1 September 2020

The Back Page: Do GP ‘gut feelings’ help catch cancer?

Cancer Clinical The Back Page

When GPs tune into their “gut feelings” they are often picking up on a complex mix of non-verbal cues and subtle symptoms that can predict cancer in well-known patients, researchers from the University of Oxford say.

However, GPs don’t always record these gut feelings in referral letters for fear that specialists will question their diagnostic value, even though NICE guidelines on suspected cancer now state that GPs should trust their own and their patients’ intuition, the researchers said.

The systematic review and meta-analysis was led by Dr Brian Nicholson, a GP and academic at the University of Oxford, and published in the British Journal of General Practice last week.

All 12 studies included in the review found GP gut feelings had diagnostic utility in cancer diagnosis.

In one Danish study, for instance, the positive predictive value of GPs’ gut feelings for cancer or other serious disease was 9.8 within two months of the initial consultation, and 16.4 up to six months after the initial consultation.

“GPs conceptualised gut feeling as an uneasy feeling, typically triggered by a rapid summing up of multiple verbal and non-verbal cues,” the researchers said.

“In adults, non-verbal cues included inconsistencies with what was considered the patients ‘normal’ physical appearance or usual consulting frequency or behaviour, including the way patients sat or spoke during the consultation.”

One study included in the review (Bankhead, 2005) reported, “Certainly if you know them well and if you see a dramatic change as they’re walking through the door, either weight loss or, there’s a colour about them often, they have a change in colour, it’s not a natural just anaemia, it’s just a magnolia colour often … It’s just a gut instinct … I think you just have to know the patient.”

This shows the importance of continuity of care in cancer diagnosis as “understanding of the patient’s ‘normal’ must be built over time”, the researchers said.

“Within fragmented and overstretched primary care systems, there is a danger that the relational and empathic aspects of the GP-patient relationship, which are repeatedly cited as contributors to gut feeling, could be damaged,” they said.

GPs often don’t record their intuitions about a patient in the context of cancer diagnosis, which itself is a barrier to using them in clinical practice, the authors said.

“[Some GPs] recounted instances when referrals made because of a gut feeling had been rejected by specialist colleagues due to a perceived lack of clinical evidence,” the authors said.

“These patients were later diagnosed with cancer, suggesting that earlier diagnosis may have been possible. GPs also reported leaving their gut feelings out of referral decisions due to their own perception that they were only based on a feeling and ‘nothing big’.”

Overall, it seems like spotting cancer is about thinking fast and slow – using intuition as well as analytical methods like risk calculators and clinical investigations. And cancer is easiest to catch if patients keep going to see the same doctor… which will be of zero surprise to most Australian GPs.

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