Diagnostic accuracy systematic review of rectal bleeding in combination with other symptoms, signs and tests in relation to colorectal cancer

Bekkink, Marleen Olde; McCowan, Colin; Falk, Gavin A.; Teljeur, Conor; Laar, F.A. van de; Fahey, Tom

doi:10.1038/sj.bjc.6605426

Cited by 41 publications

(40 citation statements)

References 39 publications

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“…A recent systematic review and meta-analysis on studies that only involved the recruitment of cases of rectal bleeding by GPs commented on the difficulties of complete identification and follow-up of all incident cases of rectal bleeding in primary care and differences in age cut-off points between studies. 38 The authors gave an estimated PPV of over 5% in those aged ≥60 years with rectal bleeding.…”

Section: Strengths and Limitations Of The Reviewmentioning

confidence: 99%

“…Three recent systematic reviews on the diagnostic utility of combinations of symptoms, signs, and test results for colorectal cancer showed that evidence in primary care is lacking, and when present only shows modest diagnostic value. [38][39][40] A potential criticism of this review is that it only included symptoms, signs, and tests with a point estimate PPV of 5% or more. It is likely that it excluded good-quality studies with a point estimate of less than 5%, but in which the 95% CIs included 5%.…”

Section: Strengths and Limitations Of The Reviewmentioning

confidence: 99%

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Positive predictive values of ≥5% in primary care for cancer: systematic review

et al. 2010

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When a patient consults a GP, part of the management of the individual involves an assessment of the probability of serious illness including malignancy. One way of expressing this probability is in terms of the positive predictive value (PPV): the proportion of people with the symptom, sign, or test result who develop cancer. Research on medical decision models reveals that probabilities and the valuation of outcomes are distorted by individuals, 1 and thus theories of behaviour based on cognitive assessment of risk are not directly applicable to the consultation.2 For instance, in one model of the consultation, the 'evidence' from research that allows the calculation of probabilities of risk and benefit is modified by an individual doctor's knowledge, skills, attitudes, resources, and legal requirements, and an individual patient's ideas, concerns, expectations, beliefs, and values, to produce the final outcome.3 These factors vary widely between individuals.Decision makers who wish to maximise desirable outcome often adopt models based on probabilities of benefits and harms. AimTo identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer. Design of studySystematic review. SettingPrimary care. MethodFourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer. ResultsTwenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer. ConclusionRobust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal. Keywordscancer; positive predictive values; predictive value of tests; primary care. British Journal of General Practice, September 2010is that much of the evidence that underpins these guidelines is not derived from those patients who consult a GP during a routine consultation. 5 This is important, because predictive values are dependent on the prevalence of the disease in the population from which they are derived and thus applied. The prevalence of cancers within populations and their associated PPVs of symptoms, signs, and nondiagnostic test results increase from community to primary care to hospital populations.The level of the predictive value given in guidelin...

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Section: Strengths and Limitations Of The Reviewmentioning

confidence: 99%

Section: Strengths and Limitations Of The Reviewmentioning

confidence: 99%

Positive predictive values of ≥5% in primary care for cancer: systematic review

et al. 2010

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“…These independent eff ects have greater diagnostic yield when presenting in combination than individually. The prior probability of colorectal cancer in patients presenting to their PCPs in primary care ranged from 3·3% to 15·4% in eight community-based studies, 131 so even when a patient presents with a full complement of symptoms and signs, the probability of colorectal cancer remains modest at around 20-25%. This means that further diagnostic testing is always needed.…”

Section: Epidemiology Of Cancer Symptomsmentioning

confidence: 99%

“…This means that further diagnostic testing is always needed. 131 Further research from the QCancer (colorectal) study showed that assessment of anaemia in a patient presenting with rectal bleeding is important for additional diagnostic yield. 132 Breast symptoms are a common reason for encounter in primary care.…”

Section: Epidemiology Of Cancer Symptomsmentioning

confidence: 99%

The expanding role of primary care in cancer control

Rubin

Berendsen

Crawford

et al. 2015

The Lancet Oncology

448

450

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The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise-from epidemiologists, psychologists, policy makers, and cancer specialists-has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to eff ect change are outlined. The strengths of primary care-its continuous, coordinated, and comprehensive care for individuals and families-are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

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“…Accurate diagnosis, however, is essential in patients with rectal cancer (13). Consequently, physical examination is of paramount importance in every patient, especially when gastrointestinal bleeding is present (14).…”

Section: Discussionmentioning

confidence: 99%

Prospective analysis of clinician accuracy in the diagnosis of benign anorectal pathology: the value of clinical information

Jimeno

Vallverdú

Tubella

et al. 2012

Rev. esp. enferm. dig.

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Aim: the prevalence of anorectal disorders in general population is high. The aim of this study was to analyze the influence of clinical symptoms on diagnostic accuracy for benign anorectal pathology among different specialists and evaluate the relation ship between diagnostic accuracy and years of professional expe rience.Methods: seven typical cases were selected. In a first interview, participants were shown images and asked to make a diagnosis. Afterwards, images with additional information (clinical symptoms) were used. Two groups (group 1 = general surgeons and group 2 = medical specialists who attended emergency department) completed both phases of the study to analyze the influence of clinical symptoms on the final diagnosis.Results: forty four specialists were interviewed. The percentage of participants making a correct diagnosis in groups 1 and 2, respectively, was as follows: case 1 (perianal abscess): 100 vs. 80.6%, (p = 0.157); case 2 (fissure): 92.3 vs. 51.6% (p = 0.015); case 3 (thrombosed hemorrhoid): 92.3 vs. 74.2% (p = 0.321); case 4 (anal condyloma): 100 vs. 87.1% (p = 0.302); case 5 (rectal prolapse): 100 vs. 83.9% (p = 0.301); case 6 (prolapsed hemorrhoid): 92.3 vs. 29% (p = 0.001), and case 7 (fistula): 100 vs. 67.7% (p = 0.021). There were significant differences in the number of correctly diagnosed cases between groups (p < 0.001). Information about clinical symptoms significantly increased overall and specific accuracy. There was no correlation between experience and accuracy.Conclusions: clinical symptoms are important for diagnostic accuracy in anorectal pathology. Training in anorectal pathology in medical specialists is warranted.

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Diagnostic accuracy systematic review of rectal bleeding in combination with other symptoms, signs and tests in relation to colorectal cancer

Cited by 41 publications

References 39 publications

Positive predictive values of ≥5% in primary care for cancer: systematic review

Positive predictive values of ≥5% in primary care for cancer: systematic review

The expanding role of primary care in cancer control

Prospective analysis of clinician accuracy in the diagnosis of benign anorectal pathology: the value of clinical information

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