Cancer Referral Guidelines Research Articles

Leveraging AI and patient metadata to develop a novel risk score for skin cancer detection

Melanoma of the skin is the 17th most common cancer worldwide. Early detection of suspicious skin lesions (melanoma) can increase 5-year survival rates by 20%. The 7-point checklist (7PCL) has been extensively used to suggest urgent referrals for patients with a possible melanoma. However, the 7PCL method only considers seven meta-features to calculate a risk score and is only relevant for patients with suspected melanoma. There are limited studies on the extensive use of patient metadata for the detection of all skin cancer subtypes. This study investigates artificial intelligence (AI) models that utilise patient metadata consisting of 23 attributes for suspicious skin lesion detection. We have identified a new set of most important risk factors, namely “C4C risk factors”, which is not just for melanoma, but for all types of skin cancer. The performance of the C4C risk factors for suspicious skin lesion detection is compared to that of the 7PCL and the Williams risk factors that predict the lifetime risk of melanoma. Our proposed AI framework ensembles five machine learning models and identifies seven new skin cancer risk factors: lesion pink, lesion size, lesion colour, lesion inflamed, lesion shape, lesion age, and natural hair colour, which achieved a sensitivity of 80.46±2.50%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$80.46\\pm 2.50\\%$$\\end{document} and a specificity of 62.09±1.90%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$62.09\\pm 1.90\\%$$\\end{document} in detecting suspicious skin lesions when evaluated using the metadata of 53,601 skin lesions collected from different skin cancer diagnostic clinics across the UK, significantly outperforming the 7PCL-based method (sensitivity 68.09±2.10%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$68.09\\pm 2.10\\%$$\\end{document}, specificity 61.07±0.90%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$61.07\\pm 0.90\\%$$\\end{document}) and the Williams risk factors (sensitivity 66.32±1.90%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$66.32\\pm 1.90\\%$$\\end{document}, specificity 61.71±0.6%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$61.71\\pm 0.6\\%$$\\end{document}). Furthermore, through weighting the seven new risk factors we came up with a new risk score, namely “C4C risk score”, which alone achieved a sensitivity of 76.09±1.20%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$76.09\\pm 1.20\\%$$\\end{document} and a specificity of 61.71±0.50%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$61.71\\pm 0.50\\%$$\\end{document}, significantly outperforming the 7PCL-based risk score (sensitivity 73.91±1.10%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$73.91\\pm 1.10\\%$$\\end{document}, specificity 49.49±0.50%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$49.49\\pm 0.50\\%$$\\end{document}) and the Williams risk score (sensitivity 60.68±1.30%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$60.68\\pm 1.30\\%$$\\end{document}, specificity 60.87±0.80%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$60.87\\pm 0.80\\%$$\\end{document}). Finally, fusing the C4C risk factors with the 7PCL and Williams risk factors achieved the best performance, with a sensitivity of 85.24±2.20%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$85.24\\pm 2.20\\%$$\\end{document} and a specificity of 61.12±0.90%\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$61.12\\pm 0.90\\%$$\\end{document}. We believe that fusing these newly found risk factors and new risk score with image data will further boost the AI model performance for suspicious skin lesion detection. Hence, the new set of skin cancer risk factors has the potential to be used to modify current skin cancer referral guidelines for all skin cancer subtypes, including melanoma.

Understanding GPs' referral decisions for younger patients with symptoms of cancer: a qualitative interview study.

Cancer incidence increases with age, so some clinical guidelines include patient age as one of the criteria used to decide whether a patient should be referred through the urgent suspected cancer (USC) pathway. Little is known about how strictly GPs adhere to these age criteria and what factors might influence their referral decisions for younger patients. To understand GPs' clinical decision making for younger patients with concerning symptoms who do not meet the age criteria for USC referral. Qualitative study using in-depth, semi-structured interviews with GPs working in surgeries across England. Participants (n = 23) were asked to recall consultations with younger patients with cancer symptoms, describe factors influencing their clinical decisions, and discuss their overall attitude to age thresholds in cancer referral guidelines. A thematic analysis guided by the Framework approach was used to identify recurring themes. GPs' decision making regarding younger patients was influenced by several factors, including personal experiences, patients' views and behaviour, level of clinical concern, and ability to bypass system constraints. GPs weighted potential benefits and harms of a referral outside guidelines both on the patient and the health system. If clinical concern was high, GPs used their knowledge of local systems to ensure patients were investigated promptly even when not meeting the age criteria. While most GPs interpret age criteria flexibly and follow their own judgement and experience when making clinical decisions regarding younger patients, system constraints may be a barrier to timely investigation.

P01.21.A Testing Semantic Verbal Fluency (SVFT) in patients with headache suspicious of cancer helps predict those with tumour on imaging

Abstract Background Differentiating secondary headache from primary headache on history alone can sometimes be difficult. Headache “plus” other subtle cognitive features improves prediction. Patients and relatives may attribute subtle cognitive or behavioural changes to other causes (e.g. anxiety, low mood). Sematic verbal fluency - “how many animals can you think of in a minute” is commonly impaired on admission in patients with headache harbouring a tumour. We were interested whether SVFT at point of referral for scan would help predict a tumour and requested GPs report the SVFT on electronic referral for direct access scanning in cases with a history of headache suspicious of cancer. The aim of the pilot study was to establish if the SVFT was a “red flag” for secondary causes of headache. We report the results of a 20-month audit of cases. Material and Methods An electronic Protocol Based Referral (PBR) was developed for Headache Suspicious of Cancer to expedite scanning. The PBR sat alongside the routine e-DACI system that had been in use for some years. The GP was asked to complete the SVFT at the time of referral for scanning. Other data were gathered: PMH cancer; other symptoms/signs; co-morbid conditions and medications. Results GPs submitted requests for ePBR scanning in 669 cases over 20 months (62% females; Mean age 53: 60% <60 years). SVFT was completed on the request form in 381 (57%) cases. In these cases median SVFT was 17 animals. 11/381 cases were found to have cancer on scanning (2.9%): 10/188 cases with intracranial tumours had a SVFT <17 (5.32%) compared with one with a SVFT >=17. The median SVFT in cases with cancer was 10 animals. Other possible causes of SVFT <17 were - 53 psychiatric or chronic pain conditions on multiple drugs;12 were not native English speakers; 19 had co-existing dementia; 5 had small vessel disease; 4 cysts; 4 Giant Cell Arteritis ; 2 Chiari 1 malformation; PMH - encephalitis (1). Conclusion A SVFT result <17, at the point of referral for brain imaging, in patients with headache suspicious of cancer was associated with intracranial cancer in more than 1:20 cases, whereas a SVFT of >=17 was associated with cancer in 1:200 cases. SVFT may be an additional useful “red flag”. The most appropriate SVFT cut-off requires more research in a larger study. Low SVFT in headache patients may inform Cancer Referral Guidelines, improve the identification of secondary headache and help expedite cases.

TP6.2.16General practitioner compliance with Scottish cancer referral guideline for Oesophago-gastric cancer

Abstract Aims The outcome of oesophago-gastric cancer is often poor. Timely referral of suspected cancer is essential for early diagnosis and optimal outcome. This study aims to audit the General Practitioners (GPs) compliance with the Scottish referral guidelines for suspected oesophago-gastric cancer. Methods A retrospective cohort study of all newly diagnosed oesophago-gastric cancers who were referred from the primary care and discussed in a single regional MDT was performed between October 2019 and September 2020. Electronic records were interrogated and symptomatology audited against the Scottish cancer referral guidelines. Results Of the 349 patients, 227 (65.0%) were referred from the primary care. 150 (66.1%) were male and the mean age was 69.5 ± 10.9 years. Mean Scottish Index of Multiple Deprivation was 5 ± 3. 149 (65.6%) had dysphagia and/or odynophagia and 181 (79.7%) were oesophageal cancers. 67 (29.5%) were T4 disease and 87 (38.3%) were metastatic at presentation. Urgency of referral was: 25 (11.0%) routine, 54 (23.7%) urgent and 148 (65.2%) Urgent Suspicion of Cancer (USOC). 192 (84.6%) patients qualified to be referred as USOC, of these 138 (71.9%) were actually referred as USOC. Of the 35 (15.4%) patients who did not qualify for the USOC referral, 10 (28.6%) patients were referred as USOC. The sensitivity was 71.9% and specificity 71.4%. Conclusions GP compliance with the adherence with the National guidelines remains a barrier in the USOC in oesophago-gastric cancer. Further GP education and awareness is required to improve their compliance.

EP.TH.359Improved Oesophagogastric Cancer Outcomes in Rural Patients

Abstract Introduction Despite advances in medical therapies and surgical techniques, oesophagogastric cancer survival remains low. Poorer cancer outcomes and survival for rural dwellers is well documented worldwide and has been an area of focus in Scotland since 2007, with changes to suspected cancer referral guidelines and a government report on delivering remote and rural healthcare. Methods A prospective, single-centre observation study was conducted utilising data from oesophago-gastric cancer MDT referrals and outcomes from January 2013 to December 2019. The Scottish Index of Multiple Deprivation 2020 tool provided a rurality code based on patient postcode at time of referral. Survival outcomes for urban and rural patients were compared across demographic factors, disease factors and stage at presentation. Results 1046 patients were included in this study. The median age of presentation for urban and rural patients was 73.7 and 72.4 respectively. There was no significant difference between oesophageal versus gastric cancer presentations nor was there any difference between T, N or M stage at presentation between the groups. No difference was identified between those commenced on a radical therapy with other treatment plans. On Kaplan-Meier analysis there was a difference in survival between the groups favouring rural dwellers (p = 0.012). Discussion The difference in survival demonstrated here between urban and rural groups is not easily explained but may represent improvements to rural access to healthcare delivered as a result of policy change. This is an interesting finding and this study should be expanded to include performance status at time of referral.

Is Flexible Cystoscopy Necessary in the Investigation of Non-visible Haematuria?

Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) referrals result in Urological cancer diagnosis. The majority are bladder cancers, for which flexible cystoscopy is regarded the “gold standard” diagnostic procedure. Recent changes to suspected cancer referral guidelines, public information campaigns and reduced smoking prevalence may have changed this percentage. We retrospectively calculated cancer detection rates from NVH referrals to assess whether flexible cystoscopy, an invasive and morbid procedure, remains necessary. Patients and methods: All patients referred to our University teaching hospital on a suspected (“twoweek”) cancer pathway with NVH over a 16-week period were included. Clinical and demographic data were collected for a series of 200 patients (96 male, age range 27–92, median 68). Results: Only eight patients had urological malignancy found (two renal and six bladder cancers). Both renal, and four bladder cancers, were identified on imaging prior to flexible cystoscopy. Only two bladder cancers were therefore detected by cystoscopy; one low-risk non-muscle invasive (patient has already been discharged) and one in a patient that was unfit for treatment (died of heart failure). Only seven (3.5%) of the patients were offered the option of not undergoing flexible cystoscopy. Conclusion: Our analyses suggest that flexible cystoscopy is rarely of benefit in patients with NVH. We suggest that patients should be given an accurate risk of bladder cancer diagnosis during the consent process. We advocate that flexible cystoscopy can be avoided for the majority of NVH referrals, particularly in patients without strong risk factors for urothelial cell carcinoma. Avoidance of flexible cystoscopy would reduce patient risks from procedural morbidity, reduce risks of acquiring coronavirus from hospital attendance, and there could be huge reductions in financial and service delivery demands in an overstretched secondary-care service.

Delphi method to identify expert opinion to support children’s cancer referral guidelines

BackgroundThe National Institute for Health and Care Excellence (NICE) guidance for referral of children with suspected cancer was first published in 2005 and updated in 2015. The updated version relied...

A Survey on awareness, knowledge, and attitude toward NICE oral cancer referral guidelines among general dental practitioners in edo state

A Survey on awareness, knowledge, and attitude toward NICE oral cancer referral guidelines among general dental practitioners in edo state

A Survey on awareness, knowledge, and attitude toward NICE oral cancer referral guidelines among general dental practitioners in edo state

Background: The NICE oral cancer referral guidelines (NICE OCRG) are yet to be adopted in Nigeria. The level of awareness, knowledge, and attitude among general dental practitioners (GDPs) in Nigeria toward NICE OCRG is evaluated. Materials and Methods: A self-administered questionnaire was used to collect information from GDPs in Edo state on the awareness, knowledge, and attitude toward the NICE OCRG. A total of 83 respondents participated in the study. Data collected were analyzed and presented in descriptive and tabular forms as numbers and percentages. The study was analyzed using Statistical Package for Social Sciences (SPSS) version 21 (IBM, USA). Results: The male-to-female ratio was 1.4:1.0. The mean age was 33.3 ± 5.30 years, with age range from 21 to 50 years. Nearly 63.9% of the respondents were found to have heard of the NICE OCRG, of which 43.4% had their source from the Internet. Most of the respondents (n = 43, 51.8%) had fair knowledge of OCRG followed by those with good knowledge (n = 25, 30.1%) and those with poor knowledge of OCRG (n = 15, 18.1%). Overall 55.4% of the respondents agreed that the NICE OCRG will help reduce diagnostic delay and false-positive referral of oral cancers if adopted in Nigeria. Furthermore, 77.1% of the respondents were willing to implement the NICE OCRG if adopted in Nigeria. Conclusion: The awareness and knowledge of the NICE OCRG among GDPs in Nigeria is encouraging, and most of them had favorable attitude toward the NICE OCRG. There is a clear need to adopt the NICE OCRG in Nigeria to reduce diagnostic delay and false-positive referral of oral cancers.

Two week wait referral criteria - heading in the right direction?

The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses. The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer. Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent. The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10-15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.

Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study

BackgroundAlarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis.MethodsA nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated.ResultsA total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact.ConclusionIn general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR + show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review.

BackgroundUrgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval.ObjectivesWe conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer.MethodPRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis.Main FindingsTwenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs’ competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE.ConclusionWe do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.

Benign ano-rectal disorders

Benign ano-rectal disorders are a common adult presentation to primary care; they also generate a significant number of secondary referrals. The exact prevalence of these conditions is difficult to determine, due to under-reporting of symptoms, which patients can find embarrassing and difficult to disclose. It can be challenging to distinguish between different ano-rectal disorders which present with similar symptoms. A high index of suspicion is required to detect serious malignant pathology. The aim of this article is to outline the epidemiology, pathophysiology, diagnosis and management of common benign ano-rectal disorders in primary care. The indications for surgical referral and important cancer referral guidelines are included.

Breast and ovarian cancer referrals to the ACT Genetic Service: are we meeting guidelines?

The ACT Genetic Service at The Canberra Hospital evaluates the genetic risk of individuals for inherited diseases, and provides counselling and genetic testing where appropriate. To evaluate the current referral practice for patients with a personal and/or family history of breast and/or ovarian cancer, and to assess whether these referrals are made according to eviQ cancer referral guidelines. A retrospective clinical audit of patients seen by the ACT Genetic Service for evaluation of genetic risk of breast and/or ovarian cancer between 1 January 2013 and 30 June 2015. Statistical analysis included Chi-squared and Poisson distribution tests. Of the 711 patients referred during the 30-month period, 671 were seen by the service. The number of patients seen increased steadily over the time period, as did waiting times. The majority of referrals were made by general practitioners (403/711; 57%) and oncologists (172/711; 24%). Of note, 300 of 711 (42%) of all referrals made to the service during this time period did not meet eviQ referral guidelines. Patients who met guidelines for referral were more likely both to be offered genetic testing and to have a positive result. Demand on the ACT Genetic Service increased over the time period assessed. As a significant proportion of patients did not meet eviQ cancer referral guidelines, it is worth reviewing the referral process in order to optimise utility of this limited resource.

18: How has including “unexplained haemoptysis” in 2015 NICE lung cancer referral guidelines changed referral and diagnosis rates?

18: How has including “unexplained haemoptysis” in 2015 NICE lung cancer referral guidelines changed referral and diagnosis rates?

Do new NICE oral cancer referral guidelines (NG12) risk delay in cancer diagnosis? An audit comparing outcomes of the new guidelines against old guidelines

Do new NICE oral cancer referral guidelines (NG12) risk delay in cancer diagnosis? An audit comparing outcomes of the new guidelines against old guidelines

Refining the head and neck cancer referral guidelines: a two centre analysis of 4715 referrals

Our aim was to identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. We analysed the referral criteria and outcomes from two tertiary care cancer centres in the United Kingdom. Between 2007 and 2010, 4715 patients were referred via the fast track system with a suspected HNC. The main outcome measures were the parameters of diagnostic efficacy, a multivariate regression model to calculate estimated probability of HNC and the area under the receiver operating characteristic curve (AUROC). We found that the majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified 9 symptoms to be linked with HNC. Of these, only 4 are included in the latest NICE guidelines. The best fit predictive model for this dataset included the following symptoms: hoarseness>3 weeks, dysphagia>3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, presence of blood in mouth with concurrent sensation of lump in throat, and presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (p<0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html. This paper presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.

Refining the head and neck cancer referral guidelines: a two-centre analysis of 4715 referrals.

To identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. Statistical analysis of referral criteria and outcomes. Two tertiary care cancer centres in the United Kingdom. 4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010. Parameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve (AUROC). The majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3 weeks, dysphagia >3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3 weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (P < 0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html. This study presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

PTU-301 Suspected upper gi cancer referrals in secondary care centre: are they always appropriate?

<h3>Introduction</h3> According to NICE guidelines all patients with suspected cancer should be seen within 2 weeks of referral. Our Gastroenterology Department is experiencing an increasing workload burden due to a high number of suspected upper GI cancer referrals. We therefore decide to perform an audit to evaluate the nature, appropriateness and diagnostic findings of these referrals. <h3>Method</h3> We reviewed 90 consecutive referrals from 26^thSeptember 2013 to 4^thNovember 2013. We focused our attention on duration of symptoms, type of symptoms and diagnosis. <h3>Results</h3> 36 patients were male (40%) and 54 patients were female (60%) with a mean age of 64 years (range 32–89). The most common reason for the referral was weight loss, present in 42 patients (47%), followed by dysphagia, in 34 patients (38%) and iron deficiency anaemia (21 patients-23%). Other symptoms that prompted the referral were abdominal pain in 20 patients (22%), dyspepsia in 19 (21%), altered bowel habits in 12 (13%) nausea and vomiting in 11 (12%) and abnormal imaging in 7 (8%). The majority of patients presented with a duration of symptoms of &lt;6 months (65 patients-72%) and 43 (47%) had a symptom duration of &lt;2 months. Twenty-one patients (23%) had symptoms for &gt;6 months and 7 had symptoms of &gt;2 years duration (7%). Looking at appropriateness of referrals we took into account the duration of symptoms and evidence of recent investigations which had already excluded a malignant cause, and considered 17 (19%) of target referrals not appropriate. Investigations didn’t reveal any pathology in 19% of the cases (17 patients). The most common finding was hiatus hernia, seen in 21 patients (23%), followed by gastritis, seen in 17 patients (19%). The cancer detection rate in our series was 10% (9 patients), 2 of the cancers were not gastrointestinal (1 renal, 1 lung). In few cases a diagnosis could not be reached because patients didn’t attend their appointments (6%). <h3>Conclusion</h3> The cancer detection rate (10%) hasn’t improved over the last few years and is very similar to other GI cancers yields in literature.¹The symptoms most predictive of upper GI malignancy were dysphagia, weight loss and iron deficiency anaemia (IDA). Weight loss and IDA were not seen as isolated symptoms in patients diagnosed with a malignancy. These results would suggest that our upper GI cancer referral guidelines should be reviewed in order to make a better use of our resources, perhaps focusing on a symptom spectrum more predictive of upper GI malignancy. We have also to point out that there is a high rate (19%) of referrals that could be made without using the target referral proforma. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Patel K, <i>et al</i>. Are upper gastrointestinal cancer two week referrals an appropriate use of National Health Service resources? Clin Med. 2011;11(4):412