Cancer and gut feelings
GUT FEELINGS AND CANCER DIAGNOSIS
Author Bernardino Oliva Fanlo, GP and PhD, from Majorca (Spain).
General practitioners (GPs) consider gut feelings (GF) as a kind of compass that can help them to handle the many situations of uncertainty they face on a daily basis in their job . One of the most fearful situations of uncertainty is when a GP has a doubt as to whether or not a patient has cancer. Some reasons for this are the rarity of cancer diagnosis , the heterogenicity of types and presentations of the different cancers, the bad prognosis of many of them and the dark connotations of the diagnosis, and the low positive predictive values (PPV) of signs and symptoms usually considered as red flags of alarm . To complicate it more, we are still unable of determine the right strategy for screening and early diagnosis of the most common cancers [4,5]. To join GPs gut feelings with the lack of fully proper diagnosis strategies we can cite the law one from the book The laws of medicine. Field notes from an uncertain science, authored by Siddartha Mukherjee (an oncologist): ‚ÄėA strong intuition is much more powerful than a weak test‚Äô .
In Denmark  and the UK  protocols have been designed especially for those patients with common symptoms in whom the diagnosis of cancer should not be missed (‚Äúpatients with low risk but not no-risk‚ÄĚ). Patients are allowed to enter these special pathways to be studies faster than normally if they present any of the symptoms considered as referral criteria. One of these criteria is, in both cases, the GP‚Äôs gut feeling.
The study of the role of GFs in the diagnosis, as well as other aspects, of cancer has been increasing in recent years as the existence and value of GPs‚Äô gut feelings gained prominence. Focusing on primary care we can find qualitative and quantitative approaches. Below is a summary of some of these studies.
Qualitative studies about diagnosis:
- Johansen et al  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.
- Clarke et al  interviewed 9 GPs of children diagnosed with acute leukemia. GPs recognised that a child is acutely unwell drawing primarily on their physical appearance and behaviour, and the gut feelings these provoked.
- Green et al  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‚Äô ability, in the absence of red flag symptoms, to identify patients in need of further investigation (to either rule in or rule out cancer).
- Robinson  interviewed 36 GPs using clinical case scenarios and in-depth exploration of the process of recognition and referral of patients with suspected lung cancer symptoms. They used gut feelings as a metaphor describing intuitive prompts when involced in a decisional situation.
- Oliva et al  interviewed 21 Spanish GPs to explore the existence, significance, determinants and triggers of gut feelings among Spanish GPs. They mentioned the presence of GFs when a patient presents with symptoms that may suggest serious diseases, such as cancer.
- Kostopoulou et al  studies, using interactive simulated consultations online, the association between 19 UK GPs first impressions about patients presenting with subtle indications of cancer. When the possibility of cancer was verbalized by the GP, the odds of subsequently diagnosing it were on average 5 times higher (OR 4.90)
- Friedemann et al  interviewed 19 GPs who had referred patients to a cancer pathway allowing the use of gut feeling as a referral criterion. GPs described their gut feelings as important to decision-making in primary care and a necessary addition to clinical guidance. This was especially true for patients who fell within a ‚Äėgrey-area‚Äô where clinical guidelines inadequately represented the patient‚Äôs presentation, or the patient‚Äôs presentation was missing.
- In a grounded theory analysis of primary care physicians survey responses and interviews intended to explore how cancer could be diagnosed in a more timely way, Thulesius et al  concluded that the ability to alternate between the analytic and the intuitive decision-making systems (something that has been proposed as one of the GFs features ) is crucial for avoiding diagnostic delay and achieving a more timely diagnosis.
- The opinion of patients with cancer has also been addressed. Friedemann et al  conducted semi-structured interviews with 21 patients whose referral to a cancer pathway was based on their GP‚Äôs gut-feeling. Patients saw GPs gut feelings as a part of the process of diagnosis, grounded in their experience. They justified the use of GPs gut feelings in cancer diagnosis, and even some of them saw GFs as an indication that they were being taken seriously.
Quantitative studies about diagnosis:
- Scheel et al  recorded 6321 consultations of patients with warning signs of cancer and the presence of GPs‚Äô cancer suspicion. GPs‚Äô correct cancer suspicions were six times more frequent than their erroneous lack of suspicion.
- Hjertholm et al  studied 4518 consultations of 404 Danish GPs. After every consultation the GP had to answer to the question: ‚ÄėAre you left with the slightest suspicion of cancer or another serious disease (new)?‚Äô. The GP suspicion of cancer had a PPV of 3,1 and a negative predictive value (NPV) of 99,5 six months after the consultation.
- Ingeman et al  investigated on the reasons for referring 1278 patients to the Danish pathway implemented for patients with non-specific symptoms and signs of cancer  . 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%),
- Donker et al  studies cancer-related gut feelings among 59 Dutch GPs. Gut feeling were most often triggered by weight loss and rare GP visits. Most GPs acted immediately on the gut feeling. The average PPV of cancer-related gut feeling was 35%, getting increased as patients and GPs becomes older.
- Holtedahl et al  recorded data from 6264 patients with abdominal symptoms: frequency, cancer suspicions raised, and actions taken by 493 GPs in six European countries. The GP‚Äôs intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11).
- Pedersen et al  examined whether the quality of the patient‚Äďphysician relationship, assessed by both the GP and the patient, associates with GPs‚Äô use of GFs in cancer diagnosis. The physician-reported level of empathy was positively associated with use of GF (OR 2.6). GPs were less likely to use GF when they assessed relational aspects of the patient encounter as difficult compared with less difficult (OR 0.67).
- Oliva et al  assessed the prevalence of GFs in general practice, and measured their diagnostic value for cancer and serious diseases. GFs of alarm were found in 22% of the consultations, and the odds of a patient being diagnosed with cancer or other serious diseases were more than 3 times higher (OR 3.67) 6 months after a GP‚Äôs sense of alarm.
Studies about management and prognosis:
- Moroni et al  and Moss et al  studied, among GPs and oncologists respectively, the prognostic value of the ‘surprise question’. This question (‚Äė’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 ‚Äúsurprise‚ÄĚ question the patient hazard ratio of being dead in one year is increased seven times compared to patients with a ‘yes’ answer.
- Prichard et al  evaluated the choice of treatment modality (surgical vs endocrine) of older women with breast cancer based on clinicians ‘gut-feeling’ compared to comorbidity scoring indices. The study concluded that physician’s GFs are often correct in identifying patients who may benefit from primary hormone therapy.
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6 ¬†¬†¬†¬†¬†¬†¬† Mukherjee S. The laws of medicine‚ÄĮ: field notes from an uncertain science. 2015. http://www.simonandschuster.ca/books/The-Laws-of-Medicine/Siddhartha-Mukherjee/TED-Books/9781476784847 (accessed 22 Apr 2018).
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8 ¬†¬†¬†¬†¬†¬†¬† Nicholson BD, Oke J, Friedemann Smith C, et al. The Suspected CANcer (SCAN) pathway: protocol for evaluating a new standard of care for patients with non-specific symptoms of cancer. BMJ Open 2018;8:e018168. doi:10.1136/bmjopen-2017-018168
9 ¬†¬†¬†¬†¬†¬†¬† 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;30:135‚Äď40. doi:10.3109/02813432.2012.688701
10 ¬†¬†¬†¬†¬† Clarke RT, Jones CHHD, Mitchell CD, et al. ‚ÄėShouting from the roof tops‚Äô: A qualitative study of how children with leukaemia are diagnosed in primary care. BMJ Open 2014;4:1‚Äď9. doi:10.1136/bmjopen-2013-004640
11 ¬†¬†¬†¬†¬† Green T, Martins T, Hamilton W, et al. Exploring GPs‚Äô experiences of using diagnostic tools for cancer: A qualitative study in primary care. Fam Pract 2015;32:101‚Äď5. doi:10.1093/fampra/cmu081
12 ¬†¬†¬†¬†¬† Robinson S. What are the factors influencing gps in the recognition and referral of suspected lung cancer? 2016.
13 ¬†¬†¬†¬†¬† Oliva B, March S, Gadea C, et al. Gut feelings in the diagnostic process of Spanish GPs: a focus group study. BMJ Open 2016;6. doi:10.1136/bmjopen-2016-012847
14 ¬†¬†¬†¬†¬† Kostopoulou O, Sirota M, Round T, et al. The role of physicians‚Äô first impressions in the diagnosis of possible cancers without alarm symptoms. Med Decis Mak 2017;37:9‚Äď16. doi:10.1177/0272989X16644563
15 ¬†¬†¬†¬†¬† Friedemann Smith C, Moller Kristensen B, Sand Andersen R, et al. GPs‚Äô use of gut feelings when assessing cancer risk in primary care: A qualitative study. Br J Gen Pract 2020;:bjgp21X714269. doi:10.3399/bjgp21X714269
16 ¬†¬†¬†¬†¬† Thulesius H, Sand√©n U, Petek D, et al. Pluralistic task shifting for a more timely cancer diagnosis. A grounded theory study from a primary care perspective. Scand J Prim Health Care 2021;39:486‚Äď97. doi:10.1080/02813432.2021.2004751
17 ¬†¬†¬†¬†¬† Stolper E, Van De Wiel M, Van Royen P, et al. Gut feelings as a third track in general practitioners‚Äô diagnostic reasoning. J Gen Intern Med 2011;26:197‚Äď203. doi:10.1007/s11606-010-1524-5
18 ¬†¬†¬†¬†¬† Friedemann Smith C, Moller Kristensen B, Sand Andersen R, et al. Building the case for the use of gut-feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathway. Br J Gen Pract 2021;:BJGP.2021.0275. doi:10.3399/BJGP.2021.0275
19 ¬†¬†¬†¬†¬† Scheel BI, Ingebrigtsen SG, Thorsen T, et al. Cancer suspicion in general practice: the role of symptoms and patient characteristics, and their association with subsequent cancer. Br J Gen Pract 2013;63:e627‚Äď35. doi:10.3399/bjgp13X671614
20 ¬†¬†¬†¬†¬† Hjertholm P, Moth G, Ingeman ML, et al. Predictive values of GPs‚Äô suspicion of serious disease: A population-based follow-up study. Br J Gen Pract 2014;64:346‚Äď53. doi:10.3399/bjgp14X680125
21 ¬†¬†¬†¬†¬† Ingeman ML, Christensen MB, Bro F, et al. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer‚Äďa cross-sectional study of patient characteristics and cancer probability. BMC Cancer 2015;15:421‚Äď31. doi:10.1186/s12885-015-1424-5
22 ¬†¬†¬†¬†¬† Donker GA, Wiersma E, van der Hoek L, et al. Determinants of general practitioner‚Äôs cancer-related gut feelings‚ÄĒa prospective cohort study. BMJ Open 2016;6:e012511.http://bmjopen.bmj.com/content/6/9/e012511.abstract
23 ¬†¬†¬†¬†¬† Holtedahl K, Vedsted P, Borgquist L, et al. Abdominal symptoms in general practice: Frequency, cancer suspicions raised, and actions taken by GPs in six European countries. Cohort study with prospective registration of cancer. Heliyon 2017;3:e00328. doi:10.1016/j.heliyon.2017.e00328
24 ¬†¬†¬†¬†¬† Pedersen AF, Andersen CM, Ingeman ML, et al. Patient-physician relationship and use of gut feeling in cancer diagnosis in primary care: A cross-sectional survey of patients and their general practitioners. BMJ Open 2019;9:1‚Äď10. doi:10.1136/bmjopen-2018-027288
25 ¬†¬†¬†¬†¬† Oliva-Fanlo B, March S, Gadea-Ruiz C, et al. Prospective Observational Study on the Prevalence and Diagnostic Value of General Practitioners‚Äô Gut Feelings for Cancer and Serious Diseases. J Gen Intern Med 2022;37:3823‚Äď31. doi:10.1007/s11606-021-07352-w
26 ¬†¬†¬†¬†¬† Moroni M, Zocchi D, Bolognesi D, et al. The ‚Äėsurprise‚Äô question in advanced cancer patients: A prospective study among general practitioners. Palliat Med 2014;28:959‚Äď64. doi:10.1177/0269216314526273
27 ¬†¬†¬†¬†¬† Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the ‚Äėsurprise‚Äô question in cancer patients. J Palliat Med 2010;13:837‚Äď40. doi:10.1089/jpm.2010.0018
28 ¬†¬†¬†¬†¬† Prichard RS, Haren¬† a., Evoy D, et al. Physician‚Äôs initial impression of elderly breast cancer patients allows appropriate treatment stratification despite lack of quantitative assessment. Ir Med J 2010;103:314‚Äď6.