Oral cancer: falling through the cracks

Delay in oral cancer diagnosis is common and affects survival. Differences in 5-year mortality rates based on staging are marked, with >80% survival in those with localised disease, compared with <30% in those with advanced disease. Wilcock and colleagues analysed 16 studies in which patients presented to a GP or dentist. Patients had 2 to 3 consultations before they were referred to a specialist, whether they initially saw a GP or a dentist. At present, NICE guidance includes referral of patients suspected of having oral cancer from GPs to dentists, and, rather confusingly, recommends that patients with an unexplained persistent mouth ulcer for more than 3 weeks are referred to a cancer specialist. If a GP refers a patient to a dentist, the emphasis is placed on the patient to attend, regardless of whether they are registered, can afford to pay, or whether there is one readily accessible. Clearer advice and referral pathways are needed to improve early detection. Also see: Dental problems need more coordinated care.

Polymyalgia rheumatica – still an elusive diagnosis

Presentation of polymyalgia rheumatica (PMR) can be variable and diagnosis may not always be quick and accurate. Helliwell and colleagues at Keele University analysed data from over 1000 GPs, and found that features used to identify PMR are largely in line with current guidance, with a heavy reliance on patients’ response to treatment with steroids to confirm diagnosis. Current guidelines advise additional investigations to identify or rule out alternative diagnoses, such as liver function tests, protein electrophoresis, and inflammatory markers, but these are not routinely requested, and many respondents had concerns about adverse effects and monitoring of steroids. Useful guidance on diagnosis and treatment is provided by the British Society for Rheumatology, but more primary care research is needed.

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.