When should unexpected weight loss warrant further investigation to exclude cancer? – The BMJ

Posted: September 23, 2019 at 8:43 am

Unexpected weight loss can be associated with cancer, but also with a range of other conditions

Weight loss codes in primary care typically represent 5% loss within a 6 month period, but there is a lack of evidence on how much weight loss and over what time period increase the likelihood of a cancer diagnosis in primary care

Urgently refer people over the age of 60 years with unexpected weight loss for investigations to exclude cancer

The optimal diagnostic strategy to detect cancer in patients with weight loss remains unclear

Unexpected weight loss presents a diagnostic challenge in primary care. It is associated with a wide range of benign and serious conditions (box 1).1

CardiovascularEnd stage heart failure (cardiac cachexia)

EndocrineAdrenal insufficiency, diabetes, hyperthyroidism

GastrointestinalDiarrhoea, colitis, malabsorption, mesenteric ischaemia

InfectionChronic infection (such as HIV, tuberculosis)

MalignancySolid tumours more likely than haematological malignancies

MedicationAntidepressants, antiepileptics, anxiolytics, diuretics, laxatives, stimulants

NeurologicalDementia, multiple sclerosis, neuromuscular disease, Parkinsons disease, stroke

PsychiatricAnorexia nervosa, anxiety, bulimia, depression

RenalEnd stage renal failure (uraemic cachexia)

RespiratoryChronic obstructive pulmonary disease (COPD), interstitial lung disease, vasculitis

RheumatologicRheumatoid arthritis

SocialExcess alcohol consumption, neglect, use of opiates, poor oral health, poverty, smoking

Weight loss may be missed or misattributed because of several factors (see box 2). Once it is detected, the uncertainty for clinicians is not about whether unexpected weight loss is a symptom of concern, it is about who should be investigated further and who can be spared unnecessary investigation. Specifically, how much weight loss, over how much time, in combination with what other clinical features makes cancer sufficiently likely to warrant urgent investigation?

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When should unexpected weight loss warrant further investigation to exclude cancer? - The BMJ

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