Gastrointestinal Malignancy in Iron Deficiency Anemia
Gastrointestinal Malignancy in Iron Deficiency Anemia
Objective Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This analysis – the Iron Deficiency as an Indicator Of Malignancy (IDIOM) study – was undertaken to assess whether five simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on subsequent investigation of patients with IDA.
Design Retrospective observational study, with multivariable analysis of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of underlying GI malignancy.
Setting District General Hospital IDA clinic.
Patients 720 adults with confirmed IDA.
Results Sex, age and Hb were strongly associated with the risk of GI malignancy—the parsimonious model including only these variables yielded ORs of 4.0 (95% CI 2.3 to 7.0) for males compared with females; 3.3 (95% CI 1.7 to 6.4) for age >70 years compared with ≤70 years; and 5.3 (95% CI 2.4 to 11.7) for a Hb of ≤91.4 g/L compared with ≥111.5 g/L. Combining these risk factors identified a subgroup (12% of the study population) at particularly low risk (<2% likelihood), and a second subgroup (16% of the study population) at especially high risk (>20% likelihood) of underlying GI malignancy.
Conclusions Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.
Iron deficiency anaemia (IDA) is a common clinical problem. In adult males or postmenopausal females, about 30% of subjects overall will have underlying gastrointestinal (GI) pathology. Malignancy accounts for about a third of these, about 10% of the total, often in the absence of localising symptoms.
The IDA clinic at Poole Hospital has been operational since 2004, and is the point of referral for patients with IDA who have minimal or no symptoms to indicate the nature or location of the underlying cause of iron deficiency. Basic patient data have been collected since inception, for the purposes of clinical care, audit and service evaluation. The register now exceeds 1000 subjects.
It is inherently unlikely that all subjects with IDA will have the same pretest probability of malignancy, but without the tools to predict individual risk it is currently standard practice to recommend urgent investigation for IDA on the grounds that there might be an underlying malignancy. A simple but reliable pretest predictor of risk would help considerably with patient counselling. It could also facilitate better use of resources, with prioritisation of high-risk subjects for fast-track investigation and perhaps avoidance of investigation in particularly low-risk individuals.
Abstract and Introduction
Abstract
Objective Ten percent of adults presenting with iron deficiency anaemia (IDA) have underlying cancer. This analysis – the Iron Deficiency as an Indicator Of Malignancy (IDIOM) study – was undertaken to assess whether five simple clinical parameters can usefully predict the likelihood of gastrointestinal (GI) malignancy on subsequent investigation of patients with IDA.
Design Retrospective observational study, with multivariable analysis of the predictive value of sex, age, haemoglobin concentration (Hb), mean red cell volume (MCV) and iron studies for the risk of underlying GI malignancy.
Setting District General Hospital IDA clinic.
Patients 720 adults with confirmed IDA.
Results Sex, age and Hb were strongly associated with the risk of GI malignancy—the parsimonious model including only these variables yielded ORs of 4.0 (95% CI 2.3 to 7.0) for males compared with females; 3.3 (95% CI 1.7 to 6.4) for age >70 years compared with ≤70 years; and 5.3 (95% CI 2.4 to 11.7) for a Hb of ≤91.4 g/L compared with ≥111.5 g/L. Combining these risk factors identified a subgroup (12% of the study population) at particularly low risk (<2% likelihood), and a second subgroup (16% of the study population) at especially high risk (>20% likelihood) of underlying GI malignancy.
Conclusions Three simple and objective clinical parameters can be combined to provide a clinically useful cancer risk stratification model for subjects with IDA. This may assist with patient counselling and the prioritisation of investigational resources.
Introduction
Iron deficiency anaemia (IDA) is a common clinical problem. In adult males or postmenopausal females, about 30% of subjects overall will have underlying gastrointestinal (GI) pathology. Malignancy accounts for about a third of these, about 10% of the total, often in the absence of localising symptoms.
The IDA clinic at Poole Hospital has been operational since 2004, and is the point of referral for patients with IDA who have minimal or no symptoms to indicate the nature or location of the underlying cause of iron deficiency. Basic patient data have been collected since inception, for the purposes of clinical care, audit and service evaluation. The register now exceeds 1000 subjects.
It is inherently unlikely that all subjects with IDA will have the same pretest probability of malignancy, but without the tools to predict individual risk it is currently standard practice to recommend urgent investigation for IDA on the grounds that there might be an underlying malignancy. A simple but reliable pretest predictor of risk would help considerably with patient counselling. It could also facilitate better use of resources, with prioritisation of high-risk subjects for fast-track investigation and perhaps avoidance of investigation in particularly low-risk individuals.
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