Microcytosis as a risk marker of cancer in primary care: a cohort study using electronic patient records

Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

OBJECTIVES

Guidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation.

DESIGN

Historical prospective study.

SETTING AND PARTICIPANTS

Patients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database.

METHODS

Based on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice.

RESULTS

Compared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02).

CONCLUSIONS AND IMPLICATIONS

Although mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non-guideline adherence and a wait-and-see approach could be discussed in a shared-decision-making consultation.

A taxonomy of early diagnosis research to guide study design and funding prioritisation

Researchers and research funders aiming to improve diagnosis seek to identify if, when, where, and how earlier diagnosis is possible. This has led to the propagation of research studies using a wide range of methodologies and data sources to explore diagnostic processes. Many such studies use electronic health record data and focus on cancer diagnosis. Based on this literature, we propose a taxonomy to guide the design and support the synthesis of early diagnosis research, focusing on five key questions: Do healthcare use patterns suggest earlier diagnosis could be possible? How does the diagnostic process begin? How do patients progress from presentation to diagnosis? How long does the diagnostic process take? Could anything have been done differently to reach the correct diagnosis sooner? We define families of diagnostic research study designs addressing each of these questions and appraise their unique or complementary contributions and limitations. We identify three further questions on relationships between the families and their relevance for examining patient group inequalities, supported with examples from the cancer literature. Although exemplified through cancer as a disease model, we recognise the framework is also applicable to non-neoplastic disease. The proposed framework can guide future study design and research funding prioritisation.

Colorectal cancer in symptomatic patients: How to improve the diagnostic pathway

Even in countries with national screening programmes for colorectal cancer, most cancers are identified after the patient has developed symptoms. The patients present these symptoms usually to primary care, or in some countries to specialist care. In either healthcare setting, the clinician has to consider cancer to be a possibility, then to perform triage investigations, followed by definitive investigation, usually by colonoscopy. This apparently simple pathway is not simple: most symptoms of colorectal cancer are more likely to represent benign disease than cancer, and each of these stages represents selection of patients into a higher-risk pool. This article summarises a symptom-based approach to selection and initial investigation of such patients in primary care. Some special groups need particular attention, including the younger patient, those with an inherited predisposition to cancer, and those with co-morbidities.

Pre-Referral Primary Care Blood Tests and Symptom Presentation before Cancer Diagnosis: National Cancer Diagnosis Audit Data

BACKGROUND

Blood tests can support the diagnostic process in primary care. Understanding how symptomatic presentations are associated with blood test use in patients subsequently diagnosed with cancer can help to benchmark current practices and guide interventions.

METHODS

English National Cancer Diagnosis Audit data on 39,751 patients with incident cancer in 2018 were analysed. The frequency of four generic (full blood count, urea and electrolytes, liver function tests, and inflammatory markers) and five organ-specific (cancer biomarkers (PSA or CA125), serum protein electrophoresis, ferritin, bone profile, and amylase) blood tests was described for a total of 83 presenting symptoms. The adjusted analysis explored variation in blood test use by the symptom-positive predictive value (PPV) group.

RESULTS

There was a large variation in generic blood test use by presenting symptoms, being higher in patients subsequently diagnosed with cancer who presented with nonspecific symptoms (e.g., fatigue 81% or loss of appetite 79%), and lower in those who presented with alarm symptoms (e.g., breast lump 3% or skin lesion 1%). Serum protein electrophoresis (reflecting suspicion of multiple myeloma) was most frequently used in cancer patients who presented with back pain (18%), and amylase measurement (reflecting suspicion of pancreatic cancer) was used in those who presented with upper abdominal pain (14%). Prostate-specific antigen (PSA) use was greatest in men with cancer who presented with lower urinary tract symptoms (88%), and CA125 in women with cancer who presented with abdominal distention (53%). Symptoms with PPV values between 2.00-2.99% were associated with greater test use (64%) compared with 52% and 51% in symptoms with PPVs in the 0.01-0.99 or 1.00-1.99% range and compared with 42% and 31% in symptoms with PPVs in either the 3.00-4.99 or ≥5% range (p < 0.001).

CONCLUSIONS

Generic blood test use reflects the PPV of presenting symptoms, and the use of organ-specific tests is greater in patients with symptomatic presentations with known associations with certain cancer sites. There are opportunities for greater blood test use in patients presenting with symptoms that do not meet referral thresholds (i.e., <3% PPV for cancer) where information gain to support referral decisions is likely greatest. The findings benchmark blood test use in cancer patients, highlighting opportunities for increasing use.

Primary care blood tests before cancer diagnosis: National Cancer Diagnosis Audit data

BACKGROUND

Blood tests can support the diagnostic process in patients with cancer but how often they are used is unclear.

AIM

To explore use of common blood tests before cancer diagnosis in primary care.

DESIGN AND SETTING

English National Cancer Diagnosis Audit data on 39 752 patients with cancer diagnosed in 2018.

METHOD

Common blood test use (full blood count [FBC], urea and electrolytes [U&E], and liver function tests [LFTs]), variation by patient and symptom group, and associations with the primary care interval and the diagnostic interval were assessed.

RESULTS

At least one common blood test was used in 41% (n = 16 427/39 752) of patients subsequently diagnosed with cancer. Among tested patients, (n = 16 427), FBC was used in 95% (n = 15 540), U&E in 89% (n = 14 555), and LFTs in 76% (n = 12 414). Blood testing was less common in females (adjusted odds ratio versus males: 0.92, 95% confidence interval [CI] = 0.87 to 0.98) and Black and minority ethnic patients (0.89, 95% CI = 0.82 to 0.97 versus White), and more common in older patients (1.12, 95% CI = 1.06 to 1.18 for ≥70 years versus 50-69 years). Test use varied greatly by cancer site (melanoma 2% [ n = 55/2297]; leukaemia 84% [ n = 552/661]). Fewer patients presenting with alarm symptoms alone were tested (24% [ n = 3341/13 778]) than those with non-alarm symptoms alone (50% [ n = 8223/16 487]). Median primary care interval and diagnostic interval were longer in tested than non-tested patients (primary care interval: 10 versus 0 days; diagnostic interval: 49 versus 32 days, respectively, P<0.001 for both), including among tested patients with alarm symptoms (primary care interval: 4 versus 0 days; diagnostic interval: 41 versus 22 days).

CONCLUSION

Two-fifths of patients subsequently diagnosed with cancer have primary care blood tests as part of their diagnostic process. Given variable test use, research is needed on the clinical context in which blood tests are ordered.

Underlying cancer risk among patients with fatigue and other vague symptoms: a population-based cohort study in primary care

BACKGROUND

Presenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other 'vague' symptoms.

AIM

To quantify cancer risk in patients with fatigue who present with other 'vague' symptoms in the absence of 'alarm' symptoms for cancer.

DESIGN AND SETTING

Cohort study of patients presenting in UK primary care with new-onset fatigue during 2007-2015, using Clinical Practice Research Datalink data linked to national cancer registration data.

METHOD

Patients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other 'vague' potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue-vague symptom cohort were calculated.

RESULTS

Of 285 382 patients presenting with new-onset fatigue, 84% (n = 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n = 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue-weight loss, 65 years for fatigue-abdominal pain, 67 years for fatigue-constipation, and 67 years for fatigue-other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue-weight loss (from 65 years), fatigue-abdominal pain (from 79 years), or fatigue-abdominal bloating (from 80 years).

CONCLUSION

In the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.

Applying a genetic risk score for prostate cancer to men with lower urinary tract symptoms in primary care to predict prostate cancer diagnosis: a cohort study in the UK Biobank

BACKGROUND

Prostate cancer is highly heritable, with >250 common variants associated in genome-wide association studies. It commonly presents with non-specific lower urinary tract symptoms that are frequently associated with benign conditions.

METHODS

Cohort study using UK Biobank data linked to primary care records. Participants were men with a record showing a general practice consultation for a lower urinary tract symptom. The outcome measure was prostate cancer diagnosis within 2 years of consultation. The predictor was a genetic risk score of 269 genetic variants for prostate cancer.

RESULTS

A genetic risk score (GRS) is associated with prostate cancer in symptomatic men (OR per SD increase = 2.12 [1.86-2.41] P = 3.5e-30). An integrated risk model including age and GRS applied to symptomatic men predicted prostate cancer (AUC 0.768 [0.739-0.796]). Prostate cancer incidence was 8.1% (6.7-9.7) in the highest risk quintile. In the lowest quintile, prostate cancer incidence was <1%.

CONCLUSIONS

This study is the first to apply GRS in primary care to improve the triage of symptomatic patients. Men with the lowest genetic risk of developing prostate cancer could safely avoid invasive investigation, whilst those identified with the greatest risk could be fast-tracked for further investigation. These results show that a GRS has potential application to improve the diagnostic pathway of symptomatic patients in primary care.

Cancer risk in persons with new-onset anaemia: a population-based cohort study in Denmark

Background

The time interval from first symptom and sign until a cancer diagnosis significantly affects the prognosis. Therefore, recognising and acting on signs of cancer, such as anaemia, is essential. Evidence is sparse on the overall risk of cancer and the risk of specific cancer types in persons with new-onset anaemia detected in an unselected general practice population. We aimed to assess the risk of cancer in persons with new-onset anaemia detected in general practice, both overall and for selected cancer types.

Methods

This observational population-based cohort study used individually linked electronic data from laboratory information systems and nationwide healthcare registries in Denmark. We included persons aged 40–90 years without a prior history of cancer and with new-onset anaemia (no anaemia during the previous 15 months) detected in general practice in 2014–2018. We measured the incidence proportion and standardised incidence ratios of a new cancer diagnosis (all cancers except for non-melanoma skin cancers) during 12 months follow-up.

Results

A total of 48,925 persons (median [interquartile interval] age, 69 [55–78] years; 55.5% men) were included in the study. In total, 7.9% (95% confidence interval (CI): 7.6 to 8.2) of men and 5.2% (CI: 4.9 to 5.5) of women were diagnosed with cancer during 12 months. Across selected anaemia types, the highest cancer incidence proportion was seen in women with ‘anaemia of inflammation’ (15.3%, CI: 13.1 to 17.5) (ferritin > 100 ng/mL and increased C-reactive protein (CRP)) and in men with ‘combined inflammatory iron deficiency anaemia’ (19.3%, CI: 14.5 to 24.1) (ferritin < 100 ng/mL and increased CRP). For these two anaemia types, the cancer incidence across cancer types was 10- to 30-fold higher compared to the general population.

Conclusions

Persons with new-onset anaemia detected in general practice have a high cancer risk; and markedly high for ‘combined inflammatory iron deficiency anaemia’ and ‘anaemia of inflammation’. Anaemia is a sign of cancer that calls for increased awareness and action. There is a need for research on how to improve the initial pathway for new-onset anaemia in general practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09912-7.

Anemia as a Problem: GP Approach

BACKGROUND

Anemia is a presentation of an underlying disease or deficiency. As stated by the WHO, anemia is defined as hemoglobin (Hb) levels <12.0 g/dL in women and <13.0 g/dL in men. This review of clinical practice aimed to determine the diagnostic approach to anemia in primary care patients.

SUMMARY

Nutritional deficiencies, medications, chronic inflammatory conditions, malignancy, renal dysfunction, and bone marrow and inherent disorders contribute to anemia development. Anemia is classified and diagnosed by the values of hematological parameters, underlying pathological mechanism, and patient history. The diagnostic approach of anemia in primary care settings is focused on history, physical examination, laboratory findings including complete blood cell count, reticulocyte count, and peripheral smear examination, fecal occult blood test, and ultrasound findings.

KEY MESSAGES

Anemia is the most common hematological disorder that represents a major health burden worldwide. Hb levels alter with gender, ethnicity, and physiological status. Anemia is often multifactorial. The evaluation of a patient with anemia in primary care includes clinical history, physical examination, and laboratory findings with fecal occult blood test and abdominal ultrasound. The wide variations in general practice in European countries are based on different health care systems but also knowledge of GPs that reflect educational and research policy.