The Diagnostic Value of the Patient’s Reason for Encounter for Diagnosing Cancer in Primary Care

Kees van Boven; Annemarie A. Uijen; Nina van de Wiel; Sibo K. Oskam; Henk J. Schers; Willem J. J. Assendelft

doi:10.3122/jabfm.2017.06.170076

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Table 1.

Alarm Symptoms of the Dutch Cancer Society and Cancer Research UK and the Corresponding International Classification of Primary Care (ICPC) Code(s)

Alarm Symptoms	ICPC Code
Any abnormal bleeding	Rectal bleeding (D16)
	Haematuria (U06)
	Post-menopausal bleeding (X12)
	Post-coital bleeding (X13)
	Intermenstrual bleeding (X08)^*
Breathlessness	Shortness of breath/dyspnea (R02)
Desquamationed skin	Skin texture symptom/complaint (S21)^*
New or changing nevus/mole	Nevus/mole (S82)
Feeling very tired all the time	Weakness/tiredness, general (A04)^*
Persistent hoarseness or cough and hemoptysis	Hemoptysis (R24)
	Voice symptom/complaint (R23)^*
	Cough R05^{^†}
Lump	Lump/swelling, localized (S04)^*
Lump	Breast lump/mass female (X19)
Nipple changes	Nipple symptom/complaint female (X20)^*
Swallowing problems	Swallowing problems (D21)
Unexplained persistent change in bowel habits	Change in feces/bowel movements (D18)
Unexplained weight loss	Weight loss (T08)
Urinary tract problems or changing in passing urine	Dysuria/painful urination (U01)^*
	Urinary frequency/urgency (U02)^*
	Urinations problems, other (U05)^*
	Prostate symptom/complaint (Y06)^*

↵* The ICPC code matches only partly with the corresponding alarm symptom.
↵† The ICPC code is cough and not persistent cough.

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Table 2.

Incidence (Pre-Test Probability) of Cancer in Patients ≥45 years (per 1000 Patients per Year; Top 10)

Type of Cancer (ICPC code)	ICPC Code	FaMe-Net	National CancerRegistration Nl
Female breast^*	X76	2.49	3.03
Skin	S77	1.75	1.13
Prostate^{^†}	Y77	1.58	2.89
Colon/rectum	D75	1.07	1.61
Bronchus/lung	R84	0.85	1.26
Female genital (cervix and female breast excluded)	X77	0.66	0.93
Digestive (stomach, pancreas, and colon/rectum excluded)	D77	0.41	0.45
Bladder	U76	0.28	0.39
Stomach	D76	0.19	0.20
Respiratory (bronchus/lung excluded)	R85	0.10	0.14

↵* Per 1000 females.
↵† Per 1000 males.
ICPC, International Classification of Primary Care.

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Table 3.

Positive Likelihood Ratios PPV in Percent of Cancer in Patients Presenting with an Alarm Symptom (1995 to 2014)

Alarm Symptoms by ICPC	Number of RFEs	N Resulting Cancer	N^{^‡} Cancer Overall	PPV (%)	LR+	Type of Cancer (N)
Breast lump, female	400	59	158	14.8	204.86	Female breast (59)
Postmenopausal bleeding	385	15	42	3.9	180.69	Female genital^* (15)
Hemoptysis	225	6	100	2.7	81.89	Bronchus/lung (6)
Rectal bleeding	913	24	127	2.6	63.53	Colon/rectum (24)
Hematuria	693	15	33	2.2	200.44	Bladder (15)
Weight loss	866	18	410	2.1		Colon/rectum (4), Stomach (3), Bronchus/lung (3), Prostate (3), Kidney (2), Pancreas (2), unknown (1)
Nipple symptom	187	4	158	2.1		Female breast (4)
Swallowing problems	302	6	71	2.0		Stomach (3), Other malignant digestive neoplasm not stomach/colon/pancreas (3)
Change in feces/bowel movements	433	8	127	1.8	44.30	Colon/rectum (8)
Lump/swelling localized	6283	112	329	1.8	16.48	Skin (112)
Nevus/mole	814	15	329	1.8	17.04	Skin (15)
Prostate symptom/complaint	343	3	87	0.9		Prostate (3)
Urinary frequency/urgency (men)	1007	6	87	0.6	7.70	Prostate (6)
Urinations problems other	653	3	120	0.5		Prostate (2), Bladder (1)
Voice symptom/complaint	804	3	41	0.4		Malignant neoplasm respiratory, other (not bronchus) (2), Hodgkin/lymphoma (1)
Skin texture symptom/complaint	716	3	329	0.4		Skin (3)
Weakness/tiredness, general	5454	18	327	0.3	3.46^{^†}	Colon/rectum (8), Pancreas (3) Leukemia (2), Other malignant digestive neoplasm (2), Hodgkin/lymphoma (1), Malignant neoplasm respiratory, other (not bronchus) (1), Malignant neoplasm genital female not cervix, not breast (1), Unknown (1)
Shortness of breath/dyspnea	4677	12	340	0.3	3.84	Bronchus/lung (9), Leukemia (2), Hodgkin/lymphoma (1), Malignant neoplasm respiratory, other (not bronchus) (1), Female breast (1), Unknown (1)
Cough	13749	13	358	0.1	1.96	Bronchus/lung (9), Hodgkin/lymphoma (1), Other malignant digestive neoplasm not stomach/colon/pancreas (1), Female breast (1), Unknown (1)
Dysuria	3269	2	120	0.1		Malignant neoplasm bladder (1), Prostate (1)
Intermenstrual bleeding	134	0
Postcoital bleeding	59	0

↵* Malignant neoplasm of uterus.
↵† For colon cancer.
↵‡ Overall number of all types of cancer on the same row.
ICPC, International Classification of Primary Care; LR, likelihood ration; PPV, positive predictive value; RFE, reason for encounter.