Cancer and gut feelings

The role of gut feelings in cancer diagnosis has been rarely studied so far. Focusing on primary care we can find qualitative and quantitative approaches. Below is a summary of some of these studies.

  • Green et al(1) interviewed 55 English GPs about the GP’s role in the early detection of cancer, cancer awareness, cancer screening and the NHS policies. GPs made reference to gut feelings, as a tool developed through experience, having a role in GPs’ ability, in the absence of red flag symptoms, to identify patients in need of further investigation (to either rule in or rule out cancer).
  • Johansen et al(2) interviewed 14 Norwegian GPs about their care of people with cancer, and how they come to think of cancer when interviewing a patient. They referred to intuitive knowing and gut feelings as one of the four main ways awareness of cancer may arise. They defined gut feelings as the sum of medical knowledge, experience and contextual (about the community) and personal (about the patient) knowledge.
  • We also have two Danish papers with a more quantitative approach to gut feelings and intuition. Hjertholm et al(3) studied 4518 consultations of 404 Danish GPs. After every consultation the GP had to answer to the question: ‘Are you left with the slightest suspicion of cancer or another serious disease (new)?’. The GP suspicion of cancer had a PPV of 3,1 and a NPV of 99,5 six months after the consultation. Not bad if you compare, for instance, with the PPV of 4,57 achieved by rectal bleeding for colorectal cancer in older adults(4).
  • Ingeman et al(5) asked for the reasons for refering 1278 patients to a Danish pathway implemented for patients with non-specific symptoms and signs of cancer to their GPs. The second most common clinical finding were the GP’s gut feeling (22,5% of the cases). These gut feelings achieved the third highest probability of cancer as 24% of the cases ended with a cancer diagnosis, only after enlarged lymph nodes (27.3 %) and neurological findings (26.7 %)
  • In the Netherlands, Donker and Dorsman(6) found that Dutch GPs have gut feelings related with cancer in 20 cases per 10000 registered patients per year. This gut feelings of cancer were confirmed in one third of the cases after three months. (see also Poster-WONCA2016-Determinants of general practitioner’s cancer related gut feelings)
  • In a bigger study Donker et al (7) asked 59 Dutch GPs to complete a questionnaire if they noticed a gut feeling concerning any kind of cancer. Outcomes of 366 patients were assessed 3 monyhs later. Weight loss, rare GP visits and duration of complaints were the more frequently reported triggers of gut feelings, although a palpable tumour was the only statiscally significant predictor of cancer 3 months later. 95% of the GPs acted immediately following their gut feeling. The predictive value of gut feelings for the diagnosis of cancer was 35%, with a significant influence of patient and GP’s age, how long the GP knows the patient and GP’s years of experience.
  • Scheel et al (8) investigated the relationship between ten symptoms commonly considered to be warning signs of cancer and diagnosis of cancer, taking into account the GP’s suspicion of cancer. 396 GPs participated, with a population of 51073 patients. Outcomes were assessed 6 months later. Regarding GP suspicion, 3,8% of the positive were correct, while 0,6% of patients recorded as not likely to have cancer were diagnosed as having cancer.
  • Moroni et al(9) and Moss et al(10) studied, among GPs and oncologists respectively, the prognostic value of the ‘surprise question’. This question (‘’Would you be surprised if this patient die in the next year?’) has been used in several palliative care protocols to decide wheter the patient is in need of entering these protocols or not. We can interpret this question as a kind of intuition about prognosis. When GPs or oncologists answer ‘no’ to the “surprise” question the patient hazard ratio of being dead in one year is increased seven times compared to patients with a ‘yes’ answer.

References

1) Green T, Atkin K, Macleod U. Cancer detection in primary care: insights from general practitioners. British Journal of Cancer. 2015;112:41-49 [cited 2015 Oct 6].

2) Johansen M-L, Holtedahl KA, Rudebeck CE. How does the thought of cancer arise in a general practice consultation? Interviews with GPs. Scand J Prim Health Care. 2012;30(3):135-40. [cited 2015 Oct 6].

3) Hjertholm P, Moth G, Ingeman ML, Vedsted P. Predictive values of GPs’ suspicion of serious disease: A population-based follow-up study. Br J Gen Pract. 2014;64:346-53. [cited 2015 Oct 6].

4) Shapley M, Mansell G, Jordan JL, Jordan KP. Positive predictive values of >=5% in primary care for cancer: Systematic review. Br J Gen Pract. 2010;60(September):366-77. [cited 2015 Oct 6]

5) Ingeman ML, Christensen MB, Bro F, Knudsen ST, Vedsted P. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer–a cross-sectional study of patient characteristics and cancer probability. BMC Cancer 2015;15:421[cited 2015 Oct 6]

6)Donker G DS. Cancer related gut feelings among Dutch general practitioners. Abstract. In: Abstractbook 6th Annual Meeting of the Cancer and Primary Care Research International (Ca-PRI) network. 15th-16th april 2013, Cambridge. [cited 2015 Oct 13].

7) Donker GA, Wiersma E, van der Hoek L, Heins M. Determinants of general practitioner’s cancer-related gut feelings—a prospective cohort study. BMJ Open. 2016;6(9) [cited 2016 Sept 17]

8) Scheel BI, Ingebrigtsen SG, Thorsen T, Holtedahl K. Cancer suspicion in general practice: the role of symptoms and patient characteristics, and their association with subsequent cancer. Br J Gen Pract. 2013 Sep;63(614):e627–35. [cited 2016 Sept 17]

9) Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, et al. The «surprise» question in advanced cancer patients: A prospective study among general practitioners. Palliat Med. 2014;28(7):959-64. [cited 2015 Oct 6]

10) Moss AH, Lunney JR, Culp S, Auber M, Kurian S, Rogers J, et al. Prognostic significance of the «surprise» question in cancer patients. J Palliat Med. 2010;13(7):837-40. [cited 2015 Oct 6]

Author Bernardino Oliva Fanlo, GP and PhD student from Majorca (Spain).