Primary care cancer risk assessment tool – early diagnosis of cancer

OK, so this wasn't a guideline, but a really useful course I and a few other Pallanteers recently went on. You may have seen that the 2ww forms for colorectal cancer have changed. You are now asked to work out the chance of the patient having cancer from their presenting symptoms, with the help of the handy chart on the back... You may also have seen the lovely mouse mats and flip charts with colour coded diagrams on...

This is to make a bit of sense of these, because it's not all obvious. I will also add a couple of really important learning points from the day...

The Risk Assessment Tool (RAT)

This is the colourful chart pictured above. You can use it to work out the risk of the patient having cancer from their presenting symptoms. A risk of over 3% is considered enough to warrant a 2ww referral. Unless listed otherwise on the form, other symptoms can be managed more routinely.

The numbers represent a Positive Predictive Value (ie the % risk of having cancer if you present with that symptom).

If the patient has had a symptom just once, then read the numbers off the top line (so one episode of diarrhoea is 0.9%)

If the patient has had a symptom more than once - even if it is on consecutive days - then read the numbers off the diagonal (so 2 or more episodes of diarrhoea is 1.5%).

If there are multiple symptoms, use the worst case scenario. For example if you have diarrhoea, rectal bleeding on 2 occasions and loss of weight, the risk would be 6.8%.

Other handy bits of information

You are responsible! If you order a test, looking for a sinister diagnosis (eg a CXR or USS), then it is largely your responsibility to chase the results. The MPS and MDU are settling claims with a 70:30 responsibility split between doctor and patient. So a patient presents with a chronic cough and you organise a CXR and they either don't go, or don't call up for the results and you don't call them in. They then present later with lung cancer. You are 70% responsible. Personally I feel this is crazy, but that's the situation. So, when ordering these tests, it is worth handing a 'please chase this up' slip to reception or the named GP. Hopefully there will be a form in the cupboard soon specifically for this.

Public Awareness. This is growing. Ads for colorectal and ovarian cancer have come already. Ads for Lung Cancer are coming soon telling people to come in if they've been coughing for 3/52. You don't have to order investigations on everyone - just if appropriate...

Renal cancer

  • Haematuria. In men over 50 with visible haematuria (excluding UTI) , 25% have some kind of pathology (from stones to cancer). For invisible (microscopic) this is 5%. For microscopic haematuria, take it seriously if they've had 2 or more dipstixs showing at least 1+ of blood (ie not a trace). They need referral
  • Varicocele. Beware a left sided, new onset varicocele in an elderly man, this could be a renal CA compressing the vessels.
  • PUO.  Beware pyrexia of unknown origin. Renal CA is a cause.

Lung Cancer

  •  Shoulder Pain. Beware a smoker with bad shoulder pain. This could be lung CA. Consider a CXR.
  • CXR are cheap and very low radiation, so if in doubt, get one.
  • New treatments. They can check for EGFR now, a receptor (like they can for oestrogen receptors in breast cancer). There are some targeted treatments for this which help a lot. There are also some new investigations, like endoscopic ultrasound, which patients may have.

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