Diagnostic Value of Alarm Symptoms for Upper GI Malignancy
Diagnostic Value of Alarm Symptoms for Upper GI Malignancy
Background: With the advent of empirical treatment strategies for patients with dyspeptic symptoms, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy. Usually alarming symptoms are used for this matter, but their diagnostic value is by no means clear.
Aim: To investigate the diagnostic value of alarm symptoms for upper gastrointestinal malignancy.
Methods: Meta-analysis of studies describing prevalence of alarm symptoms in patients with and without endoscopically verified upper gastrointestinal malignancy were identified through a Medline search. The prevalence, pooled sensitivity, specificity, positive and negative predictive values were calculated.
Results: About 17 case studies and nine cohort studies were selected. The mean prevalence of gastrointestinal malignancies in the cohort studies was 2.8% of 16 161 patients. Five cohort studies indicated that 25% of the patients diagnosed with upper gastrointestinal malignancy had no alarm symptoms. The pooled sensitivities of individual alarm symptoms varied from 9 to 41%, the pooled positive predictive value ranged from 4.6 to 7.9%, and was 5.9% for 'having any alarm symptom'. The pooled negative predictive value was 99.4% for 'having any alarm symptom'.
Conclusion: The risk of upper gastrointestinal malignancy in any individual without alarm symptoms is very low, but approximately one in four patients with upper gastrointestinal cancer have no alarm symptoms at the time of diagnosis.
With the advent of empirical treatment strategies (like Helicobacter pylori test-and-treat or acid suppressive therapy) for patients with dyspeptic symptoms, fewer patients have upper gastrointestinal (GI) endoscopy. However, it is important not to delay diagnosis in patients with underlying malignant disease. Therefore, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy in order to safely treat the remaining patients empirically. On the contrary, this selection should be specific in order to prevent large number of people having unnecessary endoscopy, which is costly and troublesome to the patients. Usually alarm symptoms such as weight loss, dysphagia, nausea, vomiting and anaemia or bleeding are used for this matter. However, although generally accepted, the diagnostic value of alarm symptoms is by no means clear, in spite of the amount of research conducted in this area.
Recently Boldys et al. concluded that weight loss and melaena are certainly indices of more advanced cancer, and in order to diagnose gastric cancer at an early stage the occurrence of these symptoms should not be awaited. On the contrary, Meineche-Schmidt and Jørgensen did not find a higher risk of cancer in patients with alarm symptoms in a large cohort comprising more than 600 patients.
A difficulty in the identification of factors related to diagnosis of upper GI malignancies is the low incidence of these cancers. As a result, large cohorts need to be studied, which often is not feasible. This problem may be overcome by performing meta-analysis. The aim of this study was to evaluate the diagnostic value of alarm symptoms for upper GI malignancy by means of a meta-analysis.
Background: With the advent of empirical treatment strategies for patients with dyspeptic symptoms, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy. Usually alarming symptoms are used for this matter, but their diagnostic value is by no means clear.
Aim: To investigate the diagnostic value of alarm symptoms for upper gastrointestinal malignancy.
Methods: Meta-analysis of studies describing prevalence of alarm symptoms in patients with and without endoscopically verified upper gastrointestinal malignancy were identified through a Medline search. The prevalence, pooled sensitivity, specificity, positive and negative predictive values were calculated.
Results: About 17 case studies and nine cohort studies were selected. The mean prevalence of gastrointestinal malignancies in the cohort studies was 2.8% of 16 161 patients. Five cohort studies indicated that 25% of the patients diagnosed with upper gastrointestinal malignancy had no alarm symptoms. The pooled sensitivities of individual alarm symptoms varied from 9 to 41%, the pooled positive predictive value ranged from 4.6 to 7.9%, and was 5.9% for 'having any alarm symptom'. The pooled negative predictive value was 99.4% for 'having any alarm symptom'.
Conclusion: The risk of upper gastrointestinal malignancy in any individual without alarm symptoms is very low, but approximately one in four patients with upper gastrointestinal cancer have no alarm symptoms at the time of diagnosis.
With the advent of empirical treatment strategies (like Helicobacter pylori test-and-treat or acid suppressive therapy) for patients with dyspeptic symptoms, fewer patients have upper gastrointestinal (GI) endoscopy. However, it is important not to delay diagnosis in patients with underlying malignant disease. Therefore, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy in order to safely treat the remaining patients empirically. On the contrary, this selection should be specific in order to prevent large number of people having unnecessary endoscopy, which is costly and troublesome to the patients. Usually alarm symptoms such as weight loss, dysphagia, nausea, vomiting and anaemia or bleeding are used for this matter. However, although generally accepted, the diagnostic value of alarm symptoms is by no means clear, in spite of the amount of research conducted in this area.
Recently Boldys et al. concluded that weight loss and melaena are certainly indices of more advanced cancer, and in order to diagnose gastric cancer at an early stage the occurrence of these symptoms should not be awaited. On the contrary, Meineche-Schmidt and Jørgensen did not find a higher risk of cancer in patients with alarm symptoms in a large cohort comprising more than 600 patients.
A difficulty in the identification of factors related to diagnosis of upper GI malignancies is the low incidence of these cancers. As a result, large cohorts need to be studied, which often is not feasible. This problem may be overcome by performing meta-analysis. The aim of this study was to evaluate the diagnostic value of alarm symptoms for upper GI malignancy by means of a meta-analysis.
