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Six clinical variables in patients with dysphagia identify decreased esophageal cancer risk

Clinical Question:
Can clinical variables be used to identify patients with dysphagia who are at low risk of esophageal cancer?

Bottom Line:
Six clinical factors combined into a single score can identify patients referred to a dysphagia center who are at low risk of having esophageal cancer: age, weight loss, sex, dysphagia location, and reflux. It is not clear how well this score will perform in primary care settings. (LOE = 1b)

Reference:
Rhatigan E, Tyrmpas I, Murray G, Plevris JN. Scoring system to identify patients at high risk of oesophageal cancer. Br J Surg 2010;97(12):1831-1837.  [PMID:20737538]

Study Design:
Decision rule (validation)

Funding:
Unknown/not stated

Setting:
Outpatient (specialty)

Synopsis:
These authors used a a standardized clinical assessment form to systematically evaluate all patients referred to their dysphagia center. They compared these variables with endoscopic findings to identify clinical factors that were correlated with a finding of esophageal cancer. To develop a prediction model, they used data from 394 patients referred between August 2005 and August 2006. This prediction model, the Edinburgh Dysphagia Score (EDS), was then independently validated on a cohort of 180 patients referred to their center between January 2007 and July 2007. Six factors make up the EDS: age*, weight loss exceeding 3 kg (2 points), sex (male = 0 points, female = -1 point); location of dysphagia sensation in neck (-2 points); presence of reflux (-1 point); symptom duration at least 6 months (-1.5 points). Based on the development cohort, a total score of 3.5 or more identifies the patient as high risk of esophageal cancer (overall accuracy = 83%). In the validation cohort, 26 patients had cancer and the score identified all of them, but also predicted cancer in 100 patients who didn't have it (overall accuracy = 71%). In the validation cohort, the EDS was 100% sensitive and 35% specific (positive likelihood ratio = 1.5; negative likelihood ratio = 0.05). The primary goal of the EDS is to identify patients at low risk of cancer so that invasive diagnostic testing could be deferred. Based on the likelihood ratios, having a score less than 3.5 is very reassuring. However, since having a likelihood ratio near 1 provides no useful information, having a score above 3.5 tells us nothing about the patient's cancer risk. Finally, since the diagnostic accuracy in the validation cohort was much lower than in the development cohort, it is unclear how well this score will perform in primary care settings. *Patients 39 years and younger receive 0 points. For those aged 40 to 49 years, 4 points are assigned, and then 1 additional point is assigned for each additional decade of life.

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