Scenarios for discussing safety netting

Scenarios for discussing safety netting Dr Richard Roope Central South Coast Cancer Network

Case Study 1 – 67 yo male 67 year old male presents with 2 week history of “diarrhoea”, some abdominal pain and general malaise. He tells you his wife persuaded him to make the appointment. He recalls having eaten some “dodgy” paté around the time the diarrhoea started. The examination is unremarkable. What is your differential diagnosis? What is the RAT score? What tests do you order? Do you prescribe anything? What do you tell the patient?

RAT – Colorectal Cancer – >1 symptom/sign Positive predictive value Abdominal pain and diarrhoea

Case Study 1 – 67 yo male The stool sample reported: “faeces unformed, -ve for E Coli, Campylobacter, Salmonella etc” As requested he has returned two weeks later. He still has diarrhoea, and on direct questioning has noticed some blood streaking within the diarrhoea, and is now feeling generally tired. Examination now elicits abdominal tenderness, no other signs are elicited (inc normal pr). What is your differential diagnosis? Has it changed? What is the RAT score now? What tests do you order? Do you prescribe anything? What do you tell the patient?

RAT – Colorectal Cancer – >1 symptom/sign Positive predictive value Abdominal pain, tenderness, blood and diarrhoea

Case Study 1 – 67 yo male As requested he has some back two weeks later. The diarrhoea eventually settled down a week ago, and there has been no more blood and he reports that he feels much improved. He still feels a little tired. The abdominal examination shows no abnormality. The FBC is “not back”. On questioning he reports that he didn’t get round to having the blood test. What is your differential diagnosis? Has it changed? What tests do you order? Do you prescribe anything? What do you tell the patient?

Case Study 1 – 67 yo male The Hb result comes through on path links three days later – 9.8. What is your differential diagnosis? Has it changed? What is the RAT score now? What is your course of action? What do you tell the patient?

RAT – Colorectal Cancer – >1 symptom/sign Positive predictive value Abdominal pain, tenderness, blood and diarrhoea. Hb 9.8

Case Study 1 – 67 yo male You tell him that the low Hb raises the possibility that he may be losing blood from the bowel and that you now need to make a referral through the 2ww pathway to exclude the possibility of bowel cancer. He advises you that he is due to go to stay with his sister in Yorkshire next week for 10 days, and asks if the referral is necessary. What do you say to the patient?

Case Study 1 – 67 yo male On your advice he postpones his stay with his sister. You make a 2WW referral He is found to have a polyp in the descending colon Histology shows him to have adenocarcinoma of the colon His care is overseen by the MDT He had a Duke’s A CRC and makes a full recovery and has no further problems.

Risk Factors for Colorectal Cancer These also can be helpful to raise awareness. Know your patient’s lifestyle...

Safety-netting • Practice system if patient fails to attend for investigation or clinic? • Practice system if results/correspondence go to ground? • Not sufficient to say: “Come back if it doesn’t get better”

Safety-netting - Screening • Bowel cancer screening DNA notifications • Enter into computer history • Flag record (computerised post-it) so next contact with Primary Care Team patient will be reminded • Letter sent to patient from surgery • may be worth GP signing • To provoke a response may include phrase along lines of:

Safety-netting - Screening Dear We have recently been advised by the National Bowel Screening Programme that you failed to return the test kit for analysis. The Practice firmly believes that this simple test is a valuable aid in detecting any potential signs of bowel cancer cells, and would encourage you to reconsider your decision. You should continue to be aware of any bowel symptoms such as: • A persistent change in bowel habit, especially going to the toilet more often or diarrhoea for several weeks • Bleeding from the back passage without any obvious reason • Abdominal pain especially if it is severe • A lump in your abdomen Please remember that these symptoms do not necessarily mean that you have bowel cancer, but if you have one or more of these symptoms for four to six weeks, you should see your GP. Should you no longer have the test kit and now wish to take part, you can call the Screening freephone number 0800 707 6060 and ask for another. If, after careful consideration, you decide not to take part, please would you let us know by returning the slip below. Your decision will have no impact on any future medical services provided by the Practice. Yours Sincerely, Main and Branch Surgeries I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it. (signed)…………………………………………………

Safety-netting - Screening I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it. (signed)…………………………………………………

Safety-netting – Investigations if cancer is on differential diagnosis • Blood tests (if checking for tiredness, shortness of breath) • CXR • USS for ?ovarian cancer • Systems in practice so if result not received can be followed up.

Safety-netting – 2ww referrals • A surprising number of 2ww referral patients who fail to attend/postpone • Make sure patient understands that referral is to exclude the possibility of cancer • Have system to follow up/flag up any DNAs at 2ww appointments (similar to screening DNAs) • May be regarded as good practice to ask patient to have GP follow up 4 weeks after referral to 2ww, as by then the diagnosis is likely to have been met.

Other elements of safety-netting include: • Communicating the existence of uncertainty • Outlining exactly what the patient needs to look out for • How to seek further help and • What to expect about time course

Scenarios for discussing safety netting