Quantifying the risk of Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a case–control study using electronic records

Abstract

Research Abstract BackgroundIn the UK, approximately five people are diagnosed with Hodgkin lymphoma (HL) daily. One-tenth of diagnoses are in those aged >75 years. AimTo establish a symptom profile of HL and quantify their risk in primary care patients aged ≥40 years. Design and settingMatched case-control study using Clinical Practice Research Datalink patient records. MethodPutative clinical features of HL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs) calculated for the consulting population. ResultsTwo-hundred and eighty-three patients aged ≥40 years, diagnosed with HL between 2000 and 2009, and 1237 age, sex, and general practice-matched participants were studied. Six features were independently associated with HL: lymphadenopathy (OR 280, 95% confidence interval [CI] = 25 to 3100), head and neck mass not described as lymphadenopathy (OR 260, 95% CI = 21 to 3200), other mass (OR 12, 95% CI = 4.4 to 35), thrombocytosis (OR 6.0, 95% CI = 2.6 to 14), raised inflammatory markers (OR 5.2, 95% CI = 3.0 to 9.0), and low full blood count (OR 2.8, 95% CI = 1.6 to 4.8). Lymphadenopathy per se has a positive predictive value (PPV) of 5.6% for HL in patients aged ≥60 years. ConclusionConsistent with secondary care findings, lymphadenopathy is the clinical feature with the highest risk of HL in primary care and warrants urgent investigation. Keywords diagnosis; Hodgkin lymphoma; primary health care.Quantifying the risk of Hodgkin lymphoma in symptomatic primary care patients aged ≥ 40 years: a case-control study using electronic records

Assessing risk and improving survival in lymphoma

“…A similar low level of such systemic symptoms in the HL report 9 contrasts with the international prognostic collaboration report of 71%. 12 It seems probable that these differences reflect the combination of the typically later presentation to secondary care in the course of disease that can sometimes provide time for such symptoms to develop, and the active pursuance of these somewhat nonspecific symptoms being precipitated when a diagnosis is either strongly suspected or proven in the secondary care setting.…”

“…The historical reports indicating GPs are able to distinguish malignant from benign lymphadenopathy are important and the PPVs determined for masses in older patients by Shephard's group develop this further. 8,9 However, this should be considered in the context of recent developments in national referral practices including the cancer (2-week wait) referral pathway from which only a relatively small proportion (in the region of 10% in our centre) of suspected lymphoma referrals prove to be either NHL or HL. While Shephard et al's studies could not specifically address size from the CPRD data, lymphadenopathy ≥2 cm or rapid enlargement should be considered as urgent red flag signs and prompt referral would be judicious.…”

“…The studies by Shephard and colleagues 8,9 provide an important insight in to the presentation of NHL and HL in the primary care setting and can be used to inform referral practices, most notably in older patients. In tandem with the studies' insights, a specialised learning tool dedicated to the subject of lymphoma in the primary care sector has been produced by the Royal College of General Practitioners and the Lymphoma Association and should be a valuable resource.…”

“…In this issue, Shephard and colleagues report two large case-control studies that determine symptom and sign risk profiles for patients in the primary care setting who go on to develop NHL (n = 4362) 8 or HL (n = 283), 9 respectively. This is the first approach of this scale performed in the primary care sector to address the presenting features of lymphoma.…”

Quantifying the risk of non-Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a large case–control study using electronic records

“…The reports that GPs appear able to distinguish malignant from benign lymphadenopathy are helpful. [26][27][28] When the results of this study are added to those for Hodgkin lymphoma in the associated article, 31 the PPVs rise to 18.6% for either lymphoma or lymphadenopathy, 4.6% for head and neck mass, and 1.1% for mass elsewhere. Therefore the default decision should be referral of patients ≥60 years with these features, unless there is a clear reason not to.…”