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Round Up Email February 2020

Helping to improve cancer early diagnosis is an important motivation for me – in my practice as a GP and my role as a CRUK GP. NICE Cancer Referral Guidance (NG12) provides criteria for urgent cancer referral from primary care. This guideline (NG12) was the most significant NICE guideline that I have ever reviewed in my role as Editor of GPnotebook – as it dramatically changed what GPs are expected to refer on a 2ww referral; as well as "new" concepts such as "thrombocytosis and cancer risk".

Question 1
Thrombocytosis and cancer risk – NG12 introduced the concept of raised platelet counts being associated with various cancers. NG12 cites the LEGO cancers – lung, endometrial, and gastro-oesophageal cancers as being associated with cancer risk. Now we have LEGO C – with colorectal cancer also associated with raised platelet counts. To find out more on this subject then click here.: Thrombocytosis (raised platelet count) and subsequent cancer risk
1) Which statement regarding thrombocytosis and cancer risk is true?
- There is evidence that unexplained thrombocytosis is associated with undiagnosed prostate cancer
- Evidence from the Bailey study shows that at least 50% of patients with lung and colorectal cancer with pre-diagnosis thrombocytosis had no other symptoms indicative an urgent referral for possible malignancy
- Platelets themselves can promote primary cancer growth by releasing different types of growth factors, chemokines, proangiogenic regulatory proteins, and proteolytic enzymes that promote tumor cell growth and invasion
Question 2
PSA is mentioned many times in NG12 – but what are the practicalities of using this test. If a patient has a UTI is the test valid – if not when can the test be repeated? What if the chap has undertaken vigorous exercise? This information is summarised on GPnotebook.: Prostate specific antigen
2) Which statement regarding PSA testing is true?
- If a patient has a UTI and raised PSA then do a urinalysis and urine culture to exclude urinary tract infection. Treat him if the culture is positive, then repeat the prostate specific antigen test if after two weeks his midstream urine is clear
- Before PSA the man should not have exercised vigorously in the previous 7 days
- Before having a PSA test men should NOT have ejaculated in the previous 48 hours
Question 3
What proportion of lung cancers will be "missed" on a routine chest Xray? NG12 states the importance of safety netting when using investigations in primary care such as chest Xrays. See GPnotebook for the answer.: Chest Xray (CXR) and diagnostic accuracy for lung cancer
3) A systematic review revealed what proportion of lung cancers had been
- 5%
- 15%
- 25%
Question 4
The only urgent cancer referral guidance from NICE since NG12 is the introduction of a hearing loss criterion relating to urgent referral if a unilateral persistent middle ear effusion in certain ethnic groups - because of risk of nasopharyngeal cancer. This guidance is detailed on GPn.: Risk of nasopharyngeal cancer if hearing loss (deafness) and unilateral middle ear effusion in adult of Chinese or South-East Asian family origin
4) Which ethnic group is most associated with risk of nasopharyngeal cancer?
- People of Chinese and South-East Asian family origin
- People of African family origin
- People of Ashkenazi Jewish family origin
Question 5
FIT testing is part of the bowel screening programme. What are the advantages of FIT versus FOB. Also FIT can be used in symptomatic patients according to NICE criteria. Check GPnotebook for more information.: Faecal immunochemical tests (FIT) for hemoglobin and detection of bowel cancer
5) Which statement regarding the use of FIT which option is false?
- The level of Hb used for flagging an abnormal result is higher (i.e. less sensitive) in bowel screening than used in symptomatic FIT
- FIT results can be increased if had eaten red meat before providing the test sample
- An indication for use of symptomatic FIT is anaemia in a person over 60 years of age that is not iron deficient
Question 6
Anaemia is mentioned in multiple parts of NG12 – if a patient is over 60 years old and has iron deficiency anaemia then is a 2ww lower GI ref, if iron deficiency anaemia and unexplained rectal bleeding and under 50 years then 2ww lower GI ref, if anaemia and upper abdominal pain and over 55 years old then needs direct access OGD…there is more. The actions required for a GP to consider with different situations where anaemia occur are summarised on GPn.: Anaemia - NICE urgent cancer referral guidance
6) According to NICE guidance which option is true?
- Anaemia (iron-deficiency, unexplained) with rectal bleeding in adults under 50 is an indication for a 2ww colorectal referral
- Anaemia (iron-deficiency) without rectal bleeding in adults under 60 is an indication for a 2ww colorectal referral
- Anaemia (even in the absence of iron-deficiency) without rectal bleeding, 60 and over is an indication for a 2ww colorectal referral

Round Up Email February 2020

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6