Association between unexplained hypoalbuminaemia and new cancer diagnoses in UK primary care patients

Merriel, Samuel W D; Carroll, Robert; Hamilton, Fergus; Hamilton, William

doi:10.1093/fampra/cmw051

Cited by 27 publications

(21 citation statements)

References 18 publications

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“…Although simple blood tests are often used to investigate non-specific symptoms in primary care patients,131415 the role of such tests in selecting those with unexpected WL for further cancer investigation is poorly understood. Abnormal test results might facilitate patient triage,1617 be poor predictors of cancer,1819 or be predictive across several cancer sites 20. Triage testing in primary care is important to avoid unnecessary urgent referrals of patients for invasive investigation.…”

Section: Introductionmentioning

confidence: 99%

Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study

Nicholson

Aveyard

Price

et al. 2020

BMJ

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Objective To quantify the predictive value of unexpected weight loss (WL) for cancer according to patient’s age, sex, smoking status, and concurrent clinical features (symptoms, signs, and abnormal blood test results). Design Diagnostic accuracy study. Setting Clinical Practice Research Datalink electronic health records data linked to the National Cancer Registration and Analysis Service in primary care, England. Participants 63 973 adults (≥18 years) with a code for unexpected WL from 1 January 2000 to 31 December 2012. Main outcome measures Cancer diagnosis in the six months after the earliest weight loss code (index date). Codes for additional clinical features were identified in the three months before to one month after the index date. Diagnostic accuracy measures included positive and negative likelihood ratios, positive predictive values, and diagnostic odds ratios. Results Of 63 973 adults with unexpected WL, 37 215 (58.2%) were women, 33 167 (51.8%) were aged 60 years or older, and 16 793 (26.3%) were ever smokers. 908 (1.4%) had a diagnosis of cancer within six months of the index date, of whom 882 (97.1%) were aged 50 years or older. The positive predictive value for cancer was above the 3% threshold recommended by the National Institute for Health and Care Excellence for urgent investigation in male ever smokers aged 50 years or older, but not in women at any age. 10 additional clinical features were associated with cancer in men with unexpected WL, and 11 in women. Positive likelihood ratios in men ranged from 1.86 (95% confidence interval 1.32 to 2.62) for non-cardiac chest pain to 6.10 (3.44 to 10.79) for abdominal mass, and in women from 1.62 (1.15 to 2.29) for back pain to 20.9 (10.7 to 40.9) for jaundice. Abnormal blood test results associated with cancer included low albumin levels (4.67, 4.14 to 5.27) and raised values for platelets (4.57, 3.88 to 5.38), calcium (4.28, 3.05 to 6.02), total white cell count (3.76, 3.30 to 4.28), and C reactive protein (3.59, 3.31 to 3.89). However, no normal blood test result in isolation ruled out cancer. Clinical features co-occurring with unexpected WL were associated with multiple cancer sites. Conclusion The risk of cancer in adults with unexpected WL presenting to primary care is 2% or less and does not merit investigation under current UK guidelines. However, in male ever smokers aged 50 years or older and in patients with concurrent clinical features, the risk of cancer warrants referral for invasive investigation. Clinical features typically associated with specific cancer sites are markers of several cancer types when they occur with unexpected WL.

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Section: Introductionmentioning

confidence: 99%

Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study

Nicholson

Aveyard

Price

et al. 2020

BMJ

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“…In a study conducted by Merriel et al , in a 12-month follow-up of a total of 5753 patients with serum albumin less than 3.5 g/dL, 28.4% patients eventually developed cancer. The authors concluded that patients with low albumin had OR of 2.29 of having diagnosed with a cancer in following 12 months 6…”

Section: Discussionmentioning

confidence: 99%

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach

Kumar

Patel

Mehershahi

et al. 2019

BMJ Open Gastroenterol

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BackgroundVarious degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied.MethodsElectronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included.Results30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001).ConclusionFinding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.

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“…The strength of this study was the long follow-up and the large number of subjects. Moreover, the data from the Swedish National Cause of Death Register are comprehensive, comprising almost all the inhabitants (99%) that have died and their cause of death [22]. A study showed 77% agreement between the registered cause of death and the results from a medical record investigation, with the agreement being higher in the younger age quartiles for malignant neoplasms [23].…”

Section: Strength and Weaknesses Of The Studymentioning

confidence: 99%

Plasma albumin and calcium concentrations, and long-term mortality in primary health care patients in Sweden

Dalemo

Boström

Hjerpe

2020

Scandinavian Journal of Primary Health Care

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Objective: Low plasma (p)-albumin and p-calcium concentrations are associated with increased mortality in hospitalised patients. There are few studies addressing this in primary care. Low pcalcium has been associated with mortality, but it is not known whether this applies to p-albumin. Could p-albumin and p-calcium be used as markers of an increased risk of mortality? Purpose: To study p-albumin and p-calcium at baseline and their association with mortality after 10-14 years. Design: Prospective cohort study using data from a large primary health care area and the National Swedish Cause of Death Register. Setting: Primary health care in Skaraborg, Sweden. Subjects: 43,052 patients (39.1% men), ≥18 years, 60.7 ± 18.4 years with p-albumin and p-calcium concentrations registered in 2001-2005. Main outcome measures: P-albumin and p-calcium concentrations at baseline and their association with mortality after a mean follow-up period of 10.3 ± 4.0 years. Results: Low p-albumin was associated with total mortality compared with normal p-albumin, greatest at lower ages (18-47 years). The hazard ratios for women and men were 3.12 (95% CI 1.27-7.70) and 4.09 (95% CI 1.50-11.14), respectively. The increased mortality was seen in both cardiovascular and malignant diseases in both women and men. In contrast, low p-calcium was not associated with increased mortality, 1.00 (95% CI 0.96-1.05). Elevated p-calcium was associated with increased mortality, 1.17 (95% CI 1.13-1.22). Conclusions: Low p-albumin could be a marker of an increased risk of mortality, especially in patients of younger ages. This finding should prompt diagnostic measures in order to identify underlying causes. KEY POINTS Low p-albumin and calcium concentrations have been associated with increased mortality in hospitalised patients, but this is unexplored in primary care patients. A low p-albumin concentration at baseline was a risk marker for mortality; highest in the younger age groups. Increased mortality in both cardiovascular and malignant diseases was seen in both men and women with low compared with normal p-albumin concentrations. Elevated but not low p-calcium concentrations were associated with increased mortality after 10-14 years of follow-up.

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Association between unexplained hypoalbuminaemia and new cancer diagnoses in UK primary care patients

Abstract: Low albumin levels were associated with an increased risk of cancer. This finding needs to be confirmed in other primary care populations.

Cited by 27 publications

References 18 publications

Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study

Prioritising primary care patients with unexpected weight loss for cancer investigation: diagnostic accuracy study

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach

Plasma albumin and calcium concentrations, and long-term mortality in primary health care patients in Sweden

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