Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
Advertisement
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
Editorials

Comorbidity and the diagnosis of symptomatic-but-as-yet-undiagnosed cancer

Cristina Renzi and Georgios Lyratzopoulos
British Journal of General Practice 2020; 70 (698): e598-e599. DOI: https://doi.org/10.3399/bjgp20X712193
Cristina Renzi
Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London, UK.
Roles: Principal Clinical Research Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Georgios Lyratzopoulos
ECHO Group, University College London, London, UK.
Roles: Professor of Cancer Epidemiology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading

Multimorbidity is the norm of modern medicine. We know that multimorbidity affects healthcare use and outcomes,1 but we don’t know how the presence of pre-existing conditions can influence the diagnosis of new illness. Cancer typically affects older patients, and presents with symptoms of relatively low specificity that are shared between different conditions. Timely diagnosis is important,2,3 but missed or delayed diagnoses are common.4 Might the presence of chronic conditions help us understand why the diagnosis of patients with symptomatic-but-as-yet-undiagnosed cancer is delayed? Carney et al, in this issue of the BJGP, shed light on this complex question in the context of the diagnosis of bladder cancer.5

MECHANISMS BY WHICH COMORBIDITY MAY INFLUENCE THE DIAGNOSIS OF CANCER

Pre-existing chronic conditions may act as ‘competing demands’ that prevent the investigation of new presenting symptoms or offer ‘alternative explanations’ for them.6,7 For cancers of specific organs or systems, different morbidities can be categorised into those with unrelated symptomatology and those with shared symptoms. For patients with symptomatic-but-as-yet-undiagnosed bladder cancer, Carney et al consider that previous urinary tract infections, prostatitis, and nephrolithiasis can offer alternative explanations for their symptoms. Similar considerations may apply to other ‘dyads’ of specific cancer sites and chronic conditions, for example, lung cancer and chronic obstructive pulmonary disease, or colorectal cancer and inflammatory bowel disease.

It can be difficult to distinguish between a genuinely pre-existing morbidity and a cancer initially misdiagnosed as a chronic condition. The study by Carney et al highlights that when using electronic health records, careful consideration is needed regarding the time when morbidities were first recorded, ideally handling the months before the diagnosis of cancer differently from earlier periods. Such analyses can also indicate possible opportunities for earlier diagnosis in subgroups of comorbid patients who are at greater risk of repeat presentations with cancer-related symptoms before an emergency cancer diagnosis.8

Chronic conditions offering ‘alternative explanations’ were found to be associated with a higher risk of diagnosis of advanced stage bladder cancer.5 The study by Carney et al did not directly examine the ‘surveillance effect’ hypothesis, where chronic disease monitoring for underlying morbidities might lead to earlier detection of new illness through more frequent contacts with healthcare professionals.6,8–10 However, some of the study findings would be consistent with such a mechanism.

It is important to explore if the association between morbidity and stage at diagnosis is causal. And, if so, how it may be mediated through management decisions and intervals to testing. Given the possible mechanisms involved and that morbidity-specific effects might vary in their size and direction by cancer site, symptoms, and patient characteristics, future studies will require large patient numbers.

The study by Carney et al represents a welcome addition to the evidence base.6–8,11 Most previous studies lacked a clear hypothesis on responsible mechanisms and did not consider the type of presenting symptoms or underlying conditions. They often defined morbidity only using summary measures, such as the Charlson Comorbidity Index, and used secondary care data, which will underestimate the true breadth and prevalence of certain morbidities.6

FUTURE DIRECTIONS

Focusing on specific cancer sites and chronic conditions helps illuminate the relationship between morbidity, the diagnostic process, and its outcomes. Because many patients will have multiple chronic conditions, future research should explore if effects vary across different morbidity clusters.1 Encompassing prescription history into such inquiries is also important, as certain pharmacological treatments for managing chronic diseases, such as aspirin,12 can influence cancer incidence, and possibly cancer aggressiveness. Large longitudinal studies based on electronic health records offer promise for shedding light in this complex area.

Examining different steps along the diagnostic pathway is essential for developing appropriate interventions, bearing in mind that morbidities can influence timely access to appropriate investigations even after referral to hospital services.13 Cognitive and emotional factors may influence decisions on use of invasive investigations in patients with serious cardiac or respiratory morbidities. Comorbidities may also affect patients’ symptom appraisal and help-seeking behaviour.9,10

When assessing trade-offs between risks and benefits, preferences and tolerance of uncertainty, by both patients and doctors, can be important; therefore, greater understanding of shared decision- making in the management of patients with multimorbidity is needed. Risk-stratification tools that take chronic morbidities and their treatments into account can be developed, enhancing currently available generic instruments, to support clinicians in the decision-making process when evaluating the possibility of cancer in symptomatic patients with multiple morbidities.

Acknowledgments

This article arises from the CanTest Collaborative, which is funded by Cancer Research UK (reference number: C8640/A23385). Georgios Lyratzopoulos is supported by a Cancer Research UK Advanced Clinician Scientist Fellowship Award (reference number: C18081/A18180).

Notes

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.

  • ©The Authors
http://creativecommons.org/licenses/by/4.0/

This article is Open Access: CC BY 4.0 licence (http://creativecommons.org/licences/by/4.0/).

REFERENCES

  1. 1.↵
    1. Zhu Y,
    2. Edwards D,
    3. Mant J,
    4. et al.
    Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based studyBMC Med202018178
    OpenUrl
  2. 2.↵
    1. Neal RD,
    2. Tharmanathan P,
    3. France B,
    4. et al.
    Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic reviewBr J Cancer2015112 Suppl 1Suppl 1S92S107
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Mendonca SC,
    2. Abel GA,
    3. Saunders CL,
    4. et al.
    Pre-referral general practitioner consultations and subsequent experience of cancer care: evidence from the English Cancer Patient Experience SurveyEur J Cancer Care (Engl)2016253478490
    OpenUrl
  4. 4.↵
    1. Lyratzopoulos G,
    2. Vedsted P,
    3. Singh H
    Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentationBr J Cancer2015112 Suppl 1Suppl 1S84S91
    OpenUrlPubMed
  5. 5.↵
    1. Carney M,
    2. Quiroga M,
    3. Mounce L,
    4. et al.
    Effect of pre-existing conditions on bladder cancer stage at diagnosis: a cohort study using electronic primary care records in the UKBr J Gen Pract2020DOI: https://doi.org/10.3399/bjgp20X710921.
  6. 6.↵
    1. Renzi C,
    2. Kaushal A,
    3. Emery J,
    4. et al.
    Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanismsNat Rev Clin Oncol20191612746761
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Mounce LTA,
    2. Price S,
    3. Valderas JM,
    4. Hamilton W
    Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care recordsBr J Cancer20171161215361543
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Renzi C,
    2. Lyratzopoulos G,
    3. Hamilton W,
    4. et al.
    Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in EnglandBMC Health Serv Res2019191311
    OpenUrl
  9. 9.↵
    1. Salika T,
    2. Lyratzopoulos G,
    3. Whitaker KL,
    4. et al.
    Do comorbidities influence help-seeking for cancer alarm symptoms? A population-based survey in EnglandJ Public Health (Oxf)2018402110
    OpenUrl
  10. 10.↵
    1. Kaushal A,
    2. Waller J,
    3. von Wagner C,
    4. et al.
    The role of chronic conditions in influencing symptom attribution and anticipated help-seeking for potential lung cancer symptoms: a vignette-based studyBJGP Open2020DOI: https://doi.org/10.3399/bjgpopen20X101086.
  11. 11.↵
    1. Gurney J,
    2. Sarfati D,
    3. Stanley J
    The impact of patient comorbidity on cancer stage at diagnosisBr J Cancer2015113913751380
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Algra AM,
    2. Rothwell PM
    Effects of regular aspirin on long-term cancer incidence and metastasis: a systematic comparison of evidence from observational studies versus randomised trialsLancet Oncol2012135518527
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Pearson C,
    2. Fraser J,
    3. Peake M,
    4. et al.
    Establishing population-based surveillance of diagnostic timeliness using linked cancer registry and administrative data for patients with colorectal and lung cancerCancer Epidemiol201961111118
    OpenUrlCrossRefPubMed
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 70 (698)
British Journal of General Practice
Vol. 70, Issue 698
September 2020
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Comorbidity and the diagnosis of symptomatic-but-as-yet-undiagnosed cancer
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Comorbidity and the diagnosis of symptomatic-but-as-yet-undiagnosed cancer
Cristina Renzi, Georgios Lyratzopoulos
British Journal of General Practice 2020; 70 (698): e598-e599. DOI: 10.3399/bjgp20X712193

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Comorbidity and the diagnosis of symptomatic-but-as-yet-undiagnosed cancer
Cristina Renzi, Georgios Lyratzopoulos
British Journal of General Practice 2020; 70 (698): e598-e599. DOI: 10.3399/bjgp20X712193
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • MECHANISMS BY WHICH COMORBIDITY MAY INFLUENCE THE DIAGNOSIS OF CANCER
    • FUTURE DIRECTIONS
    • Acknowledgments
    • Notes
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • Stroke: time to address cognition
  • Was enough, and is enough, being done to protect the primary care workforce from COVID-19?
  • Primary care networks: are they fit for the future?
Show more Editorials

Related Articles

Cited By...

Advertisement

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers
  • RCGP e-Portfolio

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7679
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2021 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242