Decision support could improve bowel cancer diagnosis

Computerised decision support systems could help to improve the process of identifying patients at risk of bowel cancer, researchers argue. They say the traditional system is producing consistently poor results.

GPs currently have to weigh up the significance of symptoms such as rectal bleeding, abdominal pain and changes in bowel habit which may be due to other benign, non-cancerous conditions, as part of the ‘Two Week Wait’ scheme, which was introduced in 2000 to guarantee that any patient needing an urgent referral would see a specialist within two weeks.

However, speakers at the Association of Coloproctology of Great Britain and Ireland conference in Glasgow have argued that GP guidelines for fast-tracking patients were not specific enough.

In some areas fewer than 10% of fast-tracked patients have been diagnosed with cancer, while many patients initially classified as ‘non-urgent’ are later found to have the disease – by which time it may be harder to treat.

In an effort to combat these problems, two registrars have come up with different computerised solutions, which will enable GPs to more accurately identify at risk patients.

Sajal Rai, surgical registrar at Leicester Royal Infirmary designed a system that responds to answers given by patients on a questionnaire and calculates their risk of having cancer.

He told E-Health Insider Primary Care: “GPs in Leicester were increasingly sending patients in using the fast-track referral system, but many were not actually relevant cases and only a few were being diagnosed with cancer. I realised then that the actual symptom guidance used was not necessarily accurate for cancer referrals and wanted to expand on this more for them.”

Rai designed a detailed questionnaire for GPs which they could give to patents to fill in, looking at specific symptoms and psychological aspects of the patient’s conditions. Once completed, GPs can then scan the questionnaire and be offered a risk score based on the answers given. The higher the score, the higher the risk of cancer.

“The system has proven that we can offer GP help with diagnosing patients when already stretched with limited resources and ensure that only those who need referral to be checked are sent to hospital. This does not compromise patient care, but instead helps registrars deal better with ill patients, whilst others are reassured that they do not have cancer.”

In a trial with 1422 completed questionnaires, researchers in Leicester identified 83 cases of bowel cancer. To identify the same number of cases using the Two Week Wait system alone, the team would have had to see 225 more fast-tracked patients.

In a separate study in Bournemouth a survey of 228 GPs from 49 practices showed that only 8% knew all the referral criteria for the Two Week Wait, and over 60% wanted training for referrals under the scheme.

Solomon John, a surgical registrar at Royal Bournemouth Hospital, set out to tackle this problem by developing a Choose and Book compatible decision support system, called e-RP.

“Research we conducted showed that there was a gap in understanding by GPs on how to refer patients under Two Weeks Wait so we devised this application support software, e-RP. We asked the local provider and Connecting for Health if we could embed the e-RP system within Choose and Book in Bournemouth and they kindly agreed to make it an option under the service selection booking guidance tab,” he told EHI.

e-RP offers GPs full decision support in the referrals of bowel cancer cases. The programme evaluates the significance of combination and cluster of symptoms, signs and laboratory test results in individual patients to grade urgency of referral.

“The aim is to help the GP with Two Weeks Wait, based on what the symptoms and signs are being presented, to what is actually applicable for referrals to be made. There are two main purposes – to get the patient seen in hospital without delays, which is important because patients do not always recognise the severity of symptoms.

“Secondly it reminds the GPs that referrals should not just be made for the sake of it, but it depends on what the symptoms actually are. e-RP will grade the presenting patient and offer the GP guidance on the urgency of the individual’s case. The study we have just completed shows it helps improve care pathways, and is popular with GPs.”

Both systems are now under review by the researchers and the NHS, and it is hoped national rollout could begin within the year.

Bowel cancer is the third most common cancer in the UK (after breast and lung). About 100 new cases are diagnosed each day in the UK. In 2003 there were 35,006 new cases of bowel cancer registered in the UK, according to Cancer Research UK.

Links

Association of Coloproctology of Great Britain and Ireland