- Page navigation anchor for RE: Reply to Dr. DiTommasoRE: Reply to Dr. DiTommaso
April 28, 2021
Dear Dr. DiTommaso,I thank you for your letter and for the opportunity to further explain the relevance of the PPV’s presented in Table 1.
I would absolutely endorse that physicians continue to investigate red flag symptoms. What is more difficult as a physician, is the work up of a patient with softer “low risk-but-not-no-risk” symptoms. How does a physician identify the one patient who has cancer amongst the many who do not, while preserving the patient-physician relationship when it is needed most? This is especially true given that many patients who develop cancer never display a clear high-risk symptom.
The PPV values were presented in part to show that there have been studies which have validated these “softer” symptoms. Hamilton et al. clearly show that although individual symptoms may not strongly predict a cancer diagnosis, what is most important is the presence of multiple symptoms or non-resolving symptoms with multiple presentations, which together can result in PPV with a risk of developing a cancer of up to 20 times normal.(1)
To appreciate why a symptom such as “dyspnea” has a PPV of only 0.66, it must be understood that dyspnea may be a symptom of other, more frequent non-malignant etiologies such as CHF or COPD. If a patient presents multiple times with dyspnea, the PPV for lung cancer rises to 0.8, and continues to increase as it is combined with other symptoms: dyspnea + hemoptysis, PPV 4.9; dyspne...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Cancer diagnosis in primary care (April 2021)RE: Cancer diagnosis in primary care (April 2021)
I am baffled by Table 1 (cancer symptom PPV).
All physicians are trained to investigate patients with new-onset constipation, rectal bleeding, cough over age 50, and other "red flags".
So I am unsure of the purpose of table 1. Is there a cut-off below which investigation is unwarranted ?
For example, I investigate patients with a new unremitting cough over age 50 (PPV only 0,40) more than I would investigate new nocturia (PPV 2,2). Even new hematuria alarms me more than new nocturia.
Dyspnea only comes in at PPV 0,66 yet I pull out all the stops on patients with new dsypnea.
Perhaps the authors could explain the purpose of including Table 1 in this article.
I now spend about 1/3 of my time in home-based palliative care. Many of my dying patients feel guilty (if they feel they have neglected early symptoms) or anger towards their FP's (if they feel their FPs neglected early symptoms). Retrospectivly, it is easy to recall early symprtoms which "should have" prompted investigation. Prospectively, my office practice is swamped with a plethora of vague symptoms, and I am always concerned about balancing underinvestigation with overinvestigation.
I suppose I would like Table 1 to be more helpful in knowing "where to draw the line".
Thank you !
Stephen DiTommaso, FP
MontrealCompeting Interests: None declared.
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