Pre-Referral Primary Care Blood Tests and Symptom Presentation before Cancer Diagnosis: National Cancer Diagnosis Audit Data

Simple Summary Blood tests can support decisions by GPs about referring patients who present with symptoms of possible cancer for specialist assessment. This study analysed data on the use of blood tests in primary care in patients subsequently diagnosed with cancer to understand how often and when blood tests were used. We found that the use of generic blood tests (including full blood count, urea and electrolyte, liver function, and inflammatory marker tests) varied widely between patients presenting with different symptoms, with greater use in patients presenting with certain nonspecific symptoms (e.g., fatigue or loss of weight) and least frequently in those presenting with certain red-flag symptoms (e.g., breast or skin symptoms). Blood tests with greater specificity to certain organs/pathologies (including serum protein electrophoresis, ferritin, bone profile, and amylase tests) followed a similar use pattern regarding symptom specificity but at a lower use frequency. Commonly used cancer biomarkers were used in varying proportions depending on whether the presenting symptom could be related to prostate or ovarian cancer (for example, 88% of men presenting with lower urinary tract symptoms had presumed PSA measurement). The findings benchmark how often blood tests are used in certain clinical scenarios and identify opportunities for greater use in patients with symptoms of low (<3%) positive predictive value for cancer. Background: Blood tests can support the diagnostic process in primary care. Understanding how symptomatic presentations are associated with blood test use in patients subsequently diagnosed with cancer can help to benchmark current practices and guide interventions. Methods: English National Cancer Diagnosis Audit data on 39,751 patients with incident cancer in 2018 were analysed. The frequency of four generic (full blood count, urea and electrolytes, liver function tests, and inflammatory markers) and five organ-specific (cancer biomarkers (PSA or CA125), serum protein electrophoresis, ferritin, bone profile, and amylase) blood tests was described for a total of 83 presenting symptoms. The adjusted analysis explored variation in blood test use by the symptom-positive predictive value (PPV) group. Results: There was a large variation in generic blood test use by presenting symptoms, being higher in patients subsequently diagnosed with cancer who presented with nonspecific symptoms (e.g., fatigue 81% or loss of appetite 79%), and lower in those who presented with alarm symptoms (e.g., breast lump 3% or skin lesion 1%). Serum protein electrophoresis (reflecting suspicion of multiple myeloma) was most frequently used in cancer patients who presented with back pain (18%), and amylase measurement (reflecting suspicion of pancreatic cancer) was used in those who presented with upper abdominal pain (14%). Prostate-specific antigen (PSA) use was greatest in men with cancer who presented with lower urinary tract symptoms (88%), and CA125 in women with cancer who presented with abdominal distention (53%). Symptoms with PPV values between 2.00-2.99% were associated with greater test use (64%) compared with 52% and 51% in symptoms with PPVs in the 0.01-0.99 or 1.00-1.99% range and compared with 42% and 31% in symptoms with PPVs in either the 3.00-4.99 or & GE;5% range (p < 0.001). Conclusions: Generic blood test use reflects the PPV of presenting symptoms, and the use of organ-specific tests is greater in patients with symptomatic presentations with known associations with certain cancer sites. There are opportunities for greater blood test use in patients presenting with symptoms that do not meet referral thresholds (i.e., <3% PPV for cancer) where information gain to support referral decisions is likely greatest. The findings benchmark blood test use in cancer patients, highlighting opportunities for increasing use.

Automated summary

Blood tests play an important role in supporting decisions by GPs in referring patients with possible cancer symptoms for specialist assessment. This study analyzed data on the use of blood tests in primary care for patients subsequently diagnosed with cancer, finding that the use of different blood tests varied widely depending on the presenting symptoms. The findings highlight opportunities for greater use of blood tests in patients with low positive predictive value for cancer and benchmark current practices.