Table 4HAEMATOLOGICAL CANCER: signs and symptoms, including risk factors

AuthorSettingDescriptionNo.InclusionExclusionResultsGold StdQuality
Allhiser et al 1981USA Primary CareA retrospective and descriptive study aimed to determine the annual incidence of lymphadenopathy, analyse the clinical spectrum and management of lymphodenopathy in a representative family practice setting80All patients coded as having lymphadenopathy or acute lymphadenitis.Not included were three patients later identified with the diagnosis of chronic and non-specific lymphadenitisThe annual incidence of the problem of enlarged nodes was 0.5%.
56 (70%) of cases were discovered by patients and 15 (19%) were discovered by the physician (previously unknown to patient). It was unclear from the records who discovered the remaining 9 cases. Of those discovered by the patient, the duration of swelling by the time of first visit ranged from one day to six months, with one third reporting swelling of less than one week. Thirty-seven patients (46%) reported pain and 35 (44%) denied it. No mention of pain was found in the charts of eight patients (10%).
Seven patients (9%) had nodes measuring less than 0.5 cm, 14 patients (18%) had nodes measuring less than 0.5 cm, 14 patients (18%) had nodes 0.5 to 1 cm, and 36 (45%) had nodes recorded as greater than 1 cm.
Several clinical parameters important to the evaluation of lymphadenopathy were incompletely recorded in the medical notes. Excepting node enlargement, few associated physical and laboratory findings were discovered. Isolated cervical nodes accounted for 44% of all cases while 24% had enlarged nodes in more than one anatomic region. The most frequently performed laboratory test was the full blood count (34%) and the most frequent positive test was the throat culture (30%). Twenty percent of patients received antibiotics.
Fijten and Blijham 1988Dutch Primary Care study.A retrospective investigation into the probability of malignancy in patients presenting with lymphadenopathy as well as the characteristics that may be discriminatory for malignant causes.82Patients who had undergone biopsy for unexplained lymphadenopathy between 1982 and 1984Patients were excluded if they were not referred for unexplained lymphadenopathy or were not living in the Maastricht area.Of the 82 patients, 29 had a malignant cause. The prior probability was 1.1% (29/2256 patients presenting this problem in family practice) and a posterior probability after referral of 11.0% (29/256) Diagnosis included 14 malignant lymphomas, 15 metastases, 37 reactive lymph nodes without specific diagnosis and 16 benign causes.
Age over 40 years (4%) and the presence of an enlarged supracavicular node (50%) were related to an increased likelihood of malignancy (P <0.01).
Borderline significance was obtained for an increased sedimentation rate and weight loss.
Physician sensitivity of referral for malignant cases was 80 to 90%, 91–98% of benign cases were not referred.
Cytologic or histologic examination was used as the gold standard for malignant and benign lymphadenopathy.
Servaes et al 2002NetherlandsA review of the studies examining the relationship between cancer and fatigue The focus was on fatigue observed in patients during and after treatment for cancer using data from empirical studies.54 articlesArticles from a Medline, current contents and psychlit Search undertaken for the period July 1980–2001.Review articles, editorials/comments/practical guidelines, studies in which the sample size was less than 15, studies investigating a sample of subjects other than adult cancer patients (eg children, caregivers), studies in which evaluation of a fatgue-questionnaire was the only intention, uncontrolled intervention studies, studies published in a language other than English or dutch and studies in which fatigue was measured with one or a few items from a quality of life questionnaires.The results from the studies indicate that fatigue was investigated among patients who were undergoing treatment for cancer rather than at the time of initial diagnosis. There was little information on the relationship between fatigue and haematological cancer.
No articles were based on data in a primary care setting
Systematic review. Good review but not related to fatigue in general practice, or not specifically about Haematology.
Wang et al 2002US Cancer Centre. Participants approached in both outpatient clinics and inpatient units. Tertiary care?A cross-sectional study using a convenience sample aimed to describe fatigue severity, fatigue interference and associated haematological malignancies. Patients being treated for leukaemia and non-Hodgkin’s Lymphoma completed the Brief Fatigue inventory so that fatigue severity and functional interference caused by fatigue could be assessed. Data regarding patient demographics, Eastern Cooperative Oncology Group performance status, other physical symptoms, current treatments, and laboratory values were also collected. Descriptive statistics, bivariate correlations, and logistic regression were used for data analysis.228Patients were eligible if they were aged 18 years or older, had a pathologic diagnosis of leukaemia or lymphoma, and were able to read and understand self-report questionnaires in English.--50% of the sample reported severe fatigue (defined as ‘fatigue worst’ with a rating of 7 or more).
Patients with acute leukaemia were more likely to report severe fatigue (61%) compared with those with chronic leukaemia (47%) and non-Hodgkin’s lymphoma (46%) Increased fatigue severity significantly compromised patients’ general activity, work, enjoyment of life, mood, walking and relationships.
Fatigue severity was strongly associated with performance status, use of opioids, blood transfusions, gastrointestinal symptoms (P<0.001) and sleep disturbance (P<0.001 and pain (P<0.01). In terms of laboratory variables it was also associated with low serum haemoglobin and albumin levels. Regression analysis revealed nausea was the significant clinical predictor of severe fatigue (odds ratio, 13), and low serum albumin was the significant laboratory value predictor (odds ratio, 3.8)
Primary evidence of fatigue relationship to leukaemia
Williamson 1985US Primary CareThe primary care charts of patients with enlarged lymph nodes were reviewed to provide a primary care database for evaluating lymphadenopathy. Data recoded included age, sex, location of enlarged nodes, diagnoses made, laboratory evaluation, outcome, referrals, and information to evaluate adequacy of follow-up.249 (238 at follow up)The study population was selected from patients seen between July 1978 and June 1983. patients studied were all those seen during the 5 year study period whose diagnoses were coded ‘enlarged lymph nodes, not infected’ and ‘lymphadenitis, acute’--The mean age of patients was 24 years old and 26% were aged under 15 years. 58% of the patients were female. 51% had been seen once for enlarged lymph nodes, 23% had been seen twice and 26% three times or more.
A firm diagnosis was made in 36% of patients despite an average of 1.7 visits and two laboratory yests per patient tested. Lymph nodes were biopsied in 3% of patients. No patient was found to have a prolonged, disabling illness without a prompt diagnosis. 18% had associated upper respiratory tract infection, 8% had infected or inflamed tissue near the node site and 5% had insect bites.
No patients with potentially serious diseases presented with lumphadenopathy alone; all had associated signs or symptoms that led to a diagnosis. Older patients were more likely to have a serious disease associated with enlarged nodes

From: Appendix B, Evidence Tables

Cover of Referral Guidelines for Suspected Cancer in Adults and Children
Referral Guidelines for Suspected Cancer in Adults and Children [Internet].
NICE Clinical Guidelines, No. 27.
Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester.
Copyright © 2005, National Collaborating Centre for Primary Care.

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