The elusive diagnosis of cancer: testing times

In this issue of the BJGP, Just and colleagues question PSA testing in men with lower urinary tract symptoms (LUTS).¹ Like others, they propose that the majority of cancers detected will be indolent and unrelated to the LUTS, basing their judgement on PSA screening trial data and general population LUTS surveys.² Danish primary care data, not included by Just and colleagues, indicates that indolent prostate cancer detection increases as PSA testing increases without a corresponding change in advanced disease detection or mortality.³ Over half of UK hospitals now use multiparametric-MRI to protect men from the harms of unnecessary biopsy and treatment for indolent prostate cancer.⁴ The important question Just and colleagues raise is not which test should be performed once a patient is referred for suspected prostate cancer, but rather should patients with non-specific symptoms be tested in primary care and are there harms of testing them?

The myriad of urgent referral pathways, complex referral criteria, and regional variations in test and specialist access have created a complex bureaucracy for UK cancer diagnosis that has favoured patients with ‘alarm’ symptoms. Within this context, cancers with non-specific symptom signatures such as myeloma and pancreatic cancer have become associated with longer intervals between presentation and diagnosis, they are less likely to be diagnosed via urgent GP referral and more likely to be diagnosed as an emergency.^5,6

But general practice is dominated by common non-specific cancer symptoms such as LUTS, abdominal pain, back pain, and fatigue. Like cancer, these symptoms increase in incidence with age and comorbidity. Our conundrum as specialist generalists has always been how to efficiently differentiate benign or self-limiting causes from more serious diseases, …