Value of a simple neurocognitive test at GP Referral for CT scan for Headache Suspicious of Cancer – a “red flag” for tumour.


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Robin Grant1, Karolis Zeinius2, Will Hewins1, David Summers3, Lesley McKinlay3, Paul Brennan1, Lorna Porteous4
1University of Edinburgh, 2Hull Royal Infirmary, 3Royal Infirmary of Edinburgh, 4NHS Lothian

Abstract

Background

Headache is a common cause for referral for imaging for suspected cancer. GPs can order Direct Access Cerebral Imaging (DACI), but waiting times are > 2weeks. We developed an expedited GP e-referral pathway for Headache Suspicious of Cancer and included requirement to document Semantic Verbal Fluency Test (SVFT) -“How many animals can you think of in a minute?”) at the point of referral (GP). The aim of the pilot study was to establish if the SVFT was a “red flag” for secondary causes of headache.

Method

From 2017, in Edinburgh/Lothians, Scotland, an electronic Protocol Based Referral (PBR) was developed for Headache Suspicious of Cancer to expedite cases. The PBR sat alongside the routine e-DACI system that had been in use for some years The GP was asked to complete the SVFT at the time of referral. Other data were gathered: PMH cancer; other symptoms/signs; co-morbid conditions and medications. We also noted whether a) English was first language, b) PMH of Pain Clinic attendance or Psychiatric attendance and c) subsequent scan results and outcome of those cases where SVFT was recorded.

Results

From Mar 2017-Nov 2019 there were PBR 669 scans(62% females; Mean age 53: 60% <60 years). Average time to scan <7 days. SVFT completed in 381 (57%). Median SVFT was 17 animals. Eleven cases had cancer (2.9%): 10/188 cases with SVFT <17 (5.32%). 10/11 cancer cases had SVFT <17 (median 10). One case with cancer had SVFT >=17.

Other possible causes of  SVFT <17 were - 53 psychiatric or chronic pain conditions on multiple drugs.;12 were not native English speakers; 19 had co-existing dementia; 5 had small vessel disease; 4 cysts; 4 Giant Cell Arteritis ; 2 Chiari 1 malformation; PMH encephalitis (1).  

Conclusion

The e-PBR shortened time to scan. SVFT at “point of care” may be a useful, simple fast “red flag”. Low SVFT is associated with structural causes (e.g. brain tumour). Most useful SVFT cut-off requires more research. A larger study of headache including SVFT is justified. 

Impact statement

Low SVFT in headache patients may inform Cancer Referral Guidelines and improve the identification of secondary headache and help expedite cases.