Cases corner – 52 years old with weight loss

14th May 2019

Mr L, a 52 year old man, presents to you ”not feeling well”. He can’t articulate what he means but describes mild nausea. He denies any other symptoms including abdominal pain, change in bowel habit, rectal bleeding or difficulty swallowing. He says that he weighed himself this morning as his clothes were much looser and he has lost about 10kg over the last 3 months or so. His examination is unremarkable.

What should you do next?

  1. Do not refer the patient, but offer safety-netting
  2. Perform a non-urgent upper GI endoscopy
  3. Perform a CT of the abdomen within 2 weeks
  4. Perform a FIT test
  5. Refer the patient via a 2-week-wait pathway

Unintentional weight loss is a sinister symptom and should be taken seriously as a potential symptom of cancer. However, weight loss crosses many different cancer pathways, including: chest, gastrointestinal, gynaecological, haematological, and childhood cancers. Therefore, it can be very difficult to know what to do if a patient presents with this symptom in isolation.

If we apply the NICE Guidelines to this patient’s presentation he would satisfy DG30:

The OC Sensor, HM JACKarc and FOB Gold quantitative faecal immunochemical tests are recommended for adoption in primary care to guide referral for suspected colorectal cancer in people without rectal bleeding who have unexplained symptoms but do not meet the criteria for a suspected cancer pathway referral outlined in NICE’s guideline on suspected cancer (recommendations 1.3.1 to 1.3.3). This is taken from “Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care” (DG30) published by NICE in July 2017.

In London, this guidance is even more explicit:

Offer a FIT test (Faecal Immunochemical Test) before referring to assess for colorectal cancer in adults WITHOUT RECTAL BLEEDING who meet the following criteria:

  • ≥50 years with unexplained abdominal pain or weight loss
  • <60 years with changes in their bowel habit or iron deficiency anaemia
  • ≥60 years and have anaemia even in the absence of iron deficiency

This case also highlights a quirk of investigating patients at risk of cancer. Patients reach different cancer thresholds based on their age. NICE sets a 3% positive predictive value (where 3 patients out of 100 referred along the pathway would be diagnosed with cancer) which this patient currently achieves on colorectal cancer. However, if the patient was 55 years or older, then the nausea would add additional risk and would also reach the threshold for oesophageal cancer, which should be investigated with a non-urgent upper GI endoscopy. If the patient was 60 years or older, then they would then trigger a pancreatic cancer pathway, recommending a CT scan of the abdomen.

If you would like to find out more about FIT testing, please see our article here.