O1 Positive predictive values of symptoms for oesophageal, gastric and pancreatic cancers in primary care: a population-based study

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Background Upper abdominal cancers, comprising oesophageal, gastric, and pancreatic malignancies, have five-year survival rates below 20%, largely due to late-stage diagnosis. NICE guidance recommends urgent investigation when the positive predictive value (PPV) of symptoms for cancer reaches 3% and routine investigation for over 1%, but contemporary evidence quantifying symptom-specific PPVs in UK primary care is limited. Analysis of the National Endoscopy Database has shown a very low PPV for many symptoms for UGI cancers in patients undergoing endoscopy. Objective To calculate PPVs for symptoms and their combinations for oesophageal, gastric, and pancreatic cancers in symptomatic patients presenting to UK primary care, stratified by age and sex. Methods Population-based retrospective cohort study using CPRD AURUM (2000-2024) analysing adults presenting with upper GI symptoms were included. PPVs with 95% confidence intervals were calculated for symptoms, comorbidities, and laboratory test combinations. Cancer diagnoses within 180 days were identified using clinical codes. Results We identified 6,183,310 patients, of whom 49,917 (0.81%) were diagnosed with UGI cancer: 22,076 oesophageal, 10,191 gastric, and 18,926 pancreatic. In patients aged 50+, only jaundice (PPV 15.9%, 95% CI 15.6–16.2), dysphagia (PPV 10.4%, 95% CI 10.2–10.6), and haematemesis (3.9%, 95% CI 3.7–4.2) exceeded the 3% threshold as single symptoms. No symptom reached the threshold in patients under 50. For gastric cancer, no single symptom reached the 3% threshold; however, adding pernicious anaemia or iron deficiency anaemia to symptoms such as dysphagia, vomiting, or weight loss increased PPVs up to 4.3% (95% CI 1.5–11.9), 2.2% (95% CI 1.8–2.6) and 2.3% (95% CI 2.0–2.8) respectively. For pancreatic cancer, adding chronic pancreatitis or type 2 diabetes to abdominal pain or vomiting increased PPVs to 3.0% (95% CI 2.5–3.7) and 3.7% (95% CI 2.6–5.3) respectively. Table 1 shows the PPV for symptoms and comorbidity or laboratory test combinations with the highest positive predictive values across the factors studied. Conclusions Only jaundice, dysphagia, and haematemesis exceeded the NICE 3% threshold as single symptoms in patients aged 50+. Most symptoms prompting investigation showed PPVs below 2%. Gastric cancer presented the greatest diagnostic challenge, with low PPV across all combinations. These findings support age-stratified referral criteria and composite risk assessment approaches in particular for gastric and pancreatic cancer and a revision of the referral criteria for suspected upper gastrointestinal cancers.

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