Malignant tumors easily missed by routine physical examination

Malignant tumors detected by routine physical examinations in China only account for about 28% of all clinically diagnosed cases. The top six malignant tumors that are most likely to be missed are pancreatic cancer, ovarian cancer, small cell lung cancer, bladder cancer, early gastric cancer, and prostate cancer. Many people with "completely normal" physical examination reports are diagnosed with late-stage cancer six months to one year later. Most of them cannot escape these categories.

Last year when I was rotating in the gastroenterology department, I managed a patient who was a 56-year-old university teacher. I was particularly impressed. He does a complete set of physical examinations at work every year. In last year's report, the column of the abdominal B-ultrasound only contained a small line of words: "There is a lot of intestinal gas, and the pancreas shows unclear results." He glanced at the home page and concluded that "no obvious abnormalities were found" and stuffed the report directly into the drawer. As a result, I started to have inexplicable back pain at the beginning of this year. I called the orthopedic department for half a month to find out the problem. Finally, I did an enhanced CT and found that there was a 3cm tumor on the pancreas, which had invaded the peripheral nerves. It was late-stage pancreatic cancer. It only took 8 months from diagnosis to death. It's unfair to say that the pancreas is originally an "invisible organ" hiding behind the gastrointestinal tract. The sound waves of conventional B-ultrasound cannot penetrate the barrier of intestinal gas. The missed diagnosis rate of early-stage pancreatic cancer can reach more than 90%. It is really not that the medical examiner is irresponsible.

In fact, it is not essentially a routine physical examination that is useless. It is a "routine package" that most people do, and it is not originally designed for cancer screening. Think about it, a chest X-ray that costs tens of dollars can’t even see ground-glass nodules below 5mm in the lungs, let alone small cell lung cancer that grows quickly and is highly malignant. In many cases, it is like a thief hiding in the bronchus, and the chest X-ray cannot even capture its shadow. By the time you have symptoms of coughing and hemoptysis, metastasis has often occurred. There is also a high incidence of ovarian cancer in women. For routine physical examinations, abdominal B-ultrasounds require holding in the urine. Many people are in a hurry and cannot hold in the urine. The ovaries are hidden deep in the pelvic cavity. Early lesions of one or two centimeters cannot be scanned at all. Many patients only find out that it is ovarian cancer when their stomachs are bloated as if they are pregnant and ascites is detected. At that time, it is basically already in the third stage or above.

At this point, some people may ask: If I draw a few more tubes of blood to check all tumor markers, can I still find them? In fact, there have always been two schools of thought in the academic community: one group believes that the false negatives and false positives of tumor markers are too high. For example, CA125, which is commonly used in ovarian cancer, may be elevated if you have endometriosis, or even when you come to visit your aunt. On the other hand, 20% of patients with advanced ovarian cancer have normal CA125. If we use it as a screening standard, we don’t know how much will be missed or misdiagnosed. ； The other group believes that tumor markers can be used as an auxiliary reference, especially for high-risk groups with family histories. As long as they are combined with imaging examinations, many early signals can still be found, and there is no need to kill them with a stick. I met an aunt before. The CA199 level in the routine physical examination was three times higher than the normal value, and all other items were normal. She didn't take it seriously, but her daughter forced her to do an enhanced MRI. Finally, she was found to have early-stage cholangiocarcinoma. After the operation, it has not recurred five years ago.

When I give advice to relatives and friends, I will first ask about their basic information. For example, if they are over 40 years old, have a family history of gastric cancer, and like to eat pickled products, I will urge them to have a gastroscopy every 1-2 years and not wait for the Helicobacter pylori results of routine physical examinations. My distant cousin tested negative for Helicobacter pylori last year and thought he had no problem with his stomach. However, at the end of the year, he had a black stool and went for a gastroscopy, which revealed early-stage signet ring cell cancer. Fortunately, it was discovered early and most of his stomach was removed and he is now living well. If it had been delayed for another half a year, I really can’t imagine the consequences. There is also bladder cancer that is easily missed. A routine physical examination will detect occult blood in the urine only when the tumor ruptures and bleeds. If there is no ulceration in the early stage, the urinary routine will be completely normal. If you have experienced painless gross hematuria, even just once, don’t think it’s a problem and go for a cystoscopy as soon as possible.

There are also prostate screenings that many men are embarrassed to do. The debate in Europe and the United States is particularly fierce now: one side believes that routine PSA testing for men over 50 years old will lead to overdiagnosis. Many men's prostate cancer develops very slowly and will not have symptoms until they die. If it is detected, they will need surgery and radiotherapy, which will in vain reduce their quality of life.； However, based on domestic data, the other party believes that more than 60% of our domestic prostate cancer patients are diagnosed in the late stage. Many people wait until the pain of bone metastasis becomes unbearable. Therefore, it is recommended that men with a family history of prostate cancer or urinary abnormalities actively communicate with their doctors about whether to add PSA and prostate ultrasound. It is better than waiting until the late stage without treatment.

To be honest, you really don’t need to be anxious because “cancer is missed in routine physical examinations”. You feel that spending thousands on physical examinations every year is an IQ tax. Its original positioning is to check for common diseases and chronic diseases. Cancer screening is a very personalized thing. Don’t blindly follow the trend and buy “cancer prevention packages” worth tens of thousands. First, identify your own high-risk factors and make up for whatever is missing. It is more reliable than anything else. If you are really unsure, it is much better to talk to an oncologist for 10 minutes with the physical examination report than to speculate on your own.