Symptoms, signs, and tests: The general practitioner's comprehensive approach towards a cancer diagnosis

Figures & data

Table I. Warning signs of cancer.

	Symptoms studied	Abbreviations
Focal symptoms:	Non-healing skin lesion	Skin lesion
	Lump/nodule	Lump
	Unusual bleeding	Bleeding
	Pigmented skin lesion	Mole
	Persistent digestive problem	Digestive problem
	Cough/hoarseness of uncertain origin	Cough
	Other symptom suspicious of cancer	Other
General symptoms:	Unintentional weight loss	Weight loss
	Unusual fatigue	Fatigue
	Unusual pain	Pain

Table II. Pre-diagnostic, cancer relevant symptom and sign information available for the general practitioner in 261 patients with 263 cases of cancer: Warning signs (WSC) in different types of cancer, along with addititional symptoms, clinical findings and test results that contributed to the diagnosis of cancer.

Type of cancer	N	Initial WSC, considered related to the cancer *	N	Additional symptoms**	N	Clinical signs	N	Supplementary tests	N
Colorectal cancer***	46	Bleeding (5), Digestive problem (10),	18	Digestive problem (5), Bleeding (2), Fatigue (2), Dyspnoea (2), Urinary symptoms (2), Paleness (1), Recurrent pneumonia (1), Leg oedema (1), Rectal symptoms (1), Loss of appetite (1), Mental confusion (1)	16	Poor general condition (4), Tumour at proctoscopy (2) Palpable abdominal tumour (1), Fistula (1), Ascites (1)	9	Anaemia (8), OBS (3), Increased SR (1), Increased CEA (1)	10
Other digestive organs****	22	Bleeding (1), Digestive problem (8), Other (3)	10	Digestive problem (2), Pain (1) Icterus (2), Cholecystitis (1)	6	Palpable supraclavicular tumour (1),	3	Anaemia (1), OBS (1), Incr CRP (1), Incr liver enzymes (1)	4
Lung cancer	23	Digestive problem (3), Cough (4), Other (1)	10	Cough (4), Bleeding (1), Weight loss (2), Pain (3), Dyspnoea (2), Respiratory infection (1), Neurological symptoms (1)	11	COPD (2), Poor general condition (2), Apoplexia (1),	7	X-ray based on symptoms (5), Anaemia (1), Incr SR (2)	8
Skin cancer¤	24	Skin lesion (2), Lump (3), Mole (4), Digestive problem (1), Fatigue (1), Pain (1)	9	Skin lesion (6), Mole (5), Cough (1), Pain (1)	12		0		0
Breast cancer	35	Lump (3), Cough (1), Other (3), Fatigue (2), Pain (1)	9	Lump (7), Cough (1), Pain (2)	10	Retracted mamilla (1), Lung infection (1), Pleural effusion (2)	3	Positive mammography (10)	10
Uterine body cancer	7	Bleeding (2), Digestive problem (1), Other (1), Pain (1)	3	Bleeding (4), Leg oedema (DVT) (1)	5		0		0
Prostate cancer	27	Other (3), Pain (1)	4	Fatigue (1), Pain (1), Prostatism (6), Dyspnoea (1)	8	Lump prostate (4), Enlarged prostate (2), Hard prostate (1), Sepsis (1), Poor general condition (1), Skeletal metastasis (2)	10	Increased PSA (13), Increased SR (1)	14
Renal cancer	7	Other (2)	2	Digestive problem (1), Bleeding (1), Dyspnoea (1)	4		0	Increased SR (1)	1
Bladder cancer	15	Bleeding (4), Cough (1), Weight loss (1)	7	Bleeding (3), Fatigue (1), Urge (1), Urinary retention (1)	5	Nystagmus (1)	1	Anaemia (2), Pos imaging of bladder (1), Pos. Urinary cytology (1)	4
Lymphoid/hematopoietic cancer¤¤	28	Lump (2), Bleeding (1), Digestive problem (1)	10	Lump (3), Digestive problem (2)	8	Bacterial infections: Sepsis (1)	3	Leukocytosis (2), Increased SR (2)	6
Miscellaneous cases¤¤¤	29	Lump (2), Bleeding (1), Digestive problem (3), Cough (1), Weight loss (1), Fatigue (3), Pain (2)	8	Lump (5), Pain (4), Mental confusion (2), Diplopia (1)	11	Tumour on cervix uteri (1), Sialolthiasis (1), Unilateral elevation of floor of mouth (1), Tumour lip (1), Tumour oral mucosa (1), Tumour tongue (1)	5	Increased CA125 (1), Anaemia (1), OBS (1)	2
All types of cancer	263		90		96		41		59

N = Number of cases of cancer.

OBS = Occult blood in stool, SR = Sedimentation Rate, CEA = Carcino-Embryonal Antigen, CA125 = Cancer antigen 125, Incr = Increased, COPD = Chronic obstructive pulmonary disease.

*The 22 excluded WSC were: ‘Skin lesion’ 3 (colorectal 2, prostate 1), ‘Lump’ 2 (prostate), ‘Bleeding’ 3 (breast 2, skin 1), ‘Digestive problem’1 (skin), ‘Cough’ 5 (colorectal 1, other digestive 1, skin 2, prostate 1), ‘Other’ 6 (colorectal 1, prostate 3, skin 1, ovary 1), ‘Weight loss’ 1 (skin), ‘Pain’ 1, (skin).

**Additional symptoms include non-WSC symptoms and WSC not recorded at the initial consultation. Symptoms described in the medical journal after initial registration of WSC. Because of multiple symptoms and/or signs in some patients, the sum of symptoms listed in the columns may exceed N (number of cases).

***Colorectal: 1 Appendix, 3 coecum, 5 ascendum, 1 transversum, 5 sigmoid, 19 colon not specified, 12 rectum.

****Other digestive organs: 3 oesophageal cancer, 3 stomach cancer, 2 neuroendocrine cancer (carcinoid) of small intestine, 1 hepatocellular carcinoma, 2 biliary cancer, 1 cancer of papilla Vaterii, 9 pancreatic cancer.

¤Skin cancer: 12 malignant melanoma, 12 squamous cell carcinoma.

¤¤Lymphoid/hematopoietic cancer: 2 Mb Hodgkin, 7 Non-Hodgkin lymphoma, 3 lymphoma not spec (2 of these in stomach), 6 myleomatosis/myelodysplastic syndrome, 10 leukemia (3 AML, 3 CML, 3 CLL, 1 leukemia not specified).

¤¤¤6 cancer of mouth, pharynx, 2 laryngeal cancer, 1 mesothelioma, 4 soft tissue cancer, 4 cervical cancer, 3 ovarian cancer, 3 testicular cancer, 3 glioblastomas, 2 thyroid cancer, 2 cancer of unknown origin.

Table III. Sensitivity of cancer relevant symptoms and signs in relation to different types of cancer. 261 patients with 263 cases of cancer (N).

		Consultation-recorded WSC			Any pre-diagnostic symptom			Symptoms and clinical findings			Symptoms, signs and test results
Type of cancer	N	N	Sensitivity	95% CI	N	Sensitivity	95% CI	N	Sensitivity	95% CI	N	Sensitivity	95% CI
Colorectal	46	18	39%	26–54%	30	65%	51–77%	33	72%	57–83%	37	80%	67–89%
Other digestive organs	22	10	45%	27–65%	15	68%	47–84%	16	73%	52–87%	17	77%	57–90%
Lung	23	10	43%	26–63%	17	74%	54–87%	20	87%	68–95%	21	91%	73–98%
Skin	24	9	38%	21–57%	21	88%	69–96%	21	88%	69–96%	21	88%	69–96%
Breast	35	9	26%	14–42%	15	43%	28–59%	17	49%	33–64%	26	74%	58–86%
Uterine body	7	3	43%	16–75%	7	100%	65–100%	7	100%	65–100%	7	100%	65–100%
Prostate	27	4	15%	6–32%	11	41%	25–59%	14	52%	34–69%	18	67%	48–81%
Renal	7	2	29%	8–64%	4	57%	25–84%	4	57%	25–84%	4	57%	25–84%
Bladder	15	7	47%	25–70%	11	73%	48–89%	11	73%	48–89%	13	87%	62–96%
Lymphoid/hematopoietic	28	10	36%	21–54%	15	54%	36–70%	17	61%	42–76%	20	71%	53–85%
Miscellaneous	29	8	28%	15–46%	18	62%	44–77%	20	69%	51–83%	21	72%	54–85%
All types of cancer	263	90	34%	29–40%	164	62%	56–68%	180	68%	63–74%	205	78%	73–83%

WSC = Warning signs of cancer.

Any pre-diagnostic symptom = WSC + additional (non-WSC) symptoms. Information from consultation registrations and from medical records combined.

N for Any pre-diagnostic symptom may be lower than the sum of cases with symptoms in Table II, because one patient may have both initial and (different) additional symptoms.

N for clinical findings adds only cases where no symptoms were recorded, and N that includes test results adds cases where there was no recorded contributions from symptoms or clinical findings.