Direct access CT for suspicion of brain tumour: an analysis of referral pathways in a population-based patient group

K Zienius,P M Brennan,M Ozawa,D Summers,Ip Chak-Lam,S Mohiuddin,W Hollingworth,E Keeney,D Weller,J Park,Y Ben-Shlomo,W Hamilton,L Porteous,R Grant

doi:10.1186/s12875-019-1003-y

Abstract

BackgroundBrain tumour patients see their primary care doctor on average three or more times before diagnosis, so there may be an opportunity to identify ‘at risk’ patients earlier. Suspecting a brain tumour diagnosis is difficult because brain tumour-related symptoms are typically non-specific.MethodsWe explored the predictive value of referral guidelines (Kernick and NICE 2005) for brain imaging where a tumour is suspected, in a population-based patient group referred for direct access CT of the head. A consensus panel reviewed whether non-tumour findings were clinically important or whether further investigation was necessary.ResultsOver a 5-year period, 3257 head scans were performed; 318 scans were excluded according to pre-specified criteria. 53 patients (1.8%) were reported to have intracranial tumours, of which 42 were significant (diagnostic yield of 1.43%). There were no false negative CT scans for tumour. With symptom-based referral guidelines primary care doctors can identify patients with a 3% positive predictive value (PPV). 559 patients had non-tumour findings, 31% of which were deemed clinically significant. In 34% of these 559 patients, referral for further imaging and/or specialist assessment from primary care was still thought warranted.ConclusionExisting referral guidelines are insufficient to stratify patients adequately based on their symptoms, according to the likelihood that a tumour will be found on brain imaging. Identification of non-tumour findings may be significant for patients and earlier specialist input into interpretation of these images may be beneficial. Improving guidelines to better identify patients at risk of a brain tumour should be a priority, to improve speed of diagnosis, and reduce unnecessary imaging and costs. Future guidelines may incorporate groups of symptoms, clinical signs and tests to improve the predictive value.

Highlights

Brain tumour patients see their primary care doctor on average three or more times before diagnosis, so there may be an opportunity to identify ‘at risk’ patients earlier
We identified patients aged 16 years or older referred for direct access computed tomography (CT) (DACT) between 31 March 2010 and 1 April 2015 from a local electronic database (Fig. 1)
No patient without intracranial tumour on the DACT imaging report was subsequently identified to have a tumour on imaging within the study

Summary

Introduction

Brain tumour patients see their primary care doctor on average three or more times before diagnosis, so there may be an opportunity to identify ‘at risk’ patients earlier. People with a brain tumour see their primary care doctor on average 3 or more times before diagnosis [15], so there may be an opportunity to identify ‘at risk’ patients earlier. In the UK, only 1% of adult brain tumours are diagnosed through a “suspicion of cancer” secondary care pathway requiring patients to be seen within 2 weeks of referral [7]. This is one of the lowest of all cancers and is not improving. The 2015 guideline did not provide guidance for patients with other (e.g. cognition, headache) symptoms

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