Boulton-Jones et al22 | UK | Retrospective cohort (audit), 1997–1999 (29 months) | GP referrals to open access endoscopy, according to BSG guidance, at a district general hospital | Not reported |
Dyspepsia Dyspepsia with anorexia, weight loss or anaemia (any alarm) Dysphagia Reflux Recurrent dyspepsia Any alarm
| Total cohort, n = 1000 Single symptom, n = 471 Multiple symptoms, Alarm symptoms 15% | Gastric cancers, n = 8 Oesophageal cancers, n = 9 Prevalence, n = 529 1.70% (95% CI = 0.99 to 2.71) | GP used standard tick-box form listing commonly accepted indications for referral from BSG guidance | Endoscopy and histology |
Collins & Altman10 | UK | Retrospective cohort, 2000–2008 (90 months) | Primary care validation study of QResearch data using THIN database. Exclusions: history of gastrooesophageal cancer, registration <12 months with practice, invalid dates, aged <30years or ≥85years | Range 30–84 | Alarm symptoms
Dysphagia Haematemesis Appetite loss Weight loss Abdominal pain Anaemia
| Validation set n = 2 140 194 Cases, n = 1256 Controls, n = 2 138 938 Alarm symptoms 100% | Gastric and oesophageal cancers, n = 1256 Prevalence 0.08% (95% CI =0.08 to 0.09) | THIN database | Read Clinical Classification (version 2) |
Hansen et al 21 | Denmark | Prospective cohort, 1991–1992 (13 months) | 66 GPs in a Danish city referred all patients with dyspepsia, of any severity to open-access endoscopy. Exclusions: upper GI bleeding jaundice, abdominal surgery, previous upper GI surgery | 47 (SD 17) 62%>40 |
Dyspepsia Reflux-like Ulcer-like Dysmotility-like
| n = 612 Alarm symptoms: unknown | Upper GI cancers, n = 3 Unclassified, n = 1 Prevalence 0.65% (95% CI= 0.18 to 1.67) | Structured interview by endoscopist | Endoscopy and histology when indicated |
Hippisley-Cox & Coupland11 | UK | Retrospective, cohort 2000–2010 (129 months) | Primary care population of all practices in England and Wales, recorded in QResearch database. Exclusions: history of gastro-oesophageal cancer, registration <12 months with a practice, invalid dates, aged <30years or ≥85years | 50 (SD 15) Range 30–84 | Alarm symptoms
Dysphagia Haematemesis Appetite loss Weight loss Abdominal pain Anaemia
| Validation set n = 963 040 Alarm symptoms 100% | Gastric and oesophageal cancers, n = 986 Prevalence 0.14% (95% CI = 0.13 to 0.15) | QResearch database. Incident diagnosis of gastric or oesophageal cancer >2 years after study entry, recorded in GP record or linked ONS record | ICD-9 or 10 recording of disease classification |
Johannessen et al 12 | Norway | Prospective cohort, 1985–1987 (18 months) | Mainly GP referrals to open-access endoscopy at a regional hospital. Exclusions: jaundice, upper GI haemorrhage, acute abdominal pain, previous gastric surgery or endoscopy | 50 (SD 15) 67%>40 |
Abdominal pain Nausea Reflux Appetite loss Weight loss Retrosternal pain Epigastric pain
| n = 930 Alarm symptoms: not calculable, >1 symptom/patient | Gastric cancers, n = 9 Prevalence 0.97% (95% CI = 0.44 to 1.83) | Self-administered questionnaire of 112 items including demographic, medical history and present symptoms | Endoscopy and histology if suspicion of malignancy |
Kapoor et al 19 | UK | Prospective consecutive cohort, 2000–2002 (20 months) | GP referrals of patients at high risk with pre-determined alarm features to rapid access endoscopy according to NHS 2-week rule criteria | Mean 59, range 17–96 63% >55 |
Dysphagia Weight loss Anaemia Others — data not available
| Evaluation cohort n = 1852 Alarm symptoms: not calculable, >1 symptom/ patient | Gastric cancers, n = 25 Oesophageal cancers, n = 45 Prevalence 3.78% (95% CI = 2.96 to 4.75) | Standardised referral proforma completed by GPs noting the presence/absence of each designated alarm feature | Gastroscopy and histology |
Meineche-Schmidt & Jørgensen 13 | Denmark | Prospective cohort, 1991–1993 (36 months) | General practice referrals of patients with dyspepsia from 63 centres in Denmark | Range 18– ≥65 74% >38 50% >51 |
Dysphagia Weight loss Anaemia Melaena Dyspepsia
| Uncomplicated and complicated cohorts n = 1491 Alarm symptoms 41% | Gastric and oesophageal cancers, n = 8 Prevalence 0.54% (95% CI = 0.23 to 1.05) | Diagnostic chart based on structured interview by GPs; included 18 dyspepsia symptoms and six alarm symptoms. Follow-up by postal questionnaire to GPs | Endoscopy, radiograph, ultrasound |
Melleney and Willoughby25 | UK | Prospective audit, 1999–2000 (6 months) | ‘One-stop’ unrestricted dyspepsia clinic for GP referrals at single hospital. Proton pump inhibitors and H2-receptor agonists were stopped ≥2 weeks before clinic appointment | Median 59 Range 15–84 | 1. Any alarm | n = 100 (84 analysed) Alarm symptoms 42% | Upper GI cancers, n = 6 Prevalence 7.14% (95% CI = 2.68 to 14.91) | Special referral form designed in consultation with local GP practices | Endoscopy, blood tests and abdominal ultrasound if needed. Histology if endoscopy uncertain |
Numans et al 14 | Netherlands | Prospective, consecutive cohort, 1986–1988 (25 months) | GP referrals of patients with dyspepsia for first-time gastroscopy at nine hospitals in one city | Not reported |
Dysphagia Weight loss Anaemia Melaena Reflux Retrosternal pain Epigastric pain Haematemesis Vomiting Bloating Dyspepsia
| Study population n = 861 Alarm symptoms: not calculable, >1 symptom/patient | Gastric and oesophageal cancers, n = 21 Prevalence 2.44% (95% CI = 1.52 to 3.70) | GPs referred patients on basis of disease history and symptoms for endoscopy. Gastroscopy views were reported uniformly | Gastroscopy and histology if suspicion of malignancy |
Salo et al 15 | Finland | Consecutive cohort, 1998–2000 (24 months maximum) | Primary care referrals to open-access endoscopy in one city | Range 11–93 52% >55 |
Dysphagia Weight loss Anaemia/ GI bleeding Vomiting Bloating Reflux Diarrhoea Dyspepsia Any alarm
| n = 10 061 Alarm symptoms 13% | Gastric cancers, n = 52 Oesophageal cancers, n = 15 Duodenal cancers, n = 1 Prevalence 0.68% (95% CI = 0.53 to 0.86) | Experienced physicians who performed endoscopies interviewed patients. Alarm symptoms considered most. significant when present. gastrointestinal complaints also reported | Endoscopy, Finnish registry, histology |
Stapley et al 16 | UK | Retrospective matched case–control, 2000–2009 (120 months) | GPRD contains copies of anonymised medical records of participating UK general practices. Exclusions: metastatic, cancers controls who had ever had gastro-oesophageal cancer | Range 40– ≥85 |
Dysphagia Weight loss Low haemoglobin Nausea or vomiting Abdominal pain Chest pain Epigastric pain Reflux Constipation Dyspepsia Any alarm
| n = 40 348 Cases, n = 7471 Controls, n = 32 877 | Gastric cancers, n = 28 Oesophageal cancers, n = 18 Prevalence not available | GPRD database searched using codes for 18 oesophageal and 28 gastric cancers. Five controls matched on year of birth, sex, and practice; also identified using computer-generated random sequence | GPRD coding for gastro-oesophageal cancers |
Thomson et al 20 | Canada | Prospective cohort, 1999–2001 (16 months) One of the CADET series of studies | 49 family physician practices across Canada linked to gastroenterology unit referred patients with uninvestigated dyspepsia. Exclusions: patients with heartburn or acid regurgitation as sole symptom, recent Helicobacter pylori eradication, previous endoscopy or radiology | Mean 46, range 18–84 64% of endoscopy patients<50 |
Dyspepsia Reflux-like Ulcer-like Dysmotility-like Dysphagia Weight loss Anaemia Any alarm
| n = 1040 Alarm symptoms 3% | Oesophageal cancers, n = 1 One patient with dyspepsia had a gastric MALToma, this was not a target condition for the review. Prevalence 0.10% (95% CI = 0.02 to 0.54) | Patients completed 14-item symptom checklist ranking the three most bothersome symptoms | Endoscopy (urea breath test if refuse] and histology |
van Kerkhoven et al 23 | Netherlands | Prospective, consecutive cohort, 2002–2004 (36 months) | GP referrals for open-access upper GI endoscopy at a single general hospital. Exclusions: age <18 years, failed/previous endoscopy | Mean 54 (SD 15) |
Dyspepsia-like Reflux-like Failure of empirical treatment Any alarm
| n = 1298 Alarm symptoms: not calculable, >1 symptom/ patient | Gastric and oesophageal cancers, n = 23 Prevalence 1.77% (95% CI = 1.13 to 2.65) | GPs completed referral indications on standardised form. Endoscopic findings recorded in database | Endoscopy |
Voutilainen et al 24 | Finland | Consecutive cohort, 1996 (12 months) | GP referrals of patients with dyspepsia for upper GI endoscopy at two hospitals and eight healthcare centres. Exclusions: previous Helicobacter pylori eradication or gastrooesophageal surgery | Mean 58 (IQR 25) |
Dyspepsia Reflux Failure of empirical treatment Any alarm
| n = 3378 Alarm symptoms 33% | Gastric cancers, n = 17 on symptoms, 0.50% Prevalence (95% CI = 0.29 to 0.80) | GPs completed structured questionnaire duration, and medication. Endoscopic data recorded on pre-structured questionnaire | Endoscopy, biopsy and histology. Cancer registries |