Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
  • LinkedIn
  • Instagram
LetterLetters

Response

Anna N. Wilkinson
Canadian Family Physician June 2021; 67 (6) 398; DOI: https://doi.org/10.46747/cfp.6706398_1
Anna N. Wilkinson
Ottawa, Ont
MSc MD CCFP FCFP
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

I thank Dr DiTommaso for his letter and for the opportunity to further explain the relevance of the positive predictive values (PPVs) presented in Table 1.1

I would absolutely endorse that physicians continue to investigate red flag symptoms. A workup of a patient with softer “low risk, but not no risk” symptoms is difficult for a physician. How does a physician identify the one patient who has cancer among the many who do not, all 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 PPVs were presented in part to show that studies have validated these “softer” symptoms. Hamilton et al clearly show that although individual symptoms might 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 a PPV risk of up to 20 times normal of developing a cancer.2

To appreciate why a symptom such as dyspnea has a PPV of only 0.66, it must be understood that dyspnea might be a symptom of other, more frequent non-malignant causes such as congestive heart failure or chronic obstructive pulmonary disease. If a patient presents multiple times with dyspnea, the PPV for lung cancer rises to 0.80, and continues to increase as it is combined with other symptoms: dyspnea and hemoptysis, PPV of 4.90; dyspnea and weight loss, PPV of 2.00; and dyspnea and loss of appetite, PPV of 2.00 (please see Figure 2 in Hamilton et al for more information).2

Unfortunately, there is no table that can definitively tell you which of your patients to work up for cancer and who to merely reassure. However, there is a recent study that shows that the PPV of a physician’s gut feeling for the diagnosis of cancer is 9.80.3 Perhaps your gut, and a combination of experience, clinical, and contextual knowledge, continues to be the best way to “draw the line.”

Footnotes

  • Competing interests

    None declared

  • Copyright © the College of Family Physicians of Canada

References

  1. 1.↵
    1. Wilkinson AN.
    Cancer diagnosis in primary care. Six steps to reducing the diagnostic interval. Can Fam Physician 2021;67:265-8 (Eng), e99-103 (Fr).
    OpenUrlFREE Full Text
  2. 2.↵
    1. Hamilton W.
    The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br J Cancer 2009;101(Suppl 2):S80-6.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Smith CF,
    2. Drew S,
    3. Ziebland S,
    4. Nicholson BD.
    Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract 2020;70(698):e612-21.
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

Canadian Family Physician: 67 (6)
Canadian Family Physician
Vol. 67, Issue 6
1 Jun 2021
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Response
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Response
Anna N. Wilkinson
Canadian Family Physician Jun 2021, 67 (6) 398; DOI: 10.46747/cfp.6706398_1

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Response
Anna N. Wilkinson
Canadian Family Physician Jun 2021, 67 (6) 398; DOI: 10.46747/cfp.6706398_1
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • References
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Letters

  • Collaboration required to fix “hidden curriculum”
  • Correction
  • Long-term monitoring needed for lichen sclerosus
Show more Letters

Correspondance

  • Long-term monitoring needed for lichen sclerosus
  • Private-public partnerships not a threat to Canada’s health care system
  • Collaboration required to fix “hidden curriculum”
Show more Correspondance

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • LinkedIn
  • Instagram
  • RSS Feeds

Copyright © 2025 by The College of Family Physicians of Canada

Powered by HighWire