GPs’ direct access to cancer testing reduces diagnostic delay

Direct access testing allows GPs to refer patients for diagnostic testing without referring to, or even discussing it with, a specialist. A systematic review by Friedemann Smith and colleagues looks at the evidence on the effectiveness of direct access testing when it is made available to GPs. The evidence suggests in most cases it is just as good as when provided by a specialist. They found that there was no significant difference in the pooled cancer conversion rate between GP direct access referrals and patients who first consulted a specialist for any test, with the exception of gastroscopy. There was no significant difference between the appropriateness of referrals between GPs and consultants. Finally, there was a significantly shorter time for patients referred for direct access testing via a GP compared to a specialist, and patient satisfaction with direct access testing was consistently high.

Older patients are over-tested for thyroid problems

Thyroid function tests are performed on as many as 30% of people over the age of 65 years, at an annual cost to the NHS of around £30 million. A large research study suggests that many of these tests are unnecessary. Roberts and colleagues analysed data on almost 3000 patients who had normal thyroid function at the outset and were re-tested after about 5 years. Only a tiny proportion of them showed any change in thyroid function: 17 cases in 12,919 person-years. Thyroid function tests are frequently performed annually on older people, often in response to unexplained symptoms or as part of routine care. Based on these findings, the researchers advise against routine repeat testing in older people who have a normal thyroid function test result in the last 5 years, unless clinically indicated. As well as reducing workload and patient inconvenience, following this advice could lead to significant cost savings for the NHS.

Early detection of myeloma using simple blood tests

Multiple myeloma is a particularly difficult disease to spot and there can be delays before diagnosis. It is a rare cancer and can lead to symptoms such as bone pain and fatigue. Research by Koshiaris and colleagues aimed to identify which blood tests suggest or exclude a diagnosis of multiple myeloma. They found that the simple combination of normal haemoglobin and plasma viscosity or ESR can rule out the disease in patients tested in primary care. If these tests are normal in patients who present with back pain, rib pain, chest pain, and recurrent chest infections, this greatly lowers the possibility of myeloma. Conversely, any abnormalities in one of these two tests make it reasonable for clinicians to request urgent further blood and urine tests to get to a swift diagnosis. Integration of these results into patient records could help facilitate the early diagnosis of myeloma.

Recognising testicular cancer: new guidance for GPs

Shephard and Hamilton from the University of Exeter analysed nearly 1400 cases of testicular cancer and found that the presence of a testicular lump or swelling had a risk estimate for cancer of more than 2%, and this increased to 10% when the lump was associated with testicular pain. Testicular pain associated with groin pain or blood tests showing inflammation had a PPV for cancer above the NICE 3% threshold for urgent referral. Results support current UK recommendations and provide additional information about the symptoms or symptom combinations that warrant further investigation. They also identify possible sources of delay in diagnosis, such as misdiagnosing cancer as a hydrocele, or considering a painful testicular mass to be low risk. Contrary to traditional medical teaching, painful testicular enlargement may signify cancer.