Dv. Schapira et Ar. Jarrett, THE NEED TO CONSIDER SURVIVAL, OUTCOME, AND EXPENSE WHEN EVALUATING AND TREATING PATIENTS WITH UNKNOWN PRIMARY-CARCINOMA, Archives of internal medicine, 155(19), 1995, pp. 2050-2054
Background: Patients who present with unknown primary carcinomas repre
sent 10% to 15% of the patients with cancer who present to medical cen
ters. Despite data in the literature indicating minimal success in det
ermining the location of primary carcinomas, these patients continue t
o be evaluated exhaustively. Additionally, identification of the locat
ion of primary carcinomas does not often affect treatment. Clinical tr
eatment and prognosis are only affected if a reevaluation of the patho
logic findings yields a potentially curative diagnosis of an undiffere
ntiated lymphoma, germ cell tumor, or a hormonally sensitive carcinoma
. Methods: Tumor registry files from January 1, 1990, through December
31, 1992, were retrospectively retrieved to identify adult patients w
ho presented with metastasis of an unknown primary site at the H. Lee
Moffitt Cancer Center and Research Institute, a 162-bed tertiary care
cancer center specialty hospital affiliated with the University of Sou
th Florida College of Medicine, Tampa. Medical records were reviewed f
or age, sex, histologic findings of previous malignant growth, types a
nd duration of symptoms, and mode of presentation. Fifty-six of the 19
9 patients were included in the study; 31 were men (55.4%) and 25 were
women (44.6%), with ages ranging from 33 to 83 years. Diagnostic eval
uations were reviewed and included data from procedures conducted at b
oth the H. Lee Moffitt Cancer Center and at outside facilities. Diagno
stic studies performed included barium swallow; intravenous pyelogram;
mammogram; abdominal ultrasound; chest x-ray film; bone scan; magneti
c resonance imaging; computed tomography of the head, chest, abdomen,
and pelvis; laparotomy; bronchoscopy; gastroscopy; and colonoscopy. In
formation for the diagnostic test procedures was taken from the point
of initial patient contact until the determination of metastatic disea
se. Results: The primary cancer site was found in four (7.1%) of the 5
6 cases in the study and could not be classified as curable by systemi
c means. The average cost of diagnosis was $17 971, with 19.6% of the
patients surviving for more than 1 year. The mean survival period was
8.1 months. A total of 410 tests were performed with only four tests c
orrectly identifying the location of the primary tumor. Conclusions: O
nce a potentially curable malignancy has been excluded, there is littl
e justification to support extensive diagnostic evaluation of the pati
ent. Substantial costs are incurred and survival is often not signific
antly affected. it was estimated that 1.2 million new cancer cases wou
ld have occurred during 1994, with approximately 10% of these patients
presenting with cancer of unknown primary origin. Based on cost asses
sments, investigation of these patients would exceed $1.5 billion. Thi
s clinical scenario is one where attention to outcome, clinical manage
ment, and expense should be carefully considered.