Cancer as a Cause of Back Pain:
Frequency, Clinical Presentation, and Diagnostic Strategies
RICHARD A. DEYO, MD, MPH, ANDREW K. DIEHL, MD, MSc
Back p a i n / s very common. Rarely, it m a y b e the first m a n / -
festation of c a n c e r . Although m a n y a d v o c a t e s e l e c t / v e u s e
of l a b o r a t o r y a n d x-ray tests for b a c k p a i n patients, the
early detection of c a n c e r m a y b e a n / m p o r t a n t r e a s o n to
obtain such tests. To develop a diagnost/c a p p r o a c h that
wou/d identify malignancies wh//e r e m a i n i n g pars/mon/-
ous, the authors e v a l u a t e d 1,975 walk-in p a t i e n t s w/th a
chief complaint of b a c k pain. Th/rteen p a t / e n t s (0.66%)
p r o v e d to h a v e underlying c a n c e r . Findings s/gn/ficant/y
associated with u n d e r l y i n g c a n c e r / p < 0.05) w e r e : a g e -> 50
years, prev/ous h/story of cancer, durat/on of p a i n > I
month, §a//ure t o / r e p r o v e w/th conservat/ve therapy, ele-
v a t e d erFthrocyte sed/mentation r a t e (ESR), a n d a n e m / a .
C o m b i n i n g historical features and ESR results led to an al-
gorithm that wou/d h a v e / / m / t e d x-ray ut///zation to just 22%
of subjects wh//e r e c o m m e n d i n g a n x - r a y for e v e r y c a n c e r
patient. It wou/d further suggest which p a t i e n t s w/th n e g a -
tive x-ray findings require /urther work-up. K e y words:
c a n c e r ; b a c k p a i n ; c/in/ca/strategies;- x-ray ut'~fzat/on. J
GEN INTERN MEn 1988;3:230-238.
BACKPAINis the second leading symptom prompting
patients to visit the doctor.~ Among outpatients, it is
the symptom most often associated with x-ray u s e /
Although serious underlying d i s e a s e is rare in pa-
tients who h a v e b a c k complaints, the detection of
m a l i g n a n c y or infection is a major goal of the diag-
nostic evaluation, s Metastatic cancer, the most com-
mon of these serious underlying diseases, 4 m a y
manifest few other signs of its presence.
Although cancer-related back pain (usually due
to spinal metastases) suggests that a n y underlying
tumor is a l r e a d y a d v a n c e d , there is probably thera-
peutic value in prompt diagnosis. Because c a n c e r
m a n d a t e s specific therapy, we m a y presume that
prompt detection will l e a d to earlier relief of suffer-
ing. Among patients destined to develop spinal cord
compression, back pain almost a l w a y s precedes
neurologic deficits,S a n d timely detection of epidural
Received from the Division of General Internal Medicine, Depart-
ment of Medicine, The University of Texas Health ScienceCenter at San
Antonio, San Antonio, Texas, and the Seattle Veterans Administration
Medical Center, Seattle, Washington.
Supported in part by a grant from the Robert Wood Johnson Foun-
dation, Princeton, New Jersey. and by the Northwest Health Services
Researchand Development Field Program, Seattle V.A. Medical Center.
The opinions, conclusionsand proposalsin the text are those of the
authors, and do not necessarilyrepresent the views of the Robert Wood
Johnson Foundation.
Presented in part at the tenth annual meeting of the Society for
Research and Education in Primary Care Internal Medicine, San Diego,
April 30, 1987.
Address correspondenceand reprint requests to Dr. Deyo: Health
Services Researchand Development, Seattle V.A. Medical Center, 1660
South Columbian Way, Seattle, WA 98108.
~-30
cord compression m a y prevent substantial dis-
ability.
While cancers are a heterogeneous group of
disorders, it is r e a s o n a b l e to consider them together
in evaluating low b a c k pain. For patients with this
chief complaint, various forms of c a n c e r h a v e re-
sulted in similar clinical presentations. The diagnos-
tic methods for detecting spinal m e t a s t a s e s (e.g.,
x-ray, bone scan), the complications of spinal me-
tastases, a n d the therapeutic options (steroids, radi-
ation, surgery) a r e similar regardless of the primary
site. Finally, since all forms of c a n c e r a r e probably
the underlying c a u s e of the pain in less t h a n 1% of
patients with b a c k pain, 4 the initial clinical task is to
"rule in" or "rule out" malignancy, rather t h a n to
comprehensively assess e v e r y o r g a n from which
metastases might arise.
However, there is persistent controversy re-
g a r d i n g the proper initial evaluation of patients with
back pain. Lumbar spine films are frequently ob-
tained, but h a v e a low yield, m a y be misleading,
a n d result in large a g g r e g a t e costs? Some ob-
servers suggest that selective use of diagnostic tests
(especially radiography) could reduce costs without
missing serious underlying diseases, e'° Thus, we
sought criteria by which certain patients could be
s p a r e d x-ray examinations, while remaining as-
sured that underlying malignancies would not go
undiagnosed.
For x-ray ordering criteria, we considered his-
torical, physical, a n d laboratory d a t a that h a v e
b e e n found to be associated with underlying
c a n c e r ? -~s We h a d previously tested the screening
value of several items of clinical d a t a a m o n g early
enrollees in this study (n = 621). Is Four patients h a d
cancer, all of whom h a d clinical findings to suggest
the n e e d for x-rays. We h o p e d to confirm the success
of these clinical findings as screening tools a n d to
determine whether inexpensive laboratory tests
could improve the specificity of the clinical
evaluation.
We therefore prospectively collected d a t a in a
primary c a r e setting from a large series of patients
complaining of back pain. We sought to estimate the
prevalence of c a n c e r a s a n underlying c a u s e of
b a c k pain; to observe how frequently it is clinically
unsuspected; to determine which items of the history
a n d physical examination a r e most useful in its de-
tection; a n d to examine the performances of several
potential "screening" tests for c a n c e r a m o n g pa-
 JOURNALOFGENERALINTERNALMEDICINE,Volume 3
fients with low b a c k pain. W e h o p e d the resulting
d a t a would suggest a n e c o n o m i c a l algorithm for dis-
tinguishing those patients w h o h a d u n d e r l y i n g
c a n c e r s from the l a r g e majority with m e c h a n i c a l
b a c k pain.
METHODS
Patients and Data Collection
All patients sought t r e a t m e n t b e t w e e n March
1982 a n d S e p t e m b e r 1984 in the walk-in clinic of a
public hospital. This clinic is a source of p r i m a r y c a r e
for indigent p e r s o n s in a county of a p p r o x i m a t e l y
o n e million population. Virtually all patients a r e self-
referred. In e a c h case, b a c k p a i n w a s part of the
chief complaint. Patients w e r e e x a m i n e d b y houses-
taft physicians from the Departments of Medicine,
Family Practice, a n d Surgery. A s t a n d a r d coding
form, a d a p t e d from previous studies of b a c k pain, 9"14
w a s u s e d to r e c o r d 65 items of history a n d physical
e x a m i n a t i o n at the index visit. A listing of study sub-
jects w a s m a i n t a i n e d so that the s a m e patient w a s
not e n t e r e d twice ff two or m o r e visits w e r e m a d e .
L a b o r a t o r y a n d r a d i o g r a p h i c testing w e r e per-
formed at the discretion of the e x a m i n i n g physician.
O n the basis of prior literature, it w a s r e c o m m e n d e d
to houseofficers that a n e r y t h r o c y t e sedimentation
r a t e (ESR) a n d a complete blood count (CBC) b e
o b t a i n e d for most patients, but this w a s not a n en-
forced policy. A strictly uniform testing a p p r o a c h
w a s not implemented b e c a u s e 1) w e did not feel
there w a s sufficient basis in the literature for includ-
ing or excluding certain tests for all patients a s a
routine procedure, 2) s o m e patients h a d relative
contraindications to x - r a y testing (e.g., w o m e n with-
out contraception, p e r s o n s recently x-rayed), a n d 3)
w e could not provide uniform x - r a y a n d l a b o r a t o r y
testing a s r e s e a r c h p r o c e d u r e s for a l a r g e n u m b e r of
patients. B e c a u s e all patients did not r e c e i v e all
tests, certain a n a l y s e s a r e limited to subsets of p a -
tients for w h o m particular tests w e r e obtained.
Test results w e r e r e c o r d e d after the visit b y
s e a r c h i n g computerized l a b o r a t o r y a n d r a d i o l o g y
files. B e c a u s e tests might h a v e b e e n d o n e shortly
before or after the index visit, w e a c c e p t e d ESR a n d
CBC results o b t a i n e d within 30 d a y s of the index
visit. All tests w e r e d o n e in the routine clinical labo-
ratory, using t h e W e s t e r g r e n m e t h o d for ESR
determination.
We a c c e p t e d x - r a y results o b t a i n e d within six
months of the index visit (before or after), although
m o r e t h a n 80% of x-rays w e r e d o n e within a w e e k of
the index visit. A m o n g the 13 patients w h o h a d un-
derlying c a n c e r s , two did not h a v e spinal x-rays, six
h a d x-rays within a w e e k of the index visit, a n d five
o b t a i n e d x-rays five w e e k s to three months after the
index visit. Of the five w h o s e x-rays w e r e d e l a y e d ,
(May/Jun), 1988 231
two h a d no systemic sign or s y m p t o m at the index
visit, a n d three h a d k n o w n c a n c e r d i a g n o s e s (but
metastasis w a s initially c o n s i d e r e d unlikely). The ra-
diologist's official report w a s u s e d for all x - r a y re-
sults. Radiologists h a d a v a i l a b l e clinical d a t a en-
t e r e d on the x - r a y request form, which could h a v e
b i a s e d interpretation. However, c a n c e r w a s not sus-
p e c t e d for o v e r half the patients w h o h a d it, m a k i n g it
unlikely that biasing information w a s p r o v i d e d in
t h e s e cases. Our m e t h o d of identifying c a n c e r p a -
tients w a s i n d e p e n d e n t of x - r a y findings (see below).
Identification of Underlying Cancer
To identify patients w h o p r o v e d to h a v e a n un-
derlying m a l i g n a n c y , w e s e a r c h e d for e a c h n a m e in
the institutional tumor registry at least six months
after the index visit. We r e a s o n e d that this w a s suffi-
cient time for occult metastatic c a n c e r to b e c o m e
a p p a r e n t a n d to b e d i a g n o s e d . The registry in-
cluded e v e r y patient with a histologic diagnosis of
c a n c e r m a d e in our hospital system, r e g a r d l e s s of
the actual site of care. While this m e t h o d might fail to
identify c a n c e r patients w h o sought c a r e elsewhere,
it is likely that most patients sought follow-up for a
particular illness at the s a m e facility. A m o n g a sub-
set of study subjects who participated in a clinical
trial, 75% d e s c r i b e d our facility a s their only source of
care. This clinic population is l a r g e l y indigent, with
m a n y patients h a v i n g unstable housing a n d / o r no
telephone, so w e b e l i e v e d this m e t h o d of follow-up
would b e m o r e complete t h a n a t t e m p t e d t e l e p h o n e
contact.
W h e n a patient w a s identified in the tumor reg-
istry, w e m a d e note of the d a t e of c a n c e r diagnosis,
tumor type, a n d stage. O n the basis of chronology,
tumor location, stage, a n d imaging procedures, a
judgment w a s m a d e r e g a r d i n g the relationship be-
t w e e n the tumor a n d b a c k symptoms. For example,
b a s a l cell c a r c i n o m a s of the skin a n d non-invasive
c a n c e r s of the uterine cervix (often d i a g n o s e d a n d
t r e a t e d y e a r s b e f o r e the i n d e x visit) w e r e j u d g e d
u n r e l a t e d to b a c k p a i n w h e n there w a s no other
clinical e v i d e n c e of r e c u r r e n c e .
Analysis
We a n a l y z e d those clinical findings from the
s t a n d a r d coding form that others h a v e s u g g e s t e d
a r e a s s o c i a t e d with m a l i g n a n c y . 9-1s Sensitivities
a n d specificities of various findings for the diagnosis
of c a n c e r w e r e c a l c u l a t e d in the usual manner.IS For
e a c h finding, w e then c a l c u l a t e d the "likelihood
ratio," defined a s the p r e v a l e n c e of a given finding
in patients with underlying c a n c e r divided b y the
p r e v a l e n c e of the finding in patients without c a n c e r .
This is equivalent to test sensitivity divided b y 1 --
specificity. Likelihood ratios g r e a t e r t h a n o n e indi-
 TABLE 1 t~
r~
Clinical and Demographic Features of 13 Patients with Cancer as a Cause of Back Pain

Cancer Known Signs or

Age Tumor Prior to Back Symptoms of Cancer Considered HCT ESR Spine X-ray
(Years), Sex Diagnosis Symptoms Systemic Illness at Index Visit? (%) (mm/hr) Results

Patient 1 26, F Lymphoma No Failure to improve with conservative No 40.0 29 Normal

therapy

Patient 2 62, M Adenocarcinoma, unknown No None No 38.0 53 Lytic lesions

primary

Patient 3 52, M Prostatic cancer No None No 29.8* 45* Blastic lesions

Patient 4 56, F Retroperitoneal liposarcoma No Weight loss No 31.1 133 SpondyloUsthesis

Patient 5 51, M Squamous carcinoma, lung No Weight loss Yes 43.9* Not done Compression fractures

Patient 6 57, F Renal cell carcinoma No Gross hematuria No 40.8 Not done Not done

Patient 7 65, F Multiple myeloma No None No 29.2 58 Compression fractures =>

Patient 8 36, F Mucinous adenocarcinoma No Failure to improve with conservative No 43.0 20 Not done
(? gallbladder) therapy; abdominal pain

Patient 9 55, F Lymphoma No Lymphadenopathy Yes 40.8 17 Lytic lesions, compression

fractures

Patient 10 34, F Breast cancer Yes None Yes 36.7 63 Blastic lesions

Patient 11 71, M Squamous carcinoma, lung Yes Moderate weight loss: 9 pounds/3 Yes 37.3 125 Osteopenia, degenerativejoint
mo disease

Patient 12 73, M Prostatic cancer Yes None Yes 39.2 Not done Lyric and blastic lesions,
compression fractures

Patient 13 51, F Breast cancer Yes None Yes 48.8 6 Lyric and blastic lesions

*Tests done more than one month after the index visit; not included in calculations of test performance.
 JOURNALOFGENERALINTERNALMEDICINE.Volume 3
cate that the finding is more common in patients with
c a n c e r t h a n in those without. ~s For continuous labo-
ratory d a t a (ESR, hematocrit, white blood cell count),
receiver operating characteristic (ROC) curves were
also developed. These curves plot sensitivity (true-
positive rate) versus 1 - specificity (false-positive
rate) for e a c h of several cutoff points used to define a
"positive" test. The a r e a s under these curves indi-
cate the abilities of the tests to discriminate patients
with c a n c e r from those without. ~s
Finally, we selected those findings with the
highest likelihood ratios to develop a rudimentary
algorithm for diagnostic evaluation, seeking a n ap-
proach which would h a v e 100% sensitivity for
cancer, but minimize laboratory or x-ray use. Dis-
criminant analysis w a s used to determine which
clinical a n d laboratory findings h a d the best inde-
p e n d e n t abilities to distinguish b e t w e e n patients
with a n d without cancer. In developing a n algo-
rithm, however, we used variables not in the discrim-
inant model to a c h i e v e 100% sensitivity. The propor-
tions of patients with c a n c e r in clinically defined
subgroups were estimated, a n d 95% confidence in-
tervals were calculated. ~e, 17
RESULTS
Study Population
There were 1,975 patients, r a n g i n g in a g e from
15 to 86 y e a r s (mean, 39.5 years, SD = 15.4). Sixty-
two per cent were women. M a n y were seeking med-
ical c a r e for back pain for the first time (54%), a n d
76% h a d h a d pain for less t h a n three months. Only
3% h a d a history of prior b a c k surgery. Maximal p a i n
w a s in the low back for 84% a n d in the upper b a c k for
16% (neck pain w a s excluded). In this clinic, most
patients a r e indigent a n d poorly educated, a n d a
majority are Mexican-American, but specific d a t a
on income, education, a n d ethnicity were not col-
lected for the entire sample. For a subset of 833 sub-
jects who h a d x-rays of the lumbar spine, w e deter-
m/ned ethn/city from the hospital's computerized
d a t a file. In this subset, 73.6% were Mexican-Ameri-
can, 13.5% were white (non-Hispanic), a n d 12.9%
were black.
Patients with Cancer
Of the 1,975 study subjects, 38 were found in the
tumor registry. However, only 13 h a d tumors that
were probable causes of b a c k pain at the index visit.
Of the 25 whose cancers were j u d g e d unrelated to
current b a c k symptoms, 11 h a d cervical c a n c e r s
(diagnosed a n a v e r a g e of eight y e a r s previously);
four h a d endometrial c a n c e r s (diagnosed a n aver-
a g e of six y e a r s earlier); two h a d b a s a l cell carci-
n o m a s on the face; two h a d o v a r i a n cancers; two
(May/Jun). 1988 233
h a d breast cancers; a n d one e a c h h a d a diagnosis
of parotid mucoepiderrnoid cancer, leiomyosar-
c o m a of the duodenum, m e l a n o m a of a finger, a n d
lung cancer. In all but two cases, the diagnosis h a d
b e e n m a d e before the index visit, usually m a n y
y e a r s previously. In e a c h c a s e there w a s no evi-
d e n c e of recurrence for at least six months after the
index visit. The two patients whose c a n c e r s were
d i a g n o s e d after the index visit h a d breast c a n c e r
a n d lung cancer, discovered eight months a n d one
month after the index visit, respectively. In e a c h
case, bone scans performed after the diagnosis w a s
m a d e were negative, x-rays of the spine s h o w e d
d e g e n e r a t i v e c h a n g e s , a n d other e v i d e n c e of me-
tastases w a s a b s e n t (except for a positive axillary
n o d e in the patient with breast cancer).
Thus, underlying c a n c e r as a c a u s e of b a c k
pain w a s found in only 0.66% (13/1,975) of patients in
this primary c a r e practice. Table 1 shows demo-
graphic a n d clinical features of these 13 patients.
Ten were more t h a n 50 y e a r s old, four h a d a k n o w n
c a n c e r diagnosis at the time of the index visit, a n d in
only six c a s e s w a s m a l i g n a n c y explicitly considered
by the examining physician.
Among the nine patients with no prior c a n c e r
history, there were often d e l a y s from the index visit
tO the time of c a n c e r diagnosis. The m e a n w a s 51
days, with three patients h a v i n g d e l a y s of approxi-
mately three months.
Clinical Findings in Patients with
and Without Cancer
Table 2 compares the prevalences of certain
clinical findings a m o n g the 13 c a n c e r patients a n d
the roughly 1,900 patients without cancer. Findings
that w e r e significantly more common in patients
with c a n c e r included a g e of 50 y e a r s or more; hav-
ing sought medical care during the past month
(without relief); duration of pain longer t h a n one
month; a n d a prior history of cancer. While a third of
patients who h a d underlying c a n c e r s h a d a k n o w n
prior malignancy, only 2% of patients without under-
lying c a n c e r h a d this history. This resulted in the
highest likelihood ratio (14.7) for a n y historical or
physical examination item. Although the associa-
tions w e r e not statistically significant, u n e x p l a i n e d
weight loss a n d the a b s e n c e of recent b a c k injury
w e r e also associated with cancer, the former h a v i n g
a likelihood ratio greater t h a n 2.0. Failure of b e d rest
to relieve the pain w a s uniform a m o n g the c a n c e r
patients who reported trying this tre~hiient, but over
half the n o n - c a n c e r patients also reported failure of
bedrest to relieve the pain.
Table 2 also provides d a t a for physical exami-
nation findings. None of the physical signs were sig-
nificantly associated with underlying cancer. Physi-
234 Deyo, Diehl, CANCERAND BACK PAIN

TABLE 2
Clinical Findings among Patients with and Without Cancer as a Cause of Back Pain

Prevalence in Prevalence in
Patients with Patients Without
Underlying Cancer. Cancer, i.e.,
i.e., Sensitivity 1 -- Specificity Likelihood Significance of
(n*) (n*) Ratio Difference

History
Age -> 50 years 0.77 (13) 0.29 ( 1,939) 2.7 p = 0.0005
Unexplained weight Ioss~ O. 15 (13) 0.06 (1,938) 2.7 NS$
Previous history of cancer 0.31 (13) 0,02 (1,936) 14.7 p < 0.001
Sought medical care during past month, not improving 0.31 (13) O. 10 (1,962) 3.0 p = 0.05
Tried bedrest, but no relief 1.00 (4) 0,54 ( 9 3 9 ) 1.8 NS
Insidious onset 0,61 (13) 0.58 (1,935) 1.1 NS
Duration of this episode > 1 month 0.50 (12) O. 19 ( 1,890) 2,6 p = 0.02
Recent back injury (included lifting, fall, blow) 0 (13) O. 18 (1,952) 0 NS
Thoracic pain (vs. lumbar) O. 17 (12) O. 16 (1,920) 1,1 NS
Physical findings
Appears to be in severe pain 0.23 (13) 0.15 (1,869) 1.6 NS
Muscle spasm O. 15 (13) 0.34 (1,858) 0.5 NS
Spine tenderness O. 15 (13) 0.40 ( 1,850) 0.4 NS
Neuromotor deficit 0 (12) 0.09 (1,774) 0 NS
Fever (temperature -> IO0°F) 0 (13) 0.02 (1,946) 0 NS

*Exact numbers vary due to missing data or responses contingent on some prior action.
?Unexplained weight loss (by history) of more than 10 pounds in six months.
SNS = not significant, p > O. 1.

cians judged patients to be in severe pain somewhat
more frequently in the cancer group, but the likeli-
hood ratio w a s only 1.6. Muscle spasm and spine
tenderness w e r e actually somewhat less common in
patients with cancer. At the index visit, none of the
cancer patients had neuromotor deficits, although at
least two developed paraparesis later in the course
of the disease. Thus, neurologic deficit appeared to
be a late finding a m o n g the cancer patients. Neuro-
motor deficits w e r e also infrequent (9%) a m o n g the
non-cancer patients. Both patients w h o had pros-
tatic cancer had rectal examinations performed at
the index visit, but the results w e r e said to be normal.
Stool testing for occult blood (a single test) w a s per-
formed for nine of the 13 cancer patients and w a s
negative for all of them.
Laboratory Findings
Since laboratory tests w e r e not ordered uni-
formly, there w e r e fewer c a s e s available for assess-
ing their performance. While selection of patients for

TABLE 3
Laboratory Findings among Patients with and Without Cancer as a Cause of Back Pain

Prevalence of Test Prevalence of Test

Result in Patients Result in Patients
with Underlying Cancer. Without Cancer,
i.e., Sensitivity i.e.. 1 -- Specificity Likelihood Significance of
(n*) (n*) Ratio Difference

Erythrocyte sedimentation rate

>20 mm/hr 0.78 ( 9 ) 0.33 (999) 2.4 p = 0.01
->50 m m / h r 0.56 ( 9 ) 0.03 (999) 19.2 p <0.0001
-- 100 m m / h r 0.22 ( 9 ) 0.004 (999) 55.5 p <0.0001
Anemiat 0.54 (11) 0,14 (1,089) 4.0 p = 0.0006
Hematocrit < 3 0 % 0.09 (11) 0,006 (1,089) 15.2 p = O. 13
WBC ->- 12,000/cu mm 0.22 ( 9 ) 0.06 (528) 3.5 p = 0,21
X-ray
Lyric or blastic lesion 0.60 (1 O) 0,005 (823) 120.0 p < 0,0001
Compression fracture 0.20 ( I 0 ) 0.043 (823) 4.6 p = 0.10
Either compression fracture or ]ytic/blastic lesion 0.70 ( I 0 ) 0.047 (823) I4.9 p <0.0001

*Number of subjects varies because the test was not performed in all patients.
tAnemia was defined as a hematocrit less than 40% for men and less than 38% for women, the current standards in our clinical laboratory,
 JOURNALOFGENERALINTERNALMEDICINE,Volume 3 (May/Jun), 1 9 8 8
laboratory testing w a s probably b i a s e d by clinical
judgment, likelihood ratios h a v e the desirable prop-
erty of being quite stable in the face of c h a n g e s in
disease prevalence, is
We c o m p a r e d clinical a n d demographic fea-
tures of those receiving a n d not receiving a n ESR, a
CBC, a n d a spinal x-ray to determine how the tested
subgroups differed from the remaining patients. The
patients who received a n ESR were older t h a n those
who did not (40.8 y e a r s vs. 38.1 years), a n d h a d
s o m e w h a t greater spinal flexibility. However, the
two groups did not differ significantly with r e g a r d to
sex, spinal tenderness, weight loss, history of
cancer, neurologic deficits, failure of previous ther-
apy, duration of pain, or number of prior episodes of
pain. Those receiving a CBC differed from those
who did not in h a v i n g higher proportions with spinal
tenderness (44.8% vs. 37.3%) a n d fever (3.0% vs.
1.2%), a n d also in h a v i n g slightly better spinal flex-
ion. Those who received x-rays differed from those
who did not in sex distribution (40.6% m e n vs. 35.7%)
a n d in m e a n a g e (44 vs. 36 years). Patients who
received x-rays were more often j u d g e d to h a v e se-
vere pain, muscle spasm, spinal tenderness, or neu-
rologic deficits, h a d more often failed earlier ther-
apy, a n d h a d slightly worse spinal flexion a n d
straight-leg raising.
Table 3 shows the performances of the ESR, he-
matocrit (HCT), white blood cell count (WBC), a n d
x-ray findings as "screening tests" for c a n c e r in pa-
tients with back pain. None of the tests w a s ex-
tremely sensitive, but the likelihood ratios for certain
test results were substantially higher t h a n those for
history a n d physical findings.
The ESR w a s the most sensitive blood test, a n d
its specificity e x c e e d e d those of the HCT a n d WBC at
comparable levels of sensitivity. This is shown in
Figure 1, which illustrates ROC curves for the ESR,
HCT, a n d WBC. The ESR curve enclosed the largest
area, a n d thus best distinguished patients with
c a n c e r from those without. The m e a n ESR for pa-
tients with underlying cancers w a s 56 mm/hr, as
opposed to a m e a n of 16 m m / h r for patients without
underlying cancer. The use of a g e - a n d sex-specific
norms for the ESR is did not improve the likelihood
ratio over a n arbitrary cut-off of 20 m m / h o u r .
Any d e g r e e of a n e m i a w a s a moderately useful
discriminator b e t w e e n patients with a n d without
cancer. More severe a n e m i a (HCT < 30%) w a s asso-
ciated with a greater likelihood ratio, but w a s
present in only one c a n c e r patient, for a sensitivity of
9%. An elevated WBC (-> 12,000/cu mm) w a s less
useful as a diagnostic test, a n d altering the "cut-off"
value did not improve its performance. The ROC
curve for WBC in Figure 1 falls almost on the diago-
nal line, indicating no ability to discriminate c a n c e r
patients from n o n - c a n c e r patients.
~.35
,0
(>
-=15) (~-_-'Cm'C (?.6K~//
0.8 - (<43)
E VI w=c//
o--
(l]
(/3 0.4 I /C_J
0.2 ~ (>_914)
0.0 .~ I L I ~ q
0 0.2 0.4 0.6 0.8 1
I - Specificify
FIGURE 1. Receiver operating characteristic (ROC) curves for the
erythrocyte sedimentation rate (ESR), hematocrit (HCT), and white blood
cell count (WBC) as tests for detecting cancer among patients with low
back pain. Each point on the curves represents test performance using a
particular "cut-off" value to define a positive test. These "cut-offs" are
indicated in parentheses beside most data points. The curve enclosing the
largest area (ESR) has the best ability to discriminate patients with under-
lying cancer from those without. The diagonal line represents a test with
no ability to discriminate (the false-positive rate equals the true-positive
rate for any test result),
As expected, the x-ray finding of lytic or blastic
lesions w a s a n excellent discriminator b e t w e e n pa-
tients with a n d without underlying cancer, though
some false negatives a n d rare false positives did
occur. Two c a n c e r patients h a d compression frac-
tures without lytic or blastic lesions. It seems likely
that these were truly pathologic fractures, since they
occurred in a patient with multiple myeloma, a n d in
the thoracic spine of a patient with lung cancer.
Since compression fractures were relatively com-
mon a m o n g patients without cancer, the discrimina-
tory value of this finding w a s much less t h a n that of
lytic or blastic lesions. The greatest sensitivity for
x-ray (70%) resulted b y counting either compression
fractures or lytic/blastic lesions as positive findings,
with a corresponding specificity of 95%.
Multivariate Analysis
We used stepwise discriminant analysis to de-
termine which of the findings in Tables 2 a n d 3 (other
t h a n x-ray results) h a d the greatest i n d e p e n d e n t
ability to distinguish b e t w e e n patients with a n d
without underlying cancer. Such a discriminant rule
might help to identify the small number of subjects
with a sufficiently high probability of c a n c e r that x-
rays should be performed, while excluding from ra-
d i o g r a p h y those subjects with a low probability of
cancer. This a n a l y s i s w a s first performed using pa-
236 Deyo, Diehl,
tients with complete clinical d a t a who also received
a n ESR (n = 929). The only findings that entered the
discriminant model were a history of prior c a n c e r
a n d the ESR result (both p<0.0001). In a n analysis
including CBC results (n = 408 cases with complete
data), neither the WBC nor the HCT entered the
stepwise analysis. In the analysis including ESR as
the only laboratory test, 97% of patients were cor-
rectly classified by the discriminant rule, using the
actual prevalence of c a n c e r in the study sample as
the prior probability. While a history of c a n c e r a n d
the ESR alone might be efficient at classifying pa-
tients, the discriminant rule misclassified six c a n c e r
patients as non-cancer patients. Thus, we sought a
b r o a d e r group of findings that would be more sensi-
tive for early evaluation, e v e n at the e x p e n s e of
specificity. Such a rule might insure that all patients
with c a n c e r received x-rays, while still excluding a
substantial number of subjects for w h o m c a n c e r w a s
extremely unlikely.
Diagnostic Strategies
From the d a t a in Table 2, w e selected the clini-
cal findings with the highest likelihood ratios for
cancer. In this study, every patient with c a n c e r h a d
at least one of the four clinical findings with the
highest likelihood ratios: a g e greater t h a n 50 years,
history of cancer, unexplained weight loss, or failure
to improve with conservative therapy. Thus, if fur-
ther diagnostic tests h a d b e e n limited only to pa-
tients with these clinical findings, no patient who h a d
c a n c e r would h a v e b e e n missed. This strategy alone
would result in substantial savings over uniform ra-
diography a n d laboratory testing for all patients
with low back pain.
A more economical a p p r o a c h would be possi-
ble if patients were divided into three subgroups,
b a s e d on clinical findings. "High-risk" patients a r e
those with a prior history of cancer. In our study, 9%
of such patients proved to h a v e c a n c e r causing their
back pain (4/45). For these, a n immediate ESR a n d
x-ray would be warranted, a n d a positive result on
either would m a n d a t e further work-up. "Low-risk"
patients a r e those u n d e r a g e 50 with no history of
cancer, no weight loss or other sign of systemic ill-
ness, a n d no history of failure to improve with con-
servative therapy. In our study, there were no
cancers a m o n g 1,170 such patients (upper 95%
CI = 0.3%). For these, a strategy of no laboratory or
x-ray tests might be appropriate unless a n indica-
tion arose during follow-up (e.g., failure to improve).
An "intermediate-risk" group includes patients
over a g e 50, those with a failure of conservative ther-
apy, a n d those with unexplained weight losses or
other signs of systemic illness ( l y m p h a d e n o p a t h y
a n d hematuria in our study). In this group, 1.2% of
CANCERAND BACK PAIN
subjects h a d c a n c e r (95% CI -- 0.4%, 2.0%). For this
group, the ESR m a y be particularly useful in raising
or lowering the suspicion of cancer. Based on the
proportion of a b n o r m a l test results a m o n g subjects
who received a n ESR, we c a n estimate that 369 sub-
jects h a d a n ESR less t h a n 20 m m / h r a n d only one of
the clinical findings. No cancers were identified
a m o n g such patients (upper 95% CI -- 0.8%). On the
other hand, for subjects with a n ESR - 2 0 m m / h r or
with two or more clinical findings (e.g., a g e >50
y e a r s plus weight loss) nine of 391 subjects proved to
h a v e cancers (2.3%, with 95% CI = 0.8%, 3.8%). For
these patients, prompt spinal r a d i o g r a p h y m a y be
appropriate, although some who proved to h a v e
cancers h a d normal x-rays. Thus, persons who h a d
elevated ESRs but normal x-rays would require
close follow-up a n d / o r additional diagnostic tests.
No patient in our study who h a d underlying c a n c e r
h a d both a normal x-ray a n d a n ESR <20 m m / h r
(among those who h a d the tests done), so that further
testing a m o n g such patients would h a v e a very low
yield. Figure 2 presents a simple algorithm b a s e d on
these considerations, a n d indicates the conse-
quences a m o n g our study subjects. This algorithm
would h a v e limited x-ray use to just 22% of subjects,
a n d would h a v e r e c o m m e n d e d a n x-ray for every
c a n c e r patient.
DISCUSSION
This study supports several conclusions con-
cerning the detection of c a n c e r in patients present-
ing with back pain. First, the p r e v a l e n c e of underly-
ing cancers a m o n g back pain patients in a n
unselected primary care population is low: approxi-
mately seven c a s e s per 1,000 patients. Second, pa-
tients with underlying malignancies often h a v e few
suggestive signs, a n d the diagnosis is often initially
overlooked. Nonetheless, there a r e features of the
history that should raise the suspicion of c a n c e r a n d
prompt a directed laboratory a n d radiographic
evaluation. Third, the ESR is a useful screening tool
w h e n applied selectively. Along with suggestive his-
torical findings, a n e l e v a t e d ESR should prompt ra-
diography. Fourth, in the face of suggestive histori-
cal findings a n d a n e l e v a t e d ESR, a "negative"
x-ray of the spine should be interpreted with caution.
Clinical follow-up a n d additional diagnostic tests
m a y be indicated in this situation. And fifth, using the
history a n d ESR, it is possible to select groups of
low-risk patients who do not n e e d early radiogra-
phy, resulting in substantial cost savings.
Because 90% of patients who h a v e m e c h a n i c a l
pain improve within a month,19 longitudinal obser-
vation is a n important diagnostic tool. This is re-
flected in our algorithm, which r e c o m m e n d s no test-
 JOURNALOF GENERALINTERNALMEDICINE, Volume 3 (May/Jun), 1988 ;?,37

Low Back Pain (N = 1975)

History and Physical Exam

History of Age > 50 years No findings for other

p r e v i o u s cancer groups (n = 1170)
(n = 45) "No test" strategy may
or be appropriate unless
an indication arises
FIGURE 2. One possible algorithm for de- Failure to improve with (e.g., failure to improve
tecting underlying cancer in patients with low back conservative therapy with conservative therapy)
pain. The number of patients in our study who (No cancer patients)
or
would fall into each subgroup is shown, along with
the percentage who proved to have cancer. In some ESR, Spine Films Unexplained weight
cases, subgroup sizes are estimates, based on the (9% with cancer) loss, systemic signs
proportions of abnormal results and clinical findings (n = 760;
among the subset of patients (n = 1,008) who ac- 1.2% with cancer)
tually had an erythrocyte sedimentation rate (ESR)
performed. "Systemic signs" refers to findings that
would mandate investigation on their own: lymph- ESR
adenopathy and hematuria were examples in our
study.

Only one clinical ESR > 20

finding and or
ESR < 20 more than one
(n = 369): Stop clinical finding
(No cancer (n = 391)
patients)

X-RAY
(2.3% with cancer)

ing for the lowest-risk subjects (a majority of this
sample) unless indications subsequently arise. It is
also reflected in the use of "failure of conservative
therapy" as a n indication for testing. In subjects with
previous cancers, a g e over 50, or unexplained
weight losses, the prior probability of c a n c e r is suffi-
ciently high (1 -9%) that some immediate diagnostic
testing a p p e a r s warranted, assuming that earlier
diagnosis leads to earlier relief of suffering. Costs of
r a d i o g r a p h y per d a y of suffering a v e r t e d a p p e a r
r e a s o n a b l e for this r a n g e of probabilities ($43 to $558
per day, e v e n without the greater selectivity that the
ESR m a y permit). 4 In our study, not e v e r y subject
h a d received a trial of conservative t h e r a p y at the
index visit. Ideally, such follow-up d a t a would h a v e
b e e n available to construct a n algorithm. However,
the natural history of b a c k pain is such that uniform
return visits m a y be unnecessary, a n d rules for deci-
sion-making at a single visit m a y be important.
The indications for r a d i o g r a p h y in Figure 2 are
not the only ones to be considered in m a n a g i n g a
patient with b a c k pain. R a d i o g r a p h y would also be
indicated for patients with clinical findings that sug-
gest underlying infection, fracture, or inflammatory
spondylitis. Fortunately, the ESR is useful for detect-
ing infectious a n d inflammatory diseases as well a s
cancer, e so only minor modifications of the algorithm
m a y be n e c e s s a r y to b r o a d e n its diagnostic scope.
This study is consonant with earlier r e s e a r c h in
several respects. Bone scintigraphy (to detect
c a n c e r or osteomyelitis) w a s reported to be unhelp-
ful in the m a n a g e m e n t of patients who h a d normal
radiographs a n d laboratory findings, n F e m b a c h
a n d colleagues reported that 17 of 18 patients with
c a n c e r s a s a c a u s e of b a c k pain were over a g e 50,
a n d the ESR w a s a b n o r m a l for 94%. 12 As in other
series, the primary sites most often associated with
spinal metastases in our study were breast, lung,
a n d prostate. 2°
Nonetheless, some limitations of this study
should be noted. First, with only 13 c a n c e r patients,
the results of our study should be generalized cau-
tiously. Second, we could not ensure that all patients
presenting to the walk-in clinic on nights or week-
ends would be included. We cannot precisely quan-
tify the number of individuals who were excluded,
but b a s e d on administrative records, we believe that
two-thirds of all back pain patients presenting dur-
ing the study period were included. Third, not all
patients received e v e r y diagnostic test, a n d those
who received tests were in some respects systemati-
cally different from the remainder. To the extent that
"sicker" patients were more likely to h a v e tests done,
our estimates of a b n o r m a l results a m o n g non-
c a n c e r patients m a y be inflated. Fourth, we cannot
be certain that ascertainment of c a n c e r c a s e s w a s
238 Deyo, Diehl, CANCERAND BACK PAIN
c o m p l e t e . If p a t i e n t s s o u g h t c a r e e l s e w h e r e after the
i n d e x visit, t h e y might not a p p e a r in o u r tumor regis-
try. W e b e l i e v e this is a small risk, s i n c e most p a t i e n t s
in this walk-in clinic d e s c r i b e our institution a s their
o n l y s o u r c e of c a r e . S i n c e most w e r e indigent, it a l s o
s e e m s likely that t h e y w o u l d c o m e to our public hos-
pital for e x p e n s i v e illnesses (such a s c a n c e r ) . Fifth,
b e c a u s e o n l y 13 subjects h a d c a n c e r , t h e c o m p l e x i t y
of a multivariate statistical m o d e l for our d a t a set
w a s limited to just o n e or two p r e d i c t i v e v a r i a b l e s .
R a t h e r t h a n s e e k i n g the b e s t statistical classification
rate, h o w e v e r , w e h a v e s o u g h t a h i g h l y sensitive
rule e v e n at the e x p e n s e of r e c o m m e n d i n g a n u m b e r
of n e g a t i v e work-ups. T h e intent w a s to minimize
serious errors in p a t i e n t c a r e .
Finally, our results n e e d to b e v a l i d a t e d in a
s e p a r a t e g r o u p of patients. In part, w e h a v e t e s t e d
p r e v i o u s h y p o t h e s e s a b o u t the v a l u e of c e r t a i n clini-
c a l or l a b o r a t o r y d a t a in d e t e c t i n g u n d e r l y i n g
c a n c e r . While the results a r e c o n c o r d a n t with e a r l i e r
work, 9-~sthe a l g o r i t h m s h o u l d b e v a l i d a t e d i n d e p e n -
d e n t l y to a s s e s s its gener~liTability. T h e r a r i t y of
cancer as a c a u s e of back pain necessitates large
studies for this purpose. Future studies m a y benefit
from a policy accounting for previous x-rays, poten-
tially allowing e v e n more selective radiography.
Our data support the safety a n d v a l u e of selec-
tive x-ray u s e in the evaluation of patients with back
pain. Application of such selective criteria holds the
promise of substantially reducing costs of care with-
out a decrement in quality. Judicious use of the ESR
m a y allow e v e n more selective x-ray use than that
proposed ~s on the basis of history alone.
MargaretMoya, HelenProvot, and NancySugarekprovidedexpert technicalassist-
ance. Richard L. Bauer, MD, and DanielKent, MD, providedhelpful reviewsof an
earlierversionof the manuscript.Ms. Moyaand Kathy Minotto assistedin preparing
the manuscript.The cooperationof the housestaffof the MedicalCenterHospitalwho
completedclinicalevaluationsof the patients is greatly appreciated.
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