Download Risk Assessment Tool * Frequently Asked Questions

Risk Assessment Tool – Frequently Asked Questions
Where did the risk assessment tool come from?
The tool is based on work done by Professor Willie Hamilton in the CAPER1 studies (Cancer
Prediction in Exeter), a series of case-control studies which both identified symptoms of common
cancers that are presented to primary care and quantified them.
Why was the risk assessment tool developed?
The UK has relatively poor survival rates for cancer, which has been linked to more advanced stage
at diagnosis and to delays occurring between the onset of symptoms and the start of treatment.
Later diagnosis may be due to late presentation, delays within primary care or delays following
referral to secondary care services. In Europe, many more cancer investigations are undertaken
than in England and the RAT seeks partly to address this. In England an average GP will see seven or
eight new cases of cancer (excluding non-melanoma skin cancer) each year but will see hundreds, or
possibly, thousands, of patients with symptoms that could possibly be due to cancer. The risk
assessment tool was developed to help GPs identify the one patient with cancer among the many
who do not have the disease.
How should the risk assessment tool be used?
The risk assessment tool should be used as a reminder to GPs to consider the likelihood of an
individual patient aged 40 or over having lung or colorectal cancer given the symptom or
combination of symptoms they present with. The RAT does not replace your clinical judgement but
gives more information on which to base your referral decisions.
What does the tool look like?
The tool is presented as three tables (colorectal cancer, lung cancer for non smokers and lung cancer
for smokers) containing the risk values for each symptom in isolation or combination. The tool is
available either as a mouse mat or as an A5 desk easel, so as to be easily available and a constant
reminder.
What do the risk values in the table mean?
The risk values (positive predictive values) in the table are the proportion of those people with the
listed symptom(s) who have that cancer type. A PPV of 3 means a 3% chance that it is cancer.
What do the different colour codes mean?
Risk values of 1% or less are shaded white, above 1% and up to 2% shaded yellow, over 2% and up to
5% shaded orange and above 5% shaded red.
What level of risk should I refer at?
Hamilton, W (2009) The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in
symptomatic primary care patients, British Journal of Cancer 101, S80–S86. This paper is available free at
www.nature.com/bjc/journal/v101/n2s/index.html
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We deliberately have not picked a level. Patients, GPs and PCTs will have their own opinion on this.
We believe that a lower threshold than the current one will help tackle the UK’s poor performance.
GPs probably should consider a referral for risk values shaded orange or red; risk values shaded
yellow and white may well be best managed by review within primary care but clinical judgement
should be used.
What is the relationship with NICE Guidance?
Regard the RAT as ‘extra’ NICE, giving advice in areas NICE doesn’t cover. NICE guidelines describe
symptoms almost always with a risk of 3% or more. Much of the RAT is below 3%. We think it is
helpful to know the risk figure but leave you to make your own clinical judgement.
NICE guidelines will be updated in 2015 and will probably move in the direction of the RAT.
What if there are more than two symptoms?
For multiple symptoms, read the value from the cell combining the worst two symptoms.
What if there is only a single symptom?
The risk values for a single symptom are listed in the top row.
Why is the value for a single symptom across the top of the assessment tool different to the value
down the side?
The value along the top line is that for a single presentation with a specific symptom. When a patient
presents on two occasions within 12 months with the same symptom, then read across from the
vertical access to get the value for that symptom.
Is there any maximum time lapse between the same symptoms presenting more than once?
There is no hard and fast rule but as a guide symptoms presented over the preceding 12 months
should be taken into account as the studies from which the risk assessment tables were derived
were based on a 12 month time interval.
What should happen if patients have multiple symptoms but the 2 worst ones do not exceed the
threshold to referral?
The straightforward answer is, we don’t know, as the tool does not calculate risks for combinations
of more than two symptoms. In this case, the risk assessment tool should be used as a guide along
with clinical judgement.
Why is abdominal mass not on the colorectal RAT?
If a patient has an abdominal mass, it is likely that you will wish to investigate, so you don’t need a
RAT. We didn’t put in any symptoms that we believed mandated referral.
Chest x-ray is not diagnostic in all lung cancers: how do we respond to patients who score on the
RAT but have had a normal chest x-ray?
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Trust yourself. You may have to request another x-ray or talk to the chest physician. If your intuition
says it could still be cancer, make a two week wait referral.
Was low haemoglobin confirmed as iron deficiency – local colorectal teams ask for ferritin to
confirm sometimes?
Although we identified ferritin results (and other markers of iron deficiency) these were not included
in the RAT. In other studies we have done, the risk was even higher when markers of iron deficiency
were present.
How specific does one need to be in respect of the symptoms listed in the tool?
The symptoms identified through the CAPER studies were based on what GPs wrote in their notes.
So whilst symptoms being derived from clinical practice is one of the strengths of the risk
assessment tool, they are fairly loosely defined. Further elaboration for some symptoms is given
here:
Colorectal cancer
Rectal bleeding – the original studies did not separate out rectal bleeding which was not
anal; if the bleeding sounds like it could be anal bleeding your assessment of the risk level
might be lower than the level shown in the table.
Abnormal rectal exam – anything abnormal which is not prostate related. Haemorrhoids
cannot be palpated.
Loss of weight - there is no minimum amount of weight loss defined for the purpose of this
RAT
Lung cancer
Thrombocytosis – raised platelet count, above the upper level of normal as quoted by your
local lab
Abnormal Spirometry – there is no defined threshold level set for this, in most cases it will
reflect chronic obstructive pulmonary disease
Loss of weight - there is no minimum amount of weight loss defined for the purpose of this
RAT
My patient has recently given up smoking. Should I use the lung cancer assessment tool for
smokers or for non-smokers?
There is a standard definition for ex-smokers which should be applied when deciding whether to use
the non-smoker lung table. Namely, adults who said that they used to smoke cigarettes regularly but
no longer do are defined as ex-smokers (or ex-regular smokers). The design of the RAT used the
same definition, so we will be comparing like with like. Note that there is no specified time period
from when the person used to smoke regularly and stopped smoking regularly – so strictly speaking
the non-smoker table applies for both the person who gave up smoking 30 years ago and the person
who gave up 3 weeks ago, though GPs should use their clinical judgement.
Do GPs need to keep a record of how many times they use the RAT?
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No, the national rollout of the RAT is not being evaluated in the way that the pilot was, which
involved GPs filling in tear off sheets.
What materials are available to train GPs to use the RAT?
Presentations by Willie Hamilton, who developed the RAT, and Una McLeod who was part of the
evaluation team are available here [web link to be included] and can be adapted for local use.
NCAT is encouraging cancer networks, including the seven networks that piloted the RAT, to share
any materials they have developed locally. Any such resources will be on the NCAT website and
available through NCAT’s sharing and learning tool [http://www.ncat.nhs.uk/our-work/diagnosingcancer-earlier/resources-for-working-with-primary-care].
When will the mousemats and desk easels be delivered
By 13 January 2012
Will the rollout of the RAT be free for GPs?
NCAT is funding the production and distribution of mousemats and desk easels, and funding cancer
networks to train GPs to use them.
Can we use the RAT with other groups and in other settings such as A&E junior doctors, practice
nurses, smoking cessation clinics, pharmacies?
The RAT will work in any clinical setting where patients spontaneously describe their symptoms, so it
would be fine for practice nurses to use it.
In places such as central London many people use A&E as their GP. The RAT could be used by junior
doctors in A&E, if there was good support from the GP lead and a clinician working in the hospital on
early diagnosis.
The RAT is not recommended in pharmacies or smoking cessation clinics although a pilot project in
Sussex is trying out the latter.
Can the RAT be an iphone app?
CRUK is looking at it: this is the direction of travel.
Will using the risk assessment tool raise patient anxiety of the probability of having cancer?
This very much relies on clinical judgement. Use of the risk assessment tool and discussion of the risk
gives patients additional information and demonstrates that their symptoms are being taken
seriously. However people have different perceptions of risk and for some it may increase their
anxiety. During the pilot, some GPs showed patients the RAT but others didn’t. Other NAEDI
initiatives are helping us understand patient and public views of cancer and the implications for
awareness and early diagnosis, for example the Cancer Research UK work done for the ‘Fear
Campaign’.
How were the RAT tools received by secondary care?
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It is very important that secondary care is informed about the RAT and understands its value. You
need to answer their questions.
Concerns have been raised by our lung physicians that they will be swamped. Is there any
evidence of this from the pilots?
The results are only preliminary but suggest they won’t. Chest x-rays appear to have increased by
20% where RATs were used but two week waits only increased by a handful because the chest
physician will only get a referral if the chest x-ray is abnormal.
What about gastroenterologists?
The situation is more sensitive than for lung as there is no intermediate test for gastrointestinal
symptoms. If there is a 20% increase in referrals, that will be borne by the gastroenterologists. Also it
is sensitive because of concerns among secondary care clinicians about the impact of the national
bowel awareness campaign.
Secondary care has to recognise that if you increase diagnostic activity, the strike rate of diagnoses
(expressed as a percentage of investigated patients) will fall. However the total number of cancers
identified should rise. because you will identify some cancers that would previously not have been
identified. You also hope to see a shift in staging.
My PCT is encouraging me to decrease referrals. How can I persuade them that an increase in
referrals after RAT use is OK?
You need to say that the cancer community is behind this project and wants it to succeed. There is
support from the both the current and previous Governments. Bowel cancer is perhaps the cancer
where the most can be gained in terms of lives saved by lowering the threshold of referral.
Will RATs be rolled out for other common cancers?
Willie Hamilton’s work on colon, lung, brain, prostate and ovary has already been published and the
brain, prostate and ovarian cancer RATs can be made available in pdf form for GPs to use if they
would find them useful [link to be added].
Within the next two to five years, there will be RATs for 12 and possibly 15 different cancers: those
from Willie Hamilton’s work pancreas and bladder are awaiting publication and uterus, kidney and
oesophagogastric are under development. Other academic teams are also working on similar
systems to RATs.
Once multiple RATs are available, they will probably need to be presented in electronic form, though
NCAT is interested in GPs’ views of the usefulness of desktop tools like the easel, which could
accommodate additional RATs.
Will the risk assessment tool be incorporated into GP IT systems?
Macmillan is developing an electronic version of the lung and colorectal RATs, which will be piloted
early in 2012. Part of this project will involve translating symptoms into READ codes as well as
mechanisms for calculating a risk score in real time. There are links between this work and the risk
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assessment tool project to ensure each bit of work informs the other. NAEDI workstream 2 will be
reviewing the range of GP IT systems developments being made as a result of NAEDI related
projects. Eventually all the RATs will be integrated into all major GP IT systems.
Some of the future RATs will have to be symptom based. For instance, haematuria could be a
symptom of bladder, kidney or prostate cancer.
Are there more likely to be undiagnosed cancers in deprived populations?
Cancer mortality is higher in deprived communities but there are issues about survival rates for all
PCTs in the country, not just those areas with higher levels of deprivation. We know there is a
relationship between deprivation and early diagnosis and that public awareness campaigns have a
disproportionate impact on higher socio-economic classes. CAM provided information about socioeconomic status and awareness. The RCGP/NCAT audit showed that people with communication
difficulties and people who were housebound were particularly at risk of late diagnosis.
In development of the RAT, were searches done on read codes or free text notes?
Free text. GPs are good at recording diagnoses, but not so good at recording symptoms. If someone
has a chest infection, you will not write down fever, cough. If READ codes were used, we would have
had dramatic under-reporting of symptoms
When will the final evaluation of the lung and colorectal RAT pilot be published?
Probably February or March 2012. NCAT hopes it will be published in a peer reviewed journal.
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