Reassuring: Patients With Cancer Symptoms Mostly Early-Stage

Liam Davenport

December 03, 2019

The vast majority of patients who present with common symptoms of cancer and who are diagnosed with cancer have nonadvanced disease, a UK population-based study reveals. The finding suggests that raising symptom awareness could help reduce the burden of the disease rather than simply identify more stage IV cases, say the authors.

Minjoung Monica Koo, PhD, Epidemiology of Cancer Healthcare and Outcomes Group, University College London, United Kingdom, and colleagues examined data on almost 8000 cancer patients who were diagnosed in England during a single year.

The study, which was published online in the Lancet Oncology on November 5, evaluated 20 common presenting symptoms for twelve solid tumors.

The results showed that the proportion of patients diagnosed with stage IV disease was as low as 1% for those with an abnormal mole compared to a high of 80% for patients with neck lump who had advanced disease.

For thirteen of the symptoms, more than half of patients were diagnosed with nonadvanced cancer.

"Our findings refute concerns that early diagnosis interventions centered on common presenting symptoms of cancer would typically expedite the diagnosis of individuals with stage IV disease," the team says.

"Rather, they indicate that a substantial proportion of patients with these symptoms are diagnosed with nonadvanced disease, which is associated with potentially good prognosis."

Koo told Medscape Medical News that the results are "exciting" and that the "bottom line of our findings is they suggest it's never too late to seek help for concerning symptoms."

She added that the results go "against the fatalism amongst the medical community," in which "our secondary care colleagues or oncologists may have said, what's the point in raising awareness" over symptoms if it's "already too late for them" by the time they are diagnosed.

"Our findings show that, actually, that's not always the case."

Koo underlined that fatalism over symptoms is also "a huge problem" among patients, particularly those in the lower socioeconomic groups.

Moreover, she believes that the findings highlight the potential of early diagnosis through the targeting of symptoms "rather than fancy new biomarkers that we're trying to find among the asymptomatic population."

Jigsaw Puzzle Piece

In an accompanying comment, Katriina Whitaker, PhD, CPsychol, School of Health Sciences, University of Surrey, Guildford, United Kingdom, suggests that the study "is an essential jigsaw piece in the early diagnosis puzzle, although several questions remain."

A number of cancer control strategies have been launched around the globe that focus on the early diagnosis of symptomatic cancer, as well as primary prevention and screening, says Whitaker.

However, as the study authors point out, such initiatives "might have little impact in improving cancer outcomes" if the symptoms with which cancer is presenting predominantly represent advanced-stage disease.

The authors note that few studies have examined associations between presenting symptoms and stage at diagnosis, and those that have have typically focused on specific cancer sites, despite the fact that many symptoms are shared among cancer types.

To investigate further, the team collated data from the National Cancer Diagnosis Audit on 7997 adults in England aged ≥25 years who were diagnosed with one of twelve solid tumors in 2014 and for whom staging data were ≥85% complete.

The patients, who were registered at 439 general practices, could be diagnosed with endometrial, lung, rectal, breast, melanoma, prostate, colon, renal, bladder, ovarian, oral or oropharyngeal, or laryngeal cancer.

The most common presenting symptom was breast lump, seen in 15.8% of patients, and the least common was neck lump, which was reported by 1.3%. Two or more symptoms were reported by 34% of patients.

The proportion of patients diagnosed with stage IV disease varied widely, ranging from 1% for people with an abnormal mole to 80% for patients with a neck lump.

The team calculated that more than 50% of patients with abnormal mole, breast lump, postmenopausal bleeding, rectal bleeding, lower urinary tract symptoms, hematuria, change in bowel habit, hoarseness, fatigue, abdominal pain, lower abdominal pain, weight loss, or "any other symptom" were diagnosed with nonadvanced disease.

Moreover, at least 38% of all patients who had any symptom other than neck lump were diagnosed with nonadvanced cancer.

The team found that neck lump, chest pain, and back pain were consistently linked to an increased likelihood of stage IV cancer, wereas abnormal mole, breast lump, postmenopausal bleeding, and rectal bleeding were associated with higher rates of nonadvanced disease at diagnosis.

There was a similar pattern for stage IV disease at diagnosis when looking at symptoms reported alone or with other symptoms. Adjusting for sex, age group, ethnicity, deprivation quintile, and cancer diagnosis also did not have a large impact on the findings.

Although editorialist Whitaker believes the study underlines the importance of knowledge of warning signs for cancer, she sets out a number of outstanding questions.

"For example, what symptoms should be featured? Who should the campaigns be targeted at? What barriers (other than poor knowledge of warning signs) should they address? How should the campaigns be evaluated?"

She adds that campaigns should be developed to take into account how barriers might vary by age, socioeconomic status, and ethnicity and how fatalism and fear, among other factors, play a role.

The findings also have "important implications" for healthcare professionals, inasmuch as prompt referral and investigation of potential cancer symptoms are associated with higher cancer survival rates.

She also emphasized the need for "a well equipped and well funded workforce to deal with this core and essential activity" if referrals and investigations are to increase.

Whitaker concludes: "Although answers to many of these challenges will require an ongoing multidisciplinary and international effort, early diagnosis is likely to remain the holy grail of cancer care."

She adds: "With this in mind, it is reassuring and bolstering to see that global approaches to cancer control are on the right track."

The study was funded by the UK Department of Health's Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis and by Cancer Research UK. The authors have disclosed no relevant financial relationships.

Lancet Oncol. Published online November 5, 2019. Full text, Comment

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