Symptomatic diagnosis of cancer of the brain and central nervous system in primary care: a systematic review.

BACKGROUND: We performed a systematic review of diagnostic studies of symptomatic patients in primary care to quantify the risk of brain/central nervous system (CNS) cancer in patients presenting in primary care with symptoms that may indicate brain/CNS cancer. OBJECTIVE: To quantify the risk of brain/CNS cancer in symptomatic patients presenting in primary care. METHODS: We searched Medline, Premedline, Embase, the Cochrane Library, Web of Science and ISI Proceedings (1980 to August 2014) and PsychInfo (1980 to February 2013) for diagnostic studies of symptomatic adult patients in primary care. Study quality was assessed using QUADAS-II and data were extracted to calculate the positive predictive values (PPVs) of symptoms, singly or in combination, for brain/CNS cancer. RESULTS: Six studies with 159938 patients were included. The PPVs of single symptoms were very low with only 'new-onset seizure' being above 1% in patients aged 18 years and above, rising to 2.3% in patients aged 60-69 years. In patients aged 15-24 years, the PPVs for the individual symptoms were also very low, with the highest, also for seizure, being 0.024%, similar to that in children aged 0-14 years of 0.02%. For symptom combinations, none of the PPVs were above 0.39%. CONCLUSIONS: All the symptoms of brain tumours are individually low risk, apart from new-onset epilepsy. This provides a real diagnostic problem, as brain tumours have all the expected features seen with cancer diagnostic delay, with high proportions presenting as an emergency and having had multiple primary care consultations before referral, and the prognosis is poor. Improving these metrics can only be done by liberalizing investigation, although the health economics of that strategy is undetermined.

Does cell-of-origin or MYC, BCL2 or BCL6 translocation status provide prognostic information beyond the International Prognostic Index score in patients with diffuse large B-cell lymphoma treated with rituximab and chemotherapy? A systematic review.

We examined the additional prognostic value for survival of cell-of-origin, and MYC, BCL2 and BCL6 translocation status to that provided by the International Prognostic Index in newly-diagnosed diffuse large B-cell lymphoma (DLBCL) patients treated firstline with rituximab-containing immunochemotherapy. We searched Medline, Premedline, Embase, the Cochrane Library, Web of Science, and ISI Proceedings (2000-2015) and assessed study risk-of-bias using a prognostic study checklist. Forty-four studies of moderate-high risk of bias with 100-712 participants were included. Immunohistochemistry-determined cell-of-origin, and BCL2 and BCL6 translocation status added no additional prognostic value. Half of the studies on gene expression profiling-determined cell-of-origin and MYC translocation status found that germinal center B-cell-like (GCB) and no translocation were associated with better overall survival (OS) whereas the remaining studies found no effect of these covariates. Further studies are required to ensure that biological information assessed using newer technologies can be reliably used for studies that incorporate newer agents targeting distinct molecular abnormalities identified in high-risk DLBCL patients.

Lung cancer in symptomatic patients presenting in primary care: a systematic review of risk prediction tools.

BACKGROUND: Lung cancer is the leading cause of cancer deaths. Around 70% of patients first presenting to specialist care have advanced disease, at which point current treatments have little effect on survival. The issue for primary care is how to recognise patients earlier and investigate appropriately. This requires an assessment of the risk of lung cancer. AIM: The aim of this study was to systematically review the existing risk prediction tools for patients presenting in primary care with symptoms that may indicate lung cancer DESIGN AND SETTING: Systematic review of primary care data. METHOD: Medline, PreMedline, Embase, the Cochrane Library, Web of Science, and ISI Proceedings (1980 to March 2016) were searched. The final list of included studies was agreed between two of the authors, who also appraised and summarised them. RESULTS: Seven studies with between 1482 and 2 406 127 patients were included. The tools were all based on UK primary care data, but differed in complexity of development, number/type of variables examined/included, and outcome time frame. There were four multivariable tools with internal validation area under the curves between 0.88 and 0.92. The tools all had a number of limitations, and none have been externally validated, or had their clinical and cost impact examined. CONCLUSION: There is insufficient evidence for the recommendation of any one of the available risk prediction tools. However, some multivariable tools showed promising discrimination. What is needed to guide clinical practice is both external validation of the existing tools and a comparative study, so that the best tools can be incorporated into clinical decision tools used in primary care.

Symptoms of Pancreatic Cancer in Primary Care: A Systematic Review.

OBJECTIVES: The aim of this study was to quantify the risk of pancreatic cancer in patients presenting in primary care with symptoms that may indicate pancreatic cancer. METHODS: We searched MEDLINE, PreMEDLINE, EMBASE, the Cochrane Library, Web of Science, and ISI Proceedings (1980 to August 2014) and PsychINFO (1980 to May 2013) for diagnostic studies of symptomatic adult patients in primary care. Study quality was assessed using QUADAS-II, and data were extracted to calculate the positive predictive values (PPVs) of symptoms, singly or in combination, for pancreatic cancer. RESULTS: Eight studies with 3,438,363 patients were included. The PPV of jaundice was more than 4.1% in patients 40 years or older and increased with age, although only 30% of patients reported jaundice. The PPVs of other single symptoms were low, with the highest PPV being 1% for repeated attendance with abdominal pain in patients 60 years or older. Excluding jaundice, symptom combinations with high PPVs were those including weight loss, ranging from 1.5% to 2.7% in patients 60 years or older, apart from when weight loss was combined with malaise (PPV, 0.9%). CONCLUSION: The only high-risk feature of pancreatic cancer in primary care was jaundice, and this clearly warrants investigation. Weight loss accompanied by a second symptom may warrant investigation, although this would probably require abdominal computed tomography.

The association between symptoms and bladder or renal tract cancer in primary care: a systematic review.

BACKGROUND: Appropriate selection for further investigation of patients presenting in primary care with symptoms that may indicate cancer is key to early diagnosis. AIM: To quantify the risk of urinary tract cancer in patients presenting in primary care with symptoms that may indicate bladder or renal cancer. DESIGN AND SETTING: Systematic review of studies relating to bladder or renal cancer in primary care. METHOD: Databases searched were MEDLINE, PreMEDLINE, Embase, the Cochrane Library, Web of Science (SCI and SSCI), and ISI Proceedings from 1980 to August 2014, and PsycINFO (1980-2012) and BioMed Central (inception to 2012) for retrospective, prospective, or case-control diagnostic accuracy studies of symptomatic patients presenting to primary care with one or more symptoms for whom follow-up data were available. The target conditions were bladder or renal cancer. The studies were appraised using the QUADAS-2 tool. RESULTS: Eleven studies with 3 451 675 patients were included. The positive predictive value (PPV) from meta-analysis of visible haematuria was 5.1% in adult patients. It increased with age and was higher in males. The PPVs of other single symptoms were very low, with the highest non-haematuria PPV being 1.4% for anaemia in males. Fewer data were available on the PPVs of symptom combinations. Generally, these data showed that, with the exception of symptom combinations including haematuria, these were very low. CONCLUSION: The only high-risk feature of bladder/renal cancer in primary care was visible haematuria, and this clearly warrants investigation. However, not all patients with one of these cancers experience haematuria, so a policy restricting investigation to patients with haematuria will inevitably delay the diagnosis in some patients.