Few things seem more obviously undesirable than symptoms. Burning, aching, itching, leaking: it is hard to see the point of such problems, other than adding to the store of human discomfort. But sometimes symptoms can be helpful. I was clerking in a patient who had been admitted to hospital after coming to A&E as an emergency. Against his greyish-white hospital bedsheet, Mr F was a brilliant shade of yellow. Jaundice can be difficult to see – you may have to look at the whites of the patient’s eyes, and inspect their skin in detail, and once you’ve got involved in close examination you can lose the ability to spot anything unusual unless you step back for a minute.
But Mr F’s jaundice was what medicine calls “frank”. And it had developed, Mr F said, literally overnight – 24 hours earlier, he’d been his usual January hue, “a whiter shade of pale,” according to his wife. The rest of his history was: nothing. He hadn’t been ill, he hadn’t felt unwell, he hadn’t had stomach ache or noticed any change in his bowels. He hadn’t had any symptoms.
When the doctor in A&E felt Mr F’s abdomen, she requested an ultrasound scan; when the radiologist saw the ultrasound scan, they recommended Mr F had an urgent CT scan. No one had talked to him about any of the results yet. Mr F and his wife were anxious; their teenage daughter was in tears. I went to look at the computer. The CT showed a large mass occupying much of the pancreas; it was blocking the common bile duct (which accounted for the jaundice). It was too soon for the scan to have been formally reported, so it was hard to know much more than this.
I came back and told the family what I’d read. I told them that we couldn’t know what the mass actually was until the surgeons had done a biopsy. If you ever see anything abnormal on a scan, you need to test a piece of tissue before you can make a diagnosis. But it was likely to be cancer, yes. I was very sorry.
A recent survey by the National Cancer Intelligence Network reported that 23 per cent of cancers are diagnosed during an emergency admission. The cancer either causes the problem that sends the patient to hospital, or it is found incidentally, in the course of diagnosing something else (X-raying fractures, for example, may reveal cancerous deposits in bone). Emergency cancer diagnoses tend by their nature to be late, which means they’re most commonly of the cancers that start out with few symptoms. The study found that 58 per cent of brain and nervous system cancers, 47 per cent of pancreatic cancers and 38 per cent of lung cancers were first discovered in an emergency setting. Skin, breast and mouth cancers, by contrast, were usually diagnosed elsewhere – via the GP or through referral to specialist clinics. Being able to see and feel things, as you can with skin and breasts, is a major advantage when it comes to detecting cancers early. As is having symptoms.
When I came back a little later Mr F was scouring his year for clues. He’d developed a backache in October that wouldn’t go away. He’d had painkillers from his GP, and a course of physiotherapy. He’d lost some weight – his wife had just bought him a new pair of trousers. With jaundice, and a scan, everything became a symptom. But it was hard to say how he could have known. Some diseases remain frustratingly difficult to diagnose early.
Sophie Harrison is a hospital doctor in South Yorkshire. Some details have been changed in the interest of confidentiality