Table 16BRAIN AND CNS CANCER: investigations

AuthorSettingDescriptionNo.InclusionExclusionResultsGold StdQuality
Becker et al Part 1 1993US and CanadaA study to investigate the reasons for clinicians in primary care ordering CT scans and the results obtained.58 practices

349 CT scans were ordered.
Most scans were ordered because the clinician believed that a tumour (49%) or a subarachnoid haemorrhage (9%) might be present. 59 were ordered because of patient expectation or medicolegal concerns. Of the 293 reports reviewed, 14 indicated a tumour, a subarachnoid haemorrhage, or a subdural haematoma. Two of the 14 (14%) were false positives. 44 (15%) of the reports noted incidental findings of questionable significance. It was concluded that because there are no clear guidelines for the use of CT for the investigation of headache, physicians must exercise good clinical judgement in their attempts to identify treatable disease in a cost-effective manner.
Becker et al Part 2 1993This study was undertaken to determine the incidence and presenting signs and symptoms of intracranial tumour, subarachnoid haemorrhage, and subdural haematoma in primary care settings, and to determine whether a more aggressive investigative strategy for patients with headache is justifiable.
Weekly return cards and a chart audit were used to collect data over a 19 month period on every patient who had a new diagnosis of intracranial tumour, subarachnoid haemorrhage, or subdural haematoma
25 new tumours, 17 subarachnoid haemorrhages, and eight subdural haematomas were reported in 58 practices (a rate of 12/100,000 patients per year). Only half of these patients had headaches, and no abnormalities were found on neurological examination of many. Diagnosis was delayed in only four patients with headache caused by a brain tumour and in three patients with subarachnoid haemorrhages. Diagnosis was delayed in two of the latter because of false negative CT scans.
Consensus Conference 1982At the National Institutes of Health (NIH), the Consensus Development Conference brings together investigators in the biomedical sciences, clinical investigators, practising physicians, and consumer and special-interest groups to make a scientific assessment of technologies, including drugs, devices, and procedures, and to seek agreement on their safety and effectivenessIt was concluded that CT should not be employed as a routine screening procedure when a low diagnostic yield is anticipated. In general, patients with headache should be considered for CT scanning only if the symptom is severe, constant, unusual, or associated with abnormal neurological signs. In infants and children, CT is useful as a primary diagnostic tool in the evaluation of intracranial haemorrhage and mass lesions. CT is not necessary in evaluating conditions of the majority of children with headaches because the occurrence of a surgically treatable lesion is extremely low. The clinical situation must, in each case, be considered individually.
Larson et al 1980A careful history and physical and neurological examinations were adequate screens to detect intracranial mass lesions or systematic disease associated with headache161 patientsIn patients with normal findings from neurological examination, no clinically important abnormalities were detected by CT, skull X-ray, angiography, or nuclide brain scan. The cost of finding a case of brain tumour was estimated to be at least $1,265 for patients with abnormalities on neurological examination and $11,901 for patients with normal findings on neurological examination. Neurodiagnostic evaluation of headache patients with normal findings from neurological examination is expensive and was clinically unrewarding in this series.A careful history and physical and neurological examinations were adequate screens to detect intracranial mass lesions or systematic disease associated with headache

From: Appendix B, Evidence Tables

Cover of Referral Guidelines for Suspected Cancer in Adults and Children
Referral Guidelines for Suspected Cancer in Adults and Children [Internet].
NICE Clinical Guidelines, No. 27.
Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester.
Copyright © 2005, National Collaborating Centre for Primary Care.

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