Practice Uncertainties

Can safety-netting improve cancer detection in patients with vague symptoms?

BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i5515 (Published 09 November 2016) Cite this as: BMJ 2016;355:i5515
  1. Brian D Nicholson, clinical researcher,
  2. David Mant, emeritus professor of general practice,
  3. Clare Bankhead, university research lecturer
  1. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG
  1. Correspondence to: B D Nicholson brian.nicholson{at}phc.ox.ac.uk

What you need to know

  • Safety-netting is best practice, but there is an absence of evidence on whether it improves cancer detection and how best to do it in patients with vague symptoms

  • Explain the uncertainty about the cause of symptoms to patients, ensuring they understand why, when, and with whom they should re-consult about which concerning symptoms

  • Establish systems to ensure test results are reviewed by somebody with knowledge of cancer guidelines and that positive and negative results are communicated to the patient promptly

Patients present daily about symptoms that could represent a new diagnosis of cancer.1 Some will present with easily recognised high risk symptoms such as dysphagia (5% likelihood of cancer if age >55 years), postmenopausal bleeding (4% likelihood if age >55 years), or haemoptysis (2% likelihood if age >40 years). But most will have vague or non-specific symptoms such as cough, fatigue, or abdominal pain.2 3 4 As these symptoms are shared with benign, chronic, or self limiting conditions, the likelihood of cancer is low (mostly under 0.5%).1 The clinical consequence is that diagnosis of cancers with vague symptoms tend to be delayed: for example, about half of patients in England with multiple myeloma have to consult three or more times before referral,5 and over a third present to hospital as emergencies.6 Depending on the cancer site, reducing diagnostic delay can lead to improved survival, earlier stage at diagnosis, and improved quality of life.7

The answer to this diagnostic problem is not to investigate every low risk symptom at first consultation.8 Doctors have a responsibility to avoid causing unnecessary alarm and wasting scarce resources through over-investigation, which may result in harm to the patient. Teasing out serious disease by following up patients over time, with planned sequential investigation, is usually the best approach for …

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