Scandinavian Journal of Gastroenterology. 2015; 50: 1268–1275
ORIGINAL ARTICLE
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Pittsburgh on 08/18/15 For personal use only.
Alarm symptoms of upper gastrointestinal cancer and contact to general practice – A population-based study SANNE RASMUSSEN1, PIA VELDT LARSEN2, RIKKE PILSGAARD SVENDSEN1, PETER FENTZ HAASTRUP1, JENS SØNDERGAARD1 & DORTE EJG JARBØL1 1
Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark, and 2Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark
Abstract Introduction. Survival of upper gastrointestinal (GI) cancer depends on early stage diagnosis. Symptom-based guidelines and fast-track referral systems have been implemented for use in general practice. To improve diagnosis of upper GI cancer, knowledge on prevalence of alarm symptoms in the general population and subsequent healthcare-seeking is needed. Material and methods. A nationwide study of 100,000 adults, who were randomly selected from the general population were invited to participate in an internet-based survey. People aged ‡45 years were included in this study. Items regarding experience of specific and nonspecific alarm symptoms of upper GI cancer within the preceding 4 weeks and contact to general practitioner (GP) were included. Results. Of the 60,562 subjects aged ‡45 years, 33,040 (54.6%) completed the questionnaire. The prevalence of the specific alarm symptoms ranged between 1.1% (“repeated vomiting”) and 3.4% (“difficulty swallowing”). Women had higher odds of experiencing “repeated vomiting” and “persistent and recent-onset abdominal pain”, but lower odds of experiencing “upper GI bleeding”. The proportion of people contacting their GP with each of the four specific alarm symptoms ranged from 24.3% (“upper GI bleeding”) to 39.9% (“repeated vomiting”). For each combination of two specific alarm symptoms, at least 52% contacted their GP. Conclusion. The specific alarm symptoms of upper GI cancer are not very prevalent in the general population. The proportion of GP contacts with each of the four specific symptoms varied between 24.3% and 39.9%. The proportion of GP contacts was higher in the older age and with combinations of two symptoms.
Key Words: Esophageal disorders, gastroduodenal clinical, general
Introduction Upper gastrointestinal (GI) cancer is a serious disease, where survival and curative treatment depend on early stage diagnosis. Unfortunately, upper GI cancers are often detected in late stages. In the northern countries, there are ~2600 new cases each year [1]. The incidence increases with age, almost all cases occurring in people over 45 years of age. Cancer referral guidelines and fasttrack systems have been implemented in everyday clinical practice by general practitioners (GPs) in the attempt to improve early stage diagnosis by prompting further investigation of patients with cancer alarm
symptoms. In these guidelines a number of alarm symptoms are defined [2,3]. Guidelines vary somewhat between different countries, but they all comprise a number of organ-specific symptoms, for example, dysphagia/pain while swallowing persisting >2 weeks, persistent vomiting without any explanation, gastrointestinal bleeding or anemia, abdominal filling, and persistent and recent-onset dyspepsia or reflux symptoms in people aged >45 years. Moreover, progressive unintentional weight loss is included as a nonspecific symptom [2,3]. Since upper GI cancers often are diagnosed in late stages, one might hypothesize that the organ-specific
Correspondence: Sanne Rasmussen, MD, PhD student, Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark.Tel: +45 6550 3087. E-mail: [email protected]
(Received 22 December 2014; revised 18 February 2015; accepted 19 March 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1033745
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Pittsburgh on 08/18/15 For personal use only.
Alarm symptoms of upper GI cancer symptoms included in guidelines present in the late stages of the disease, while patients experience other more vague or nonspecific symptoms at earlier stages. Further, one might hypothesize that both specific and nonspecific symptoms influence people’s decision to contact their GP. The awareness that symptoms may represent a serious disease probably differs among different groups of people [4]. Since the incidence of upper GI cancer is rapidly increasing in people aged >45 years, the patients in this age group presenting alarm symptoms must be in particular focus in everyday clinical practice. However, a prerequisite for GPs being able to refer patients for further investigations is that people become aware of their symptoms and present them to their GP. To improve diagnosis of upper GI cancer, knowledge on how prevalent the alarm symptoms are in the general population and how they present in different age groups and among men and women is needed. Moreover, it is important to gain knowledge on the proportion of people who contact their GP when experiencing one or more specific symptoms or nonspecific symptoms of upper GI cancer. The objectives of the study therefore were: 1) to estimate the prevalence of symptom experience in the general population aged ‡45 years in regard to specific symptoms indicative of upper GI cancer; 2) to estimate the proportion of people who contact their GP when experiencing specific alarm symptoms indicative of upper GI cancer; 3) to estimate the proportion of people who contact their GP with a combination of specific and nonspecific symptoms indicative of upper GI cancer. Material and methods Study design and population The study was designed as a nationwide cohort study of 100,000 people randomly selected from the general population. All Danish citizens are registered in the Danish Civil Registration System (CRS) with a unique personal identification number. Using the CRS, 100,000 adults aged ‡20 years were randomly selected and invited to participate in a survey. The individuals received a postal letter explaining the purpose of the study. In the letter, a unique 12-digit login for a secure webpage was included. This provided access to a comprehensive web-based questionnaire. In order to prevent exclusion of people with no access to a computer, tablet, or smartphone, the participants were offered to complete the survey by telephone interview. A reminder letter followed the initial invitational letter to nonresponders after 2 weeks. After additional 2 weeks, the nonresponders were contacted by telephone and encouraged to
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participate. A private telemarketing company conducted the latter reminder procedure. Information on severe illness and subjects who had moved abroad was obtained through contact of family or relatives in the reminder procedure. The data collected from the questionnaire form the basis of this study. Questionnaire A comprehensive questionnaire concerning experience of specific and nonspecific cancer alarm symptoms, general, frequent symptoms, abdominal symptom conditions, and bodily distress syndrome was developed. The questionnaire was based on standard rating scales, previously validated questionnaires and ad hoc items. The methodological framework for developing, pilot- and field-testing the questionnaire is described in detail elsewhere [5]. This paper addresses 10 predefined specific and nonspecific symptoms indicative of upper GI cancer (Table I). The symptoms were selected based on a review of literature, national and international cancer referral guidelines, and descriptions of cancer pathways [2,3]. The responders were asked whether they had experienced each symptom within the preceding 4 weeks. The responders were additionally asked whether they had contacted their GP with the symptom. The wording of the question regarding symptom experience was: “Have you experienced any of the following bodily sensations, symptoms or discomfort within the past four weeks?” with the option to select one or more of the predefined symptoms. In regard to GP contact, the question was: “Have you contacted your GP concerning the symptom(s) you have experienced within the preceding four weeks, through appointment, by telephone or email?” An item concerning when the symptom(s) occurred for the first time was also included. The response categories were: “Less than one month ago”, “1–3 months ago”, “3–6 months ago”, or “more than six months ago”. The upper GI alarm symptoms considered in the present study are listed in Table I. The alarm symptom “upper GI bleeding” was constructed by combining two symptom experiences: “blood in vomit” and “black shiny stools”. The alarm symptom “persistent and recent-onset abdominal pain” was defined as “abdominal pain” experienced for the first time >1 month ago but 1 month ago but 1 month ago but 1 month ago but 1 month ago but
ORIGINAL ARTICLE
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Pittsburgh on 08/18/15 For personal use only.
Alarm symptoms of upper gastrointestinal cancer and contact to general practice – A population-based study SANNE RASMUSSEN1, PIA VELDT LARSEN2, RIKKE PILSGAARD SVENDSEN1, PETER FENTZ HAASTRUP1, JENS SØNDERGAARD1 & DORTE EJG JARBØL1 1
Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark, and 2Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark
Abstract Introduction. Survival of upper gastrointestinal (GI) cancer depends on early stage diagnosis. Symptom-based guidelines and fast-track referral systems have been implemented for use in general practice. To improve diagnosis of upper GI cancer, knowledge on prevalence of alarm symptoms in the general population and subsequent healthcare-seeking is needed. Material and methods. A nationwide study of 100,000 adults, who were randomly selected from the general population were invited to participate in an internet-based survey. People aged ‡45 years were included in this study. Items regarding experience of specific and nonspecific alarm symptoms of upper GI cancer within the preceding 4 weeks and contact to general practitioner (GP) were included. Results. Of the 60,562 subjects aged ‡45 years, 33,040 (54.6%) completed the questionnaire. The prevalence of the specific alarm symptoms ranged between 1.1% (“repeated vomiting”) and 3.4% (“difficulty swallowing”). Women had higher odds of experiencing “repeated vomiting” and “persistent and recent-onset abdominal pain”, but lower odds of experiencing “upper GI bleeding”. The proportion of people contacting their GP with each of the four specific alarm symptoms ranged from 24.3% (“upper GI bleeding”) to 39.9% (“repeated vomiting”). For each combination of two specific alarm symptoms, at least 52% contacted their GP. Conclusion. The specific alarm symptoms of upper GI cancer are not very prevalent in the general population. The proportion of GP contacts with each of the four specific symptoms varied between 24.3% and 39.9%. The proportion of GP contacts was higher in the older age and with combinations of two symptoms.
Key Words: Esophageal disorders, gastroduodenal clinical, general
Introduction Upper gastrointestinal (GI) cancer is a serious disease, where survival and curative treatment depend on early stage diagnosis. Unfortunately, upper GI cancers are often detected in late stages. In the northern countries, there are ~2600 new cases each year [1]. The incidence increases with age, almost all cases occurring in people over 45 years of age. Cancer referral guidelines and fasttrack systems have been implemented in everyday clinical practice by general practitioners (GPs) in the attempt to improve early stage diagnosis by prompting further investigation of patients with cancer alarm
symptoms. In these guidelines a number of alarm symptoms are defined [2,3]. Guidelines vary somewhat between different countries, but they all comprise a number of organ-specific symptoms, for example, dysphagia/pain while swallowing persisting >2 weeks, persistent vomiting without any explanation, gastrointestinal bleeding or anemia, abdominal filling, and persistent and recent-onset dyspepsia or reflux symptoms in people aged >45 years. Moreover, progressive unintentional weight loss is included as a nonspecific symptom [2,3]. Since upper GI cancers often are diagnosed in late stages, one might hypothesize that the organ-specific
Correspondence: Sanne Rasmussen, MD, PhD student, Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark.Tel: +45 6550 3087. E-mail: [email protected]
(Received 22 December 2014; revised 18 February 2015; accepted 19 March 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1033745
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Pittsburgh on 08/18/15 For personal use only.
Alarm symptoms of upper GI cancer symptoms included in guidelines present in the late stages of the disease, while patients experience other more vague or nonspecific symptoms at earlier stages. Further, one might hypothesize that both specific and nonspecific symptoms influence people’s decision to contact their GP. The awareness that symptoms may represent a serious disease probably differs among different groups of people [4]. Since the incidence of upper GI cancer is rapidly increasing in people aged >45 years, the patients in this age group presenting alarm symptoms must be in particular focus in everyday clinical practice. However, a prerequisite for GPs being able to refer patients for further investigations is that people become aware of their symptoms and present them to their GP. To improve diagnosis of upper GI cancer, knowledge on how prevalent the alarm symptoms are in the general population and how they present in different age groups and among men and women is needed. Moreover, it is important to gain knowledge on the proportion of people who contact their GP when experiencing one or more specific symptoms or nonspecific symptoms of upper GI cancer. The objectives of the study therefore were: 1) to estimate the prevalence of symptom experience in the general population aged ‡45 years in regard to specific symptoms indicative of upper GI cancer; 2) to estimate the proportion of people who contact their GP when experiencing specific alarm symptoms indicative of upper GI cancer; 3) to estimate the proportion of people who contact their GP with a combination of specific and nonspecific symptoms indicative of upper GI cancer. Material and methods Study design and population The study was designed as a nationwide cohort study of 100,000 people randomly selected from the general population. All Danish citizens are registered in the Danish Civil Registration System (CRS) with a unique personal identification number. Using the CRS, 100,000 adults aged ‡20 years were randomly selected and invited to participate in a survey. The individuals received a postal letter explaining the purpose of the study. In the letter, a unique 12-digit login for a secure webpage was included. This provided access to a comprehensive web-based questionnaire. In order to prevent exclusion of people with no access to a computer, tablet, or smartphone, the participants were offered to complete the survey by telephone interview. A reminder letter followed the initial invitational letter to nonresponders after 2 weeks. After additional 2 weeks, the nonresponders were contacted by telephone and encouraged to
1269
participate. A private telemarketing company conducted the latter reminder procedure. Information on severe illness and subjects who had moved abroad was obtained through contact of family or relatives in the reminder procedure. The data collected from the questionnaire form the basis of this study. Questionnaire A comprehensive questionnaire concerning experience of specific and nonspecific cancer alarm symptoms, general, frequent symptoms, abdominal symptom conditions, and bodily distress syndrome was developed. The questionnaire was based on standard rating scales, previously validated questionnaires and ad hoc items. The methodological framework for developing, pilot- and field-testing the questionnaire is described in detail elsewhere [5]. This paper addresses 10 predefined specific and nonspecific symptoms indicative of upper GI cancer (Table I). The symptoms were selected based on a review of literature, national and international cancer referral guidelines, and descriptions of cancer pathways [2,3]. The responders were asked whether they had experienced each symptom within the preceding 4 weeks. The responders were additionally asked whether they had contacted their GP with the symptom. The wording of the question regarding symptom experience was: “Have you experienced any of the following bodily sensations, symptoms or discomfort within the past four weeks?” with the option to select one or more of the predefined symptoms. In regard to GP contact, the question was: “Have you contacted your GP concerning the symptom(s) you have experienced within the preceding four weeks, through appointment, by telephone or email?” An item concerning when the symptom(s) occurred for the first time was also included. The response categories were: “Less than one month ago”, “1–3 months ago”, “3–6 months ago”, or “more than six months ago”. The upper GI alarm symptoms considered in the present study are listed in Table I. The alarm symptom “upper GI bleeding” was constructed by combining two symptom experiences: “blood in vomit” and “black shiny stools”. The alarm symptom “persistent and recent-onset abdominal pain” was defined as “abdominal pain” experienced for the first time >1 month ago but 1 month ago but 1 month ago but 1 month ago but 1 month ago but
