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. , 2005, Journal of clinical epidemiology.

[17]  K. Bodger,et al.  Predictive value of alarm features in a rapid access upper gastrointestinal cancer service , 2004, Gut.

[18]  R. Laheij,et al.  Meta‐analysis: the diagnostic value of alarm symptoms for upper gastrointestinal malignancy , 2004, Alimentary pharmacology & therapeutics.

[19]  P. Bossuyt,et al.  BMC Medical Research Methodology , 2002 .

[20]  A. Barkun,et al.  The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment – Prompt Endoscopy (CADET–PE) study , 2003, Alimentary pharmacology & therapeutics.

[21]  I. Kunnamo,et al.  Impact of Clinical Symptoms and Referral Volume on Endoscopy for Detecting Peptic Ulcer and Gastric Neoplasms , 2003, Scandinavian journal of gastroenterology.

[22]  C. P. Willoughby,et al.  Audit of a nurse endoscopist based one stop dyspepsia clinic , 2002, Postgraduate medical journal.

[23]  T. Jørgensen,et al.  'Alarm Symptoms' in Patients with Dyspepsia: a Three-year Prospective Study from General Practice , 2002, Scandinavian journal of gastroenterology.

[24]  M. Numans,et al.  How useful is selection based on alarm symptoms in requesting gastroscopy? An evaluation of diagnostic determinants for gastro-oesophageal malignancy. , 2001, Scandinavian journal of gastroenterology.

[25]  A. Sandvik,et al.  The predictive value of history in dyspepsia. , 1990, Scandinavian journal of gastroenterology.

[26]  M. Cowie.  National Institute for Health and Care Excellence. , 2015, European heart journal.

[27]  G. Bevan,et al.  From data to decisions?: exploring how healthcare payers respond to the NHS atlas of variation in healthcare in England , 2014 .

[28]  J. Hippisley-Cox,et al.  Identifying patients with suspected lung cancer in primary care: derivation and validation of an algorithm. , 2011, The British journal of general practice : the journal of the Royal College of General Practitioners.

[29]  A. Mahmoud,et al.  Open-Access Endoscopy: Are Age-Based Guidelines Justified? An Audit of Experience of 1000 Open-Access Endoscopies at a District General Hospital , 2003, Endoscopy.

[30]  O. B. Schaffalitzky de Muckadell,et al.  Management of dyspeptic patients in primary care. Value of the unaided clinical diagnosis and of dyspepsia subgrouping. , 1998, Scandinavian journal of gastroenterology.