Predictive value of abnormal blood tests for detecting cancer in primary care patients with nonspecific abdominal symptoms: A population-based cohort study of 477,870 patients in England.

Background: Identifying patients presenting with nonspecific abdominal symptoms who have underlying cancer is a challenge. Common blood tests are widely used to investigate these symptoms in primary care, but their predictive value for detecting cancer in this context is unknown. We quantify the predictive value of 19 abnormal blood test results for detecting underlying cancer in patients presenting with 2 nonspecific abdominal symptoms. Methods and findings: Using data from the UK Clinical Practice Research Datalink (CPRD) linked to the National Cancer Registry, Hospital Episode Statistics and Index of Multiple Deprivation, we conducted a population-based cohort study of patients aged ≥30 presenting to English general practice with abdominal pain or bloating between January 2007 and October 2016. Positive and negative predictive values (PPV and NPV), sensitivity, and specificity for cancer diagnosis (overall and by cancer site) were calculated for 19 abnormal blood test results co-occurring in primary care within 3 months of abdominal pain or bloating presentations. A total of 9,427/425,549 (2.2%) patients with abdominal pain and 1,148/52,321 (2.2%) with abdominal bloating were diagnosed with cancer within 12 months post-presentation. For both symptoms, in both males and females aged ≥60, the PPV for cancer exceeded the 3% risk threshold used by the UK National Institute for Health and Care Excellence for recommending urgent specialist cancer referral. Concurrent blood tests were performed in two thirds of all patients (64% with abdominal pain and 70% with bloating). In patients aged 30 to 59, several blood abnormalities updated a patient's cancer risk to above the 3% threshold: For example, in females aged 50 to 59 with abdominal bloating, pre-blood test cancer risk of 1.6% increased to: 10% with raised ferritin, 9% with low albumin, 8% with raised platelets, 6% with raised inflammatory markers, and 4% with anaemia. Compared to risk assessment solely based on presenting symptom, age and sex, for every 1,000 patients with abdominal bloating, assessment incorporating information from blood test results would result in 63 additional urgent suspected cancer referrals and would identify 3 extra cancer patients through this route (a 16% relative increase in cancer diagnosis yield). Study limitations include reliance on completeness of coding of symptoms in primary care records and possible variation in PPVs if extrapolated to healthcare settings with higher or lower rates of blood test use. Conclusions: In patients consulting with nonspecific abdominal symptoms, the assessment of cancer risk based on symptoms, age and sex alone can be substantially enhanced by considering additional information from common blood test results. Male and female patients aged ≥60 presenting to primary care with abdominal pain or bloating warrant consideration for urgent cancer referral or investigation. Further cancer assessment should also be considered in patients aged 30 to 59 with concurrent blood test abnormalities. This approach can detect additional patients with underlying cancer through expedited referral routes and can guide decisions on specialist referrals and investigation strategies for different cancer sites. Meena Rafiq and co-workers explore the predictive value of abnormal blood tests for detecting cancer in patients presenting to primary care with non-specific abdominal symptoms. Author summary: Why was this study done?: Half of all patients with as-yet-undetected cancer will first present with nonspecific symptoms that can be challenging to diagnose. Many of these patients are investigated in primary care with commonly used blood tests that could help to identify which patients are most likely to have underlying cancer (to prioritise them for referral) and which patients can be safely monitored in primary care. This study aimed to assess the predictive value of abnormal blood tests for detecting cancer in patients presenting to primary care with 2 nonspecific abdominal symptoms. What did the researchers do and find?: Using linked UK primary care data (CPRD), we conducted a cohort study of 477,870 patients aged ≥30 years presenting with new abdominal pain or bloating and calculated the predictive value of 19 abnormal blood test results for detecting cancer by age and sex. Males and females aged ≥60 presenting with either symptom had a risk of underlying cancer exceeding the 3% threshold used by the UK National Institute for Health and Care Excellence for recommending urgent cancer referral. In patients aged 30 to 59 with abdominal pain or bloating, several blood abnormalities updated a patient's cancer risk to above the 3% threshold and they should be considered for urgent cancer referral. What do these findings mean?: Commonly used primary care blood test results can improve the detection of underlying cancer in patients consulting with nonspecific abdominal symptoms. These findings can inform updates to clinical guidelines to allow detection of additional patients with underlying cancer through expedited referral routes and can guide decisions on specialist referrals and investigation strategies for different cancer sites. Limitations include the results applying to patients who had been recorded as having abdominal pain and bloating by their clinician and who had been selected by the clinician for blood testing (and therefore have a higher cancer risk that all patients with abdominal pain and bloating). [ABSTRACT FROM AUTHOR]