Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm

Abstract

BackgroundGastro-oesphageal is one of the most common cancers worldwide. Evidence suggested that increased awareness of symptoms and earlier diagnosis could help improve treatment options and improve survival. AimTo derive and validate an algorithm to estimate the absolute risk of having gastro-oesophageal cancer in patients in primary care with and without symptoms. Design and settingCohort study of 375 UK QResearch ® general practices for development, and 189 for validation. MethodIncluded patients were aged 30-84 years, free at baseline of a diagnosis of gastro-oesophageal cancer, and without dysphagia, haematemesis, abdominal pain, appetite loss, or weight loss recorded in previous 12 months. The primary outcome was incident diagnosis of gastrooesophageal cancer recorded in the next 2 years. Risk factors examined were age, body mass index, alcohol status, smoking status, deprivation, family history of gastrointestinal cancer, dysphagia, previous diagnosis of cancer apart from gastrooesophageal cancer, haematemesis, abdominal pain, appetite loss, weight loss, tiredness, and anaemia. Cox proportional hazards models were used to develop risk equations. Measures of calibration and discrimination assessed performance in the validation cohort. ResultsThere were 2527 incident cases of gastrooesophageal cancer from 4.1 million person-years in the derivation cohort. Independent predictors were age, smoking, dysphagia, haematemesis, abdominal pain, appetite loss, weight loss, and anaemia. On validation, the algorithms explained 71% of the variation in females and 73% in males. The receiver operating curve statistics were 0.89 (females) and 0.92 (males). The D statistic was 3.2 (females) and 3.3 (males). The 10% of patients with the highest predicted risks included 77% of all gastro-oesophageal cancers diagnosed over the next 2 years. ConclusionThe algorithm has good performance and could potentially be used to help identify those at highest risk of gastro-oesophageal cancer, to facilitate early referral and investigation.

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

“…Methodological heterogeneity due to the presence of the database studies 10,11,16 was found for dysphagia, dyspepsia, reflux, and nausea/vomiting/bloating; conversely, no heterogeneity for anaemia, weight loss, or pain was identified. As the databases reported stronger diagnostic performance than small studies when heterogeneity between study designs was present, meta-analyses of the smaller studies, representing endoscopy clinics separately, was performed.…”

“…[10][11][12][13][14][15][16]19,20 Sensitivity ranged between 0.00 and 0.78, and was <0.50 in two-thirds of studies; specificity was more precise ranging between 0.72 and 0.99 (Table 1). The LR+ ranged between 1.87 and 9.81, with the exception of one study (Table 1).…”

“…[10][11][12]14,16,20,21 Studies reporting epigastric or retrosternal pain are reported separately (Table 2). Sensitivity was low with the exception of two endoscopy clinic studies;…”

“…10,11,13,15,16,19,20 It was defined as a recorded haemoglobin of <11 g/dl over the previous year in two studies [10][11] and grouped with gastrointestinal bleeding in another. 15 Sensitivity of anaemia for oesophagogastric cancer was low, with high specificity; LR+ ranged between 1.32 and 8.33, excluding one study 20 where few patients presented with anaemia, cancer was rare, and most patients were aged <50 years (Table 1).…”

Improving early diagnosis of symptomatic cancer

“…88 In the QCancer® series of papers, risk factors and symptoms were retained in the same multivariable model; in situations in which a statistically significant association was observed between any risk factor and cancer, the odds ratio was generally much smaller than those for symptoms. [95][96][97][98][99][100] In these papers, which used pre-existing medical Selection of patients for investigation in the UK is largely guided by the NICE, although Scotland has its own guidance from the Scottish Intercollegiate Guidelines Network. 109 The 2015 version of the NICE guidance based its recommendations for investigation on an assessment of the likelihood that the patient s symptoms (sometimes supplemented by simple primary care tests) exceed a threshold risk of cancer of 3%.…”