Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis

Cancer Diagnoses After Recent Weight Loss

Importance

Weight loss is common in primary care. Among individuals with recent weight loss, the rates of cancer during the subsequent 12 months are unclear compared with those without recent weight loss.

Objective

To determine the rates of subsequent cancer diagnoses over 12 months among health professionals with weight loss during the prior 2 years compared with those without recent weight loss.

Design, Setting, and Participants

Prospective cohort analysis of females aged 40 years or older from the Nurses' Health Study who were followed up from June 1978 until June 30, 2016, and males aged 40 years or older from the Health Professionals Follow-Up Study who were followed up from January 1988 until January 31, 2016.

Exposure

Recent weight change was calculated from the participant weights that were reported biennially. The intentionality of weight loss was categorized as high if both physical activity and diet quality increased, medium if only 1 increased, and low if neither increased.

Main Outcome and Measures

Rates of cancer diagnosis during the 12 months after weight loss.

Results

Among 157 474 participants (median age, 62 years [IQR, 54-70 years]; 111 912 were female [71.1%]; there were 2631 participants [1.7%] who self-identified as Asian, Native American, or Native Hawaiian; 2678 Black participants [1.7%]; and 149 903 White participants [95.2%]) and during 1.64 million person-years of follow-up, 15 809 incident cancer cases were identified (incident rate, 964 cases/100 000 person-years). During the 12 months after reported weight change, there were 1362 cancer cases/100 000 person-years among all participants with recent weight loss of greater than 10.0% of body weight compared with 869 cancer cases/100 000 person-years among those without recent weight loss (between-group difference, 493 cases/100 000 person-years [95% CI, 391-594 cases/100 000 person-years]; P < .001). Among participants categorized with low intentionality for weight loss, there were 2687 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 1220 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 1467 cases/100 000 person-years [95% CI, 799-2135 cases/100 000 person-years]; P < .001). Cancer of the upper gastrointestinal tract (cancer of the esophagus, stomach, liver, biliary tract, or pancreas) was particularly common among participants with recent weight loss; there were 173 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 36 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 137 cases/100 000 person-years [95% CI, 101-172 cases/100 000 person-years]; P < .001).

Conclusions and Relevance

Health professionals with weight loss within the prior 2 years had a significantly higher risk of cancer during the subsequent 12 months compared with those without recent weight loss. Cancer of the upper gastrointestinal tract was particularly common among participants with recent weight loss compared with those without recent weight loss.

Patients from general practice with non-specific cancer symptoms: a retrospective study of symptoms and imaging

BACKGROUND

Patients with non-specific symptoms or signs of cancer (NSSC) present a challenge as they are a heterogeneous population who are not candidates for fast-track work-up in an organ-specific cancer pre-planned pathway (CPP). Denmark has a cancer pre-planned pathway for this population (NSSC-CPP), but several issues remain unclarified, for example, distribution and significance of symptoms and findings, and choice of imaging.

AIM

To investigate symptoms, cancer diagnoses, and diagnostic yield of computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients on NSSC-CPP to improve the overall diagnostic process.

DESIGN & SETTING

A retrospective medical chart review in a 1-year consecutive cohort (2020).

METHOD

A total of 802 referrals were reviewed for diagnostic imaging in patients with NSSP from general practices, specialist practices, or the local hospital diagnostic centre responsible for NSSC-CPP.

RESULTS

The study included 248 patients; 21% had cancer, most frequently gastrointestinal cancer (27%). The most frequent symptom was weight loss (56%). CT had a sensitivity of 85%, specificity of 87%, positive predictive value (PPV) of 65%, and negative predictive value (NPV) of 96%. For 18F-FDG-PET/CT, the numbers were sensitivity 82%, specificity 62%, PPV 33%, and NPV 94%. Patients frequently underwent subsequent examinations following initial imaging.

CONCLUSION

The findings were in accordance with the literature. Patients with NSSC had a cancer prevalence of 21%, most frequently gastrointestinal. The most frequent symptom was weight loss and, even as the only symptom, it is a potential marker for cancer. CT and 18F-FDG-PET/CT were sensitive with high NPV, whereas PPV was superior in CT. Better stratification by symptoms or findings is an obvious focus point for future studies to further optimise the NSSC-CPP work-up strategy.

The prognostic impact of pre-treatment cachexia in resectional surgery for oesophagogastric cancer: a meta-analysis and meta-regression

BACKGROUND

Cancer cachexia is not purely an end-stage phenomenon and can influence the outcomes of patients with potentially curable disease. This review examines the effect of pre-treatment cachexia on overall survival, in patients undergoing surgical resection of oesophagogastric cancer.

METHODS

A systematic literature search of MEDLINE, EMBASE and Cochrane Library databases was conducted, from January 2000 to May 2022, to identify studies reporting the influence of cachexia on patients undergoing an oesophagogastric resection for cancer with curative intent. Meta-analyses of the primary (overall survival) and secondary (disease-free survival and postoperative mortality) outcomes were performed using random-effects modelling. Meta-regression was used to examine disease stage as a potential confounder.

RESULTS

Ten non-randomized studies, comprising 7186 patients, were eligible for inclusion. The prevalence of pre-treatment cachexia was 35 per cent (95 per cent c.i.: 24-47 per cent). Pooled adjusted hazard ratios showed that cachexia was adversely associated with overall survival (HR 1.46, 95 per cent c.i.: 1.31-1.60, P < 0.001). Meta-analysis of proportions identified decreased overall survival at 1-, 3- and 5-years in cachectic cohorts. Pre-treatment cachexia was not a predictor of disease-free survival and further data are required to establish its influence on postoperative mortality. The proportion of patients with stage III/IV disease was a significant moderator of between-study heterogeneity. Cachexia may have a greater influence on overall survival in studies where more patients have a locally advanced malignancy.

CONCLUSION

Pre-treatment cachexia adversely influences overall survival following resection of an oesophagogastric malignancy.

Detection of urological cancers by the signature of organic volatile compounds in urine, from dogs to electronic noses

PURPOSE OF REVIEW

Urine volatile organic compound (VOC) testing for early detection of urological cancers is a minimally invasive and promising method. The objective of this review was to present the results of recently published work on this subject.

RECENT FINDINGS

Organic volatile compounds are produced through oxidative stress and peroxidation of cell membranes, and they are eliminated through feces, urine, and sweat. Studies looking for VOCs in urine for the diagnosis of urological cancers have mostly focused on bladder and prostate cancers. However, the number of patients included in the studies was small. The electronic nose was the most widely used means of detecting VOCs in urine for the detection of urological cancers. MOS sensors and pattern recognition machine learning were more used for the composition of electronic noses. Early detection of urological cancers by detection of VOCs in urine is a method with encouraging results with sensitivities ranging from 27 to 100% and specificities ranging from 72 to 94%.

SUMMARY

The olfactory signature of urine from patients with urological cancers is a promising biomarker for the early diagnosis of urological cancers. The electronic nose with its ability to recognize complex odors is an excellent alterative to canine diagnosis and analytical techniques. Nevertheless, additional research improving the technology of Enoses and the methodology of the studies is necessary for its implementation in daily clinical practice.

Weight Change and Risk of Atherosclerosis Measured by Carotid Intima-Media Thickness (cIMT) from a Prospective Cohort-Analysis of the First-Wave Follow-Up Data of the Canadian Longitudinal Study on Aging (CLSA)

To explore impact of weight change (WC) on risk of atherosclerosis measured by cIMT, 20,700 participants from the CLSA follow-up were included in analysis. WC was defined as the difference of weight measured at follow-up and baseline, then quartered into four groups (Q1-Q4). cIMT > 1.0 mm was defined as high risk for atherosclerosis. Adjusted odds ratio (OR (95% CI)) from logistic regression models were used to evaluate the association between WC and risk of atherosclerosis. At follow-up, participants had gained 0.118 kg weight, on average, and 16.4% of them were at high risk for atherosclerosis. The mean levels of cIMT were comparable between participants from Q1 to Q4. Compared to Q2 (reference), the ORs (95% CI) were 1.00 (0.86, 1.15), 1.19 (1.03,1.38), and 1.25 (1.08,1.45) for Q1, Q3, and Q4, respectively. A similar pattern was observed when analyses were conducted for ages < 65 vs. 65+ separately, but it was weaker for those aged 65+. Results from the jointed distribution analyses indicated that moderate weight loss might increase risk for atherosclerosis among participants with obese BMI at baseline, but not for those with cardiovascular event status at baseline. Weight gain, however, would increase risk for atherosclerosis regardless of cardiovascular event status, or overweight/obese BMI at baseline.

The underestimated impact of excess body weight on colorectal cancer risk: Evidence from the UK Biobank cohort

BACKGROUND

The association between excess weight and colorectal cancer (CRC) risk may have been underestimated due to potential weight loss during pre-clinical sojourn time of CRC. We aimed to investigate this association and the corresponding population attributable fraction (PAF), accounting for prediagnostic weight loss.

METHODS

Data from the UK Biobank prospective cohort were used. Multivariable adjusted hazard ratios (HR) and their 95% confidence intervals (CI) for various periods of follow-up and the corresponding PAF of excess weight were calculated.

RESULTS

During a median of 10.0 years of follow-up, of 453,049 participants, 4794 developed CRC. The excess weight-CRC association became substantially stronger with including increasing lengths of follow-up in the analyses and further excluding the initial years of follow-up. HRs (95% CIs) for overweight and obesity were 1.06 (0.97-1.16) and 1.14 (1.03-1.26) after 7 years of follow-up, 1.13 (1.05-1.21) and 1.23 (1.14-1.33) when including complete follow-up length, and 1.26 (1.12-1.43) and 1.42 (1.24-1.63) when excluding the initial 7 years of follow-up. The corresponding PAFs of excess weight were estimated as 6.8%, 11.3%, and 19.0%, respectively.

CONCLUSIONS

Comprehensive consideration of the potential effect of prediagnostic weight loss discloses a much stronger impact of excess body weight on CRC risk than previously assumed.

Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care

OBJECTIVES

Identify the incidence, rate of physician recognition, diagnostic practices and cancer outcomes for unintentional weight loss (UWL).

METHODS

We completed a secondary analysis of structured and unstructured EHR data collected from adult patients between January 1, 2020 and December 31, 2021. We used four common definitions to define UWL, excluding patients with known causes of weight loss, intentional weight loss, and pregnancy. Unstructured physicians' notes were used to identify both intentional weight loss (e.g. dieting) as well as physician recognition of UWL. Cancer outcomes were identified within 12 months of UWL using diagnostic codes. Physician actions (lab tests, etc.) in response to UWL were identified through manual chart review.

RESULTS

Among 29,494 established primary care patients with a minimum of two weight measurements in 2020 and in 2021, we identified 290 patients who met one or more criteria for UWL (1 %). UWL was recognized by physicians in only 60 (21 %). UWL was more common and more likely to be recognized among older patients. Diagnostic practices were quite variable. A complete blood count, complete metabolic profile, and thyroid stimulating hormone level were the three most common tests ordered in response to UWL. Five patients were diagnosed with cancer within 12 months of UWL (3 in whom UWL was recognized; two in whom it was not.).

CONCLUSIONS

Unintentional weight loss is poorly recognized across a diverse range of patients. A lack of research-informed guidance may explain both low rates of recognition and variability in diagnostic practices.

Early Diagnosis of Pancreatic Cancer: Clinical Premonitions, Timely Precursor Detection and Increased Curative-Intent Surgery

BACKGROUND

The overall poor prognosis in pancreatic cancer is related to late clinical detection. Early diagnosis remains a considerable challenge in pancreatic cancer. Unfortunately, the onset of clinical symptoms in patients usually indicate advanced disease or presence of metastasis.

ANALYSIS AND RESULTS

Currently, there are no designated diagnostic or screening tests for pancreatic cancer in clinical use. Thus, identifying risk groups, preclinical risk factors or surveillance strategies to facilitate early detection is a target for ongoing research. Hereditary genetic syndromes are a obvious, but small group at risk, and warrants close surveillance as suggested by society guidelines. Screening for pancreatic cancer in asymptomatic individuals is currently associated with the risk of false positive tests and, thus, risk of harms that outweigh benefits. The promise of cancer biomarkers and use of 'omics' technology (genomic, transcriptomics, metabolomics etc.) has yet to see a clinical breakthrough. Several proposed biomarker studies for early cancer detection lack external validation or, when externally validated, have shown considerably lower accuracy than in the original data. Biopsies or tissues are often taken at the time of diagnosis in research studies, hence invalidating the value of a time-dependent lag of the biomarker to detect a pre-clinical, asymptomatic yet operable cancer. New technologies will be essential for early diagnosis, with emerging data from image-based radiomics approaches, artificial intelligence and machine learning suggesting avenues for improved detection.

CONCLUSIONS

Early detection may come from analytics of various body fluids (eg 'liquid biopsies' from blood or urine). In this review we present some the technological platforms that are explored for their ability to detect pancreatic cancer, some of which may eventually change the prospects and outcomes of patients with pancreatic cancer.

Tuberculosis and risk of cancer: A systematic review and meta-analysis

INTRODUCTION

Cancer is a major cause of death among people who experience tuberculosis (TB), but little is known about its timing and incidence following TB treatment. Our primary objectives were to estimate the pooled risk of all and site-specific malignancies in people with TB compared to the general population or suitable controls. Our secondary objective was to describe the pooled risk of cancer at different time points following TB diagnosis.

METHODS

This study was prospectively registered (PROSPERO: CRD42021277819). We systematically searched MEDLINE, Embase, and the Cochrane Database for studies published between 1980 and 2021. We included original observational research articles that estimated cancer risk among people with TB compared to controls. Studies were excluded if they had a study population of fewer than 50 individuals; used cross-sectional, case series, or case report designs; and had a follow-up period of less than 12 months. Random-effects meta-analysis was used to obtain the pooled risk of cancer in the TB population.

RESULTS

Of the 5,160 unique studies identified, data from 17 studies were included. When compared to controls, the pooled standardized incidence ratios (SIR) of all cancer (SIR 1.62, 95% CI 1.35-1.93, I2 = 97%) and lung cancer (SIR 3.20, 95% CI 2.21-4.63, I2 = 90%) was increased in the TB population. The pooled risk of all cancers and lung cancer was highest within the first year following TB diagnosis (SIR 4.70, 95% CI 1.80-12.27, I2 = 99%) but remained over five years of follow-up.

CONCLUSIONS

People with TB have an increased risk of both pulmonary and non-pulmonary cancers. Further research on cancer following TB diagnosis is needed to develop effective screening and early detection strategies. Clinicians should have a high index of suspicion for cancer in people with TB, particularly in the first year following TB diagnosis.

The Importance of Nutrition as a Lifestyle Factor in Chronic Pain Management: A Narrative Review

In everyday clinical practice, healthcare professionals often meet chronic pain patients with a poor nutritional status. A poor nutritional status such as malnutrition, unhealthy dietary behaviors, and a suboptimal dietary intake can play a significant role in the occurrence, development, and prognosis of chronic pain. The relationship between nutrition and chronic pain is complex and may involve many underlying mechanisms such as oxidative stress, inflammation, and glucose metabolism. As such, pain management requires a comprehensive and interdisciplinary approach that includes nutrition. Nutrition is the top modifiable lifestyle factor for chronic non-communicable diseases including chronic pain. Optimizing one’s dietary intake and behavior needs to be considered in pain management. Thus, this narrative review reports and summarizes the existing evidence regarding (1) the nutrition-related health of people experiencing pain (2) the underlying potential mechanisms that explain the interaction between nutrition and chronic pain, and (3) the role of nutrition screening, assessment and evaluation for people experiencing pain and the scope of nutrition practice in pain management. Future directions in the nutrition and chronic pain field are also discussed.

Measured weight loss as a precursor to cancer diagnosis: retrospective cohort analysis of 43 302 primary care patients

BACKGROUND

Unexpected weight loss is a presenting feature of cancer in primary care. Data from primary care are lacking to quantify how much weight loss over what period should trigger further investigation for cancer. This research aimed to quantify cancer diagnosis rates associated with measured weight change in people attending primary care.

METHODS

Retrospective cohort study of primary care electronic health records data linked to the Surveillance, Epidemiology, and End Results cancer registry (Integrated healthcare delivery system in Washington State, United States). Multivariable Cox regression incorporating time varying covariates using splines to model non-linear associations (age, percentage weight change, and weight change interval). Fifty thousand randomly selected patients aged 40 years and over followed for up to 9 years (1 January 2006 to 31 December 2014). Outcome measures are hazard ratios (95% confidence intervals) to quantify the association between percentage weight change and cancer diagnosis for all cancers combined, individual cancer sites and stages; percentage risk of cancer diagnosis within 6 months of the end of each weight change episode; and the positive predictive value for cancer diagnosis.

RESULTS

There were 43 302 included in the analysis after exclusions. Over 287 858 patient-years of follow-up, including 24 272 (56.1%) females, 23 980 (55.4%) aged 40 to 59 years, 15 113 (34.9%) 60 to 79 years, and 4209 (9.7%) aged 80 years and over. Adjusted hazard ratios (95% confidence interval) for cancer diagnosis in a 60 years old ranged from 1.04 (1.02 to 1.05, P < 0.001) for 1% weight loss to 1.44 (1.23 to 1.68, P < 0.001) for 10%. An independent linear association was observed between percentage weight loss and increasing cancer risk. The absolute risk of cancer diagnosis increased with increasing age (up to 85 years) and as the weight change measurement interval decreased (<1 year). The positive predictive value for a cancer diagnosis within 1 year of ≥5% measured weight loss in a 60 to 69 years old was 3.41% (1.57% to 6.37%) in men and 3.47% (1.68% to 6.29%) in women. The risk of cancer diagnosis was significantly increased for pancreatic, myeloma, gastro-oesophageal, colorectal, breast, stage II and IV cancers.

CONCLUSIONS

Weight loss is a sign of undiagnosed cancer regardless of the interval over which it occurs. Guidelines should resist giving an arbitrary cut-off for the interval of weight loss and focus on the percentage of weight loss and the patient's age. Future studies should focus on the association between diagnostic evaluation of weight change and risk of cancer mortality.

Plasma Aromatase Activity Index, Gonadotropins and Estrone Are Associated with Frailty Syndrome in Post-Menopausal Women with Breast Cancer

Frailty syndrome is associated with poor outcomes, morbidity and premature mortality. We performed a cross-sectional study to evaluate the presence of frailty syndrome based on Fried’s frailty phenotype in post-menopausal women with breast cancer. We further analyzed the association between frailty syndrome with geriatric assessments and the association with the concentration of gonadotropins LH and FSH, estrogens, androgens and the aromatase activity index in the blood. We enrolled 47 post-menopausal women with localized breast cancer (mean age 66.8 ± 1.3 years (range 52−83)) prior to the starting of adjuvant endocrine therapy. Patients were identified as “non-frail” (robust) or “prefrail/frail” if they fulfilled at least one frailty criteria. In order to determine associations among variables and to control for other variables potentially affecting frailty syndrome (age, comorbidity index and previous chemotherapy treatment), we performed a logistic regression analysis. The receiver operating characteristic curve was performed to assess the sensitivity and specificity of the hormonal concentration to discriminate prefrail/frail versus non-frail individuals. Significant positive associations were observed between the severity of frailty syndrome and estrone, FSH and LH concentrations and the aromatase activity index in the blood (p < 0.05). Further research into the role of hormonal biomarkers should be evaluated in follow-up studies in order to recommend their use as suitable biomarkers of frailty syndrome in breast cancer patients.

Exercise-Based Interventions to Counteract Skeletal Muscle Mass Loss in People with Cancer: Can We Overcome the Odds?

Addressing skeletal muscle mass loss is an important focus in oncology research to improve clinical outcomes, including cancer treatment tolerability and survival. Exercise is likely a necessary component of muscle-mass-preserving interventions for people with cancer. However, randomized controlled trials with exercise that include people with cancer with increased susceptibility to more rapid and severe muscle mass loss are limited. The aim of the current review is to highlight features of cancer-related skeletal muscle mass loss, discuss the impact in patients most at risk, and describe the possible role of exercise as a management strategy. We present current gaps within the exercise oncology literature and offer several recommendations for future studies to support research translation, including (1) utilizing accurate and reliable body composition techniques to assess changes in skeletal muscle mass, (2) incorporating comprehensive assessments of patient health status to allow personalized exercise prescription, (3) coupling exercise with robust nutritional recommendations to maximize the impact on skeletal muscle outcomes, and (4) considering key exercise intervention features that may improve exercise efficacy and adherence. Ultimately, the driving forces behind skeletal muscle mass loss are complex and may impede exercise tolerability and efficacy. Our recommendations are intended to foster the design of high-quality patient-centred research studies to determine whether exercise can counteract muscle mass loss in people with cancer and, as such, improve knowledge on this topic.

Odors and cancer: Current status and future directions

Cancer is the second leading cause of death in the world. Because tumors detected at early stages are easier to treat, the search for biomarkers-especially non-invasive ones-that allow early detection of malignancies remains a central goal to reduce cancer mortality. Cancer, like other pathologies, often alters body odors, and much has been done by scientists over the last few decades to assess the value of volatile organic compounds (VOCs) as signatures of cancers. We present here a quantitative review of 208 studies carried out between 1984 and 2020 that explore VOCs as potential biomarkers of cancers. We analyzed the main findings of these studies, listing and classifying VOCs related to different cancer types while considering both sampling methods and analysis techniques. Considering this synthesis, we discuss several of the challenges and the most promising prospects of this research direction in the war against cancer.

Combining simple blood tests to identify primary care patients with unexpected weight loss for cancer investigation: Clinical risk score development, internal validation, and net benefit analysis

BACKGROUND

Unexpected weight loss (UWL) is a presenting feature of cancer in primary care. Existing research proposes simple combinations of clinical features (risk factors, symptoms, signs, and blood test data) that, when present, warrant cancer investigation. More complex combinations may modify cancer risk to sufficiently rule-out the need for investigation. We aimed to identify which clinical features can be used together to stratify patients with UWL based on their risk of cancer.

METHODS AND FINDINGS

We used data from 63,973 adults (age: mean 59 years, standard deviation 21 years; 42% male) to predict cancer in patients with UWL recorded in a large representative United Kingdom primary care electronic health record between January 1, 2000 and December 31, 2012. We derived 3 clinical prediction models using logistic regression and backwards stepwise covariate selection: Sm, symptoms-only model; STm, symptoms and tests model; Tm, tests-only model. Fifty imputations replaced missing data. Estimates of discrimination and calibration were derived using 10-fold internal cross-validation. Simple clinical risk scores are presented for models with the greatest clinical utility in decision curve analysis. The STm and Tm showed improved discrimination (area under the curve ≥ 0.91), calibration, and greater clinical utility than the Sm. The Tm was simplest including age-group, sex, albumin, alkaline phosphatase, liver enzymes, C-reactive protein, haemoglobin, platelets, and total white cell count. A Tm score of 5 balanced ruling-in (sensitivity 84.0%, positive likelihood ratio 5.36) and ruling-out (specificity 84.3%, negative likelihood ratio 0.19) further cancer investigation. A Tm score of 1 prioritised ruling-out (sensitivity 97.5%). At this threshold, 35 people presenting with UWL in primary care would be referred for investigation for each person with cancer referred, and 1,730 people would be spared referral for each person with cancer not referred. Study limitations include using a retrospective routinely collected dataset, a reliance on coding to identify UWL, and missing data for some predictors.

CONCLUSIONS

Our findings suggest that combinations of simple blood test abnormalities could be used to identify patients with UWL who warrant referral for investigation, while people with combinations of normal results could be exempted from referral.

Weight loss as primary indication for FDG-PET/CT

PURPOSE

Some consider fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) clinically useful in patients presenting with nonspecific symptoms of malignancy, weight loss most commonly encountered. However, the appropriateness of such FDG-PET/CT studies remains to be clarified. This study evaluated the clinical value of FDG-PET/CT in patients referred primarily for weight loss.

METHODS

From 2010 to 2017 in one academic center, 252 subjects underwent 254 FDG-PET/CT studies for weight loss as primary indication and retrospectively studied. Eighteen subjects were excluded due to ongoing active malignancy, weight loss not ultimately being the main indication for the FDG-PET/CT, technically inadequate FDG-PET/CT and insufficient follow-up. The FDG-PET/CT scans were considered clinically beneficial when true positive for the cause of weight loss that other investigations missed or would have missed, clinically neutral when true negative and clinically detrimental when false positive leading to additional investigations or false negative.

RESULTS

Ultimately 234 unique subjects (236 FDG-PET/CT studies) were included. The average subject weight loss prior to the PET was 12 kg and average follow-up time post FDG-PET/CT scan was 3.4 years. The FDG-PET/CT scans were true positive in 24 studies (10%) with 8 studies (3%) clinically beneficial; false positive in 38 studies (16%) of which 26 led to 35 additional procedures and false negative in 13 studies (6%). In total, 39 (17%) FDG-PET/CT studies were clinically detrimental. The other 149 (63%) studies were true negative, clinically neutral.

CONCLUSION

FDG-PET/CT appears to have limited value in assessing subjects with weight loss as the leading clinical indication, proving to be five times more often detrimental than beneficial.

Describing the potential of non-specific symptoms-based pathways for diagnosing less common cancers

BACKGROUND

Although less common cancers account for over half of all cancer diagnoses in England, their relative scarcity and complex presentation, often with non-specific symptoms, means that patients often experience multiple primary care consultations, longer times to diagnosis and poorer clinical outcomes. An urgent referral pathway for non-specific symptoms, the Multidisciplinary Diagnostic Centre (MDC), may address this problem.

AIM

To examine the less common cancers identified during the MDC pilots and consider if such an approach improves the diagnosis of these cancers.

DESIGN AND SETTING

A service evaluation of five MDC pilot projects in England to 31st March 2019.

METHOD

Data items were collected by pilot sites in near-real time, based mainly on the English cancer outcomes and services dataset, with additional project specific items. Simple descriptive and comparative statistics were used, including chi-squared tests for proportions and t-tests for means where appropriate.

RESULTS

From 5,134 referrals, 378 cancers were diagnosed, of which 218 (58%) were less common. Over 30 different less common tumour types were diagnosed within this cohort. 23% of MDC patients with less common cancers had ≥3 more GP consultations before referral and, at programme level, a median time of 57 days was recorded from GP urgent referral to treatment for these tumour types.

CONCLUSION

A non-specific symptomatic referral route diagnoses a broad range of less common cancers, and can support primary care case management for patients with symptoms of possible cancer that do not qualify for a site-specific urgent referral.

Time-dependent association between cancer and risk of tuberculosis: A population-based cohort study

BACKGROUND

We aimed to investigate the time-dependent association between cancer and the risk of tuberculosis (TB) before and after cancer diagnosis.

METHODS

This population-based cohort study incorporated the National Health Insurance Research Database and the National Health Interview Survey in Taiwan to estimate TB risk in cancer and noncancer populations. We estimated the period-specific incidence rate ratio (IRR) between cancer and risk of TB and used Cox proportional hazards models to estimate the average hazard ratio between cancer and TB during the peridiagnostic period.

RESULTS

From 2001 to 2015, 457 673 cancer and 3 738 122 noncancer individuals were enrolled. After stratifying the IRR of TB by year relative to the date of cancer diagnosis, the peak IRRs clustered in the year before and after the index date. In the peridiagnostic period of cancer, the adjusted hazard ratio was 2.29 (95% CI, 2.22-2.35) using the Cox model and 2.20 (95% CI, 2.09-2.32) after adjustment for missing confounders. Patients with cancers in the respiratory tract, upper digestive tract, and hematologic system were at the highest risk for TB.

CONCLUSIONS

Cancer is an independent risk factor for TB, with the highest risk observed around the time of cancer diagnosis.

Non-specific symptoms and signs of cancer: different organisations of a cancer patient pathway in Denmark

OBJECTIVE

We aimed to investigate the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP) in order to describe organisational and clinical practice similarities and differences in the diagnostic work-up of suspected cancer in Denmark.

MATERIAL AND METHODS

A questionnaire on the organisation and practice pertaining to the NSSC-CPP was completed by all 21 diagnostic units in the five healthcare regions in Denmark.

RESULTS

The questionnaire responses revealed regional and intraregional differences in the organisation and clinical practice of the NSSC-CPP. CT scan was the most often used imaging in the NSSC-CPP but there was no consensus whether the CT scan should be ordered and evaluated by general practitioners (GPs) or by the diagnostic units. Two regions were consistent but had different modalities regarding referrals from GPs. Three regions had intra-regional differences. The units reported on different types and frequency of forum for patient plan discussion and how to end a NSSC-CPP.

CONCLUSION

The NSSC-CPP is implemented with great regional and intra-regional differences in Denmark. GPs face different requirements when referring to the NSSC-CPP, which indicates that the division of role and responsibility between GPs and the diagnostic units is not well defined.KEY POINTSIn Denmark, the cancer patient pathway for non-specific symptoms and signs of cancer (NSSC-CPP) has been implemented with variations, but little is known about these different modalities. This study showed that both at a regional and an intra-regional level:•General practitioners meet different implementation of national guidelines in the diagnostic units when referring to the NSSCP-CPP•The suitable patient group for the NSSC-CPP is not well defined•Quality criteria are needed to monitor, evaluate and improve the diagnostic work-up for patients with non-specific symptoms and signs of cancer.

Evaluating the frequency of positive paraneoplastic antibodies and associated malignancy risk

OBJECTIVE

To evaluate the association between malignancy and frequently positive paraneoplastic antibodies.

METHODS

A retrospective cohort study was carried out for all patients who received paraneoplastic antibody testing in 2013-2014 at a tertiary referral center. Available medical records on included patients were reviewed through July 2020. Patients were divided into antibody positive and negative subgroups. Focused analysis was performed on the subgroup of patients who received testing via a commonly used antibody panel.

RESULTS

A total of 1860 patients (the full cohort) received 19,323 antibody testing via panel or individual antibody testing, and were followed-up for a mean period of 36.2 months (range 0-83 months). Altogether 229 antibodies in 196 patients were positive, and 9 (3.9%) in 7 patients were against onconeuronal antigens. The remaining 220 (96.1%) were positive for mostly antibodies against cell surface or synaptic antigens. A total of 1161 patients received Mayo Clinic paraneoplastic antibody panel tests (the panel cohort), and 14.9% (173) of these patients possessed one or more positive antibodies. For the panel cohort, no difference was found between antibody positive and negative groups with respect to the prevalence of previously existing malignancy (15.6% versus 16.6%, p = 0.745) or incidence of new malignancy (4.0% vs. 3.7%, p = 0.848) during the follow-up period. No difference was observed in the incidence of new malignancy during follow-up between the antibody positive and negative groups for the 7 most frequently positive antibodies.

CONCLUSIONS

The presence of frequently positive antibodies, mostly to cell surface or synaptic antigens, is not clearly associated with the development of malignancy in the subsequent three years.

Cancer Cachexia Affects Patients with Head and Neck Cancer in All Stages of Disease: A Prospective Cross-Sectional Study

The aim of the study was to determine the prevalence of cancer cachexia according to the clinical stage and determine differences in body composition, usual energy intake, and pro-inflammatory profile between cachectic and non-cachectic patients newly diagnosed with head and neck squamous cell carcinoma (HNSCC). A cross-sectional study was conducted in adult patients diagnosed with HNSCC admitted to the oncology unit before starting cancer treatment. Cancer cachexia was assessed according to Fearon criteria, and patients were divided into two groups: cachectic and non-cachectic patients. Body composition measured by bioelectrical impedance, energy intake, and biochemical and inflammatory markers were assessed. Comparative analyses were performed Student's-T test, using one-way ANOVA, chi-square and Mann Whitney-U test. Of the 79 consecutive patients included in the analysis, 72% (n = 57; 61 ± 15 years) were classified as cachectic and 28% (n = 22;59 ± 10 years) as non-cachectic. According to clinical stage, the prevalence of cachexia was stage I = 8.8%, stage II = 15.8%, stage III = 33.3% and stage IV = 42.1% (P = 0.564) and phase angle showed to be different between these groups (P < 0.05). Body composition showed that fat-free mass and total body water were significantly lower in patients with cachexia (p < 0.05). No differences were observed in phase angle, food intake or inflammatory markers between cachectic and non-cachectic patients. Cancer-cachexia is prevalent in all clinical stages in newly diagnosed patients with HNSCC. Early identification of cancer cachexia will allow initiate specialized nutrition support in a timely manner.

CASNET2: evaluation of an electronic safety netting cancer toolkit for the primary care electronic health record: protocol for a pragmatic stepped-wedge RCT

INTRODUCTION

Safety-netting in primary care is the best practice in cancer diagnosis, ensuring that patients are followed up until symptoms are explained or have resolved. Currently, clinicians use haphazard manual solutions. The ubiquitous use of electronic health records provides an opportunity to standardise safety-netting practices.A new electronic safety-netting toolkit has been introduced to provide systematic ways to track and follow up patients. We will evaluate the effectiveness of this toolkit, which is embedded in a major primary care clinical system in England:Egerton Medical Information System(EMIS)-Web.

METHODS AND ANALYSIS

We will conduct a stepped-wedge cluster RCT in 60 general practices within the RCGP Research and Surveillance Centre (RSC) network. Groups of 10 practices will be randomised into the active phase at 2-monthly intervals over 12 months. All practices will be activated for at least 2 months. The primary outcome is the primary care interval measured as days between the first recorded symptom of cancer (within the year prior to diagnosis) and the subsequent referral to secondary care. Other outcomes include referrals rates and rates of direct access cancer investigation.Analysis of the clustered stepped-wedge design will model associations using a fixed effect for intervention condition of the cluster at each time step, a fixed effect for time and other covariates, and then include a random effect for practice and for patient to account for correlation between observations from the same centre and from the same participant.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the North West-Greater Manchester West National Health Service Research Ethics Committee (REC Reference 19/NW/0692). Results will be disseminated in peer-reviewed journals and conferences, and sent to participating practices. They will be published on the University of Oxford Nuffield Department of Primary Care and RCGP RSC websites.

TRIAL REGISTRATION NUMBER

ISRCTN15913081; Pre-results.

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

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.

Clinical factors for predicting malignancy in patients with PSA < 10 ng/mL and PI-RADS 3 lesions

AIM

To determine clinical risk factors in patients with PI-RADS 3 lesions and prostate-specific antigen (PSA) < 10 ng/mL.

METHODS

In this prospective study, all patients underwent multiparametric magnetic resonance imaging. Following the 2-5 core fusion-targeted biopsy, standard 12-core prostate biopsy was performed in each patient (combined biopsy). The cutoff values were calculated with receiver-operating characteristic analysis. First, univariate logistic regression analysis was used to evaluate the relationship between total eight parameters and prostate cancer. Subsequently, multiple logistic regression analysis was performed to the parameters associated with prostate cancer.

RESULTS

Two hundred and eighty-eight patients were included in the study. Some clinical parameters are determined to be significant in univariate and multiple logistic regression analyses, including PSA, free/total PSA ratio, PSA density (PSA/total prostate volume), positive family history of PCa, and PI-RADS 3 lesion diameter. Patients were classified between 0 and 5 according to the number of risk factors. While the risk of cancer was 7.1% in patients with one or less risk factors, the PCA rate was 45.2% among patients with all risk factors.

CONCLUSION

In patients with PI-RADS 3 lesion and PSA < 10 ng/mL, histopathological results of biopsy can be estimated with higher accuracy using some clinical parameters.

First results from five multidisciplinary diagnostic centre (MDC) projects for non-specific but concerning symptoms, possibly indicative of cancer

Background

Patients with non-specific symptoms often experience longer times to diagnosis and poorer clinical outcomes than those with site-specific symptoms. This paper reports initial results from five multidisciplinary diagnostic centre (MDC) projects in England, piloting rapid referral for patients with non-specific symptoms.

Methods

The evaluation covered MDC activity from 1st December 2016 to 31st July 2018, with projects using a common dataset. Logistical regression analyses were conducted, with a diagnosis of any cancer as the dependent variable. Exploratory analysis was conducted on presenting symptoms and diagnoses of cancer, and on comparisons within these groupings.

Results

In total, 2961 patients were referred into the MDCs and 241 cancers were diagnosed. The pathway detected cancers across a broad range of tumour sites, including several rare and less common cancers. An association between patient age and cancer was identified (p < 0.001). GP ‘clinical suspicion’ was identified as a strong predictor of cancer (p = 0.006), with a reduced association with cancer observed in patients with higher numbers of GP consultation before referral (p = 0.008).

Conclusions

The MDC model diagnoses cancer in patients with non-specific symptoms, with a conversion rate of 8%, demonstrating the diagnostic potential of a non-site-specific symptomatic referral pathway.

The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations

Background

We aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines.

Methods

This retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage.

Results

In all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators.

Conclusion

UWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.

Determinants and extent of weight recording in UK primary care: an analysis of 5 million adults' electronic health records from 2000 to 2017

BACKGROUND

Excess weight and unexpected weight loss are associated with multiple disease states and increased morbidity and mortality, but weight measurement is not routine in many primary care settings. The aim of this study was to characterise who has had their weight recorded in UK primary care, how frequently, by whom and in relation to which clinical events, symptoms and diagnoses.

METHODS

A longitudinal analysis of UK primary care electronic health records (EHR) data from 2000 to 2017. Descriptive statistics were used to summarise weight recording in terms of patient sociodemographic characteristics, health professional encounters, clinical events, symptoms and diagnoses. Negative binomial regression was used to model the likelihood of having a weight record each year, and Cox regression to the likelihood of repeated weight recording.

RESULTS

A total of 14,049,871 weight records were identified in the EHR of 4,918,746 patients during the study period, representing 26,998,591 person-years of observation. Around a third of patients had a weight record each year. Forty-nine percent of weight records were repeated within a year with an average time to a repeat weight record of 1.92 years. Weight records were most often taken by nursing staff (38-42%) and GPs (37-39%) as part of a routine clinical care, such as chronic disease reviews (16%), medication reviews (6-8%) and health checks (6-7%), or were associated with consultations for contraception (5-8%), respiratory disease (5%) and obesity (1%). Patient characteristics independently associated with an increased likelihood of weight recording were as follows: female sex, younger and older adults, non-drinkers, ex-smokers, low or high BMI, being more deprived, diagnosed with a greater number of comorbidities and consulting more frequently. The effect of policy-level incentives to record weight did not appear to be sustained after they were removed.

CONCLUSION

Weight recording is not a routine activity in UK primary care. It is recorded for around a third of patients each year and is repeated on average every 2 years for these patients. It is more common in females with higher BMI and in those with comorbidity. Incentive payments and their removal appear to be associated with increases and decreases in weight recording.

The internal validation of weight and weight change coding using weight measurement data within the UK primary care Electronic Health Record

PURPOSE

To use recorded weight values to internally validate weight status and weight change coding in the primary care Electronic Health Record (EHR).

PATIENTS AND METHODS

We included adult patients with weight-related Read codes recorded in the UK's Clinical Practice Research Datalink EHR between 2000 and 2017. Weight status codes were compared to weight values recorded on the same day and positive predictive values (PPVs) were calculated for commonly used codes. Weight change codes were validated using three methods: the percentage (%) difference in kilograms at the time of the code and 1) the previous weight measurement, 2) the weight predicted using linear regression, and 3) the historic mean weight. Weight change codes were validated if estimates were consistent across two out of three methods.

RESULTS

A total of 8,108,481 weight codes were recorded in 1,000,002 patients' EHR. Twice as many were recorded in females (n=5,208,593, 64%). The mean body mass index for "overweight" codes ranged from 31.9 kg/m2 to 46.9 kg/m2 and from 17.4 kg/m2 to 19.2 kg/m2 for "underweight" codes. PPVs for the most commonly used weight status codes ranged from 81.3% (80%-82.5%) to 99.3% (99.2%-99.4%). Across the estimation methods, and using only validated weight change codes, mean weight loss ranged from - 5.2% (SD 5.8%) to -7.9% (SD 7.3%) and mean weight gain from 4.2 % (SD 5.5%) to 7.9 % (SD 8.2%). The previous and predicted weight methods were most consistent.

CONCLUSION

We have developed an internationally applicable methodology to internally validate weight-related EHR coding by using available weight measurement data. We demonstrate the UK Read codes that can be confidently used to classify weight status and weight change in the absence of weight values. We provide the first evidence from primary care that a Read code for unexpected weight loss represents a mean loss of ≥ 5 % in a 6-month period, which was broadly consistent across age groups and gender.

Patients' and GPs' expectations regarding healthcare-seeking behaviour: a Norwegian comparative study

Background

GPs are Norwegian patients' first contact point with the healthcare system for most medical problems. However, little is known regarding GPs' expectations towards their patients' healthcare-seeking behaviour, or whether doctors and patients have coinciding expectations of what GPs can do for their patients.

Aim

To investigate patients' and GPs' expectations regarding patients' healthcare-seeking behaviour in primary care, and to make comparisons between the two.

Design & setting

Norwegian data from the Quality and Costs of Primary Care in Europe (QUALICOPC) questionnaire study, with information from GPs and their patients.

Method

Binary logistic regression was used to investigate associations between expectations, sex and age of GPs and patients, list size, and geographical location of practice. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Expectation differences between GPs and patients were analysed using generalised estimating equations (GEEs). Due to multiple testing, Bonferroni correction was used to define significance level at P≤0.002.

Results

In total, 198 GPs (39.1% female) and 1529 patients (61.9% female) responded. No associations with sex or age were found for the GPs' expectations regarding patients' healthcare-seeking behaviour. Among patients, fewer males than females expected that most people would see their GP for sprained ankle (OR 0.7, 95% CI = 0.5 to 0.9), finger cut (OR 0.6, 95% CI = 0.4 to 0.7), smoking cessation (OR 0.6, 95% CI = 0.5 to 0.8), or anxiety (OR 0.4, 95% CI = 0.3 to 0.6). Older patients (aged >65 years) found it more important than younger patients to see a doctor in the presence of medical symptoms. GPs had higher expectations than their patients that people in general would see them for deteriorated vision (OR 4.2, 95% CI = 2.5 to 6.9), sexual problems (OR 1.8, 95% CI =1.3 to 2.6), and anxiety (OR 3.0, 95% CI =1.5 to 6.0).

Conclusion

For several common health problems, males are less likely than females to believe that people will see their GP. GPs may overestimate to what degree their patients will see them for a number of common medical problems.

Smoking as a risk factor for giant cell arteritis: A systematic review and meta-analysis

OBJECTIVES

To investigate the association between smoking and giant cell arteritis (GCA).

METHODS

A systematic review was performed and meta-analysis conducted on observational studies that reported absolute numbers and/or statistical comparisons with 95% confidence intervals comparing smoking history and presence of GCA, among patients with GCA and non-GCA controls. Studies were reviewed in accordance with PRISMA guidelines. Point estimates and standard errors were extracted from individual studies and were combined by the generic inverse variance method of DerSimonian and Laird. A random-effects meta-analysis was performed. Statistical heterogeneity was assessed using the Cochran's Q test which was complemented with the I² statistic.

RESULTS

The initial search yielded 3312 articles. Of these, thirteen studies (8 prospective and, 5 retrospective case-control studies) with unique cohorts were identified and included in the primary analysis (ever vs. never smoking history). Patients in the GCA cohort were more likely to have a history of smoking with an odds ratio of 1.19 (95% CI, 1.01-1.39). Considerable heterogeneity was present (I²= 85%). Five of these studies included information on current smoking status. One additional study, which only reported current smoking status, was also included. The GCA cohort showed an association with current smoking with an odds ratio of 1.18 (95% CI, 1.01-1.38).

CONCLUSION

Our study demonstrated a statistically significant increased risk of GCA among both current and ever smokers compared to non-smokers.