| Recommendations | Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for renal cancer if they are aged 45 and over and have:
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| Relative value placed on the outcomes considered | Signs and symptoms of renal cancer The GDG considered the positive predictive value to be the most important outcome when identifying which signs and symptoms predict renal cancer. Investigations in primary care for renal cancer The GDG identified sensitivity, specificity, positive predictive values and false negative rates as relevant outcomes to this question. No evidence was found on any of these outcomes |
| Quality of the evidence | Signs and symptoms of renal cancer The quality of the evidence as assessed by QUADAS-II varied from low to high for the positive predictive values for the different symptoms. The GDG noted some limitations of the evidence. Firstly, all the evidence with the exception of two papers had merged all urinary tract cancers making it difficult to tease out the specifics related to renal cancer. Secondly, the evidence did not distinguish between visible and non-visible haematuria, but largely grouped these two together as haematuria. The GDG judged, based on their clinical experience, that most of that evidence was likely to reflect visible haematuria. Investigations in primary care for renal cancer No evidence was found pertaining to the diagnostic accuracy of abdominal ultrasound, urine cytology, intravenous pyelogram, abdominal/pelvic CT scan or X-ray in primary care patients with suspected renal cancer. |
| Trade-off between clinical benefits and harms | The GDG considered that a potential benefit of recommending which symptoms should prompt a suspected cancer pathway referral would be to identify those people with renal cancer more rapidly. However, the GDG recognised the importance of recommending the “right” symptoms, in order to minimise the number of people without renal cancer who get inappropriately referred whilst maximising the number of people with renal cancer who get appropriately referred. In order to strike an appropriate balance between these considerations, the GDG agreed to recommend referral for those symptoms with a positive predictive value of 3% or above. The GDG were confident that at this threshold the advantages of a suspected cancer pathway referral in those with renal cancer outweighed the disadvantages to those without. The GDG noted, based on the evidence, that visible haematuria presenting in a primary care setting was associated with a positive predictive value of above 3% for renal cancer. They therefore recommended this symptom should prompt a suspected cancer pathway referral. The GDG also noted that, based on the evidence, the positive predictive value of visible haematuria for renal cancer increased with age. They therefore agreed to recommend referral for those people aged 45 or over. The GDG agreed, based on their clinical experience that urinary tract infections often cause visible haematuria. They therefore recommended that if visible haematuria persists or recurs after successful treatment of urinary tract infection, a suspected cancer pathway referral should be made. Although the symptoms of abdominal pain and microcytosis had positive predictive values above 3%, the GDG noted that referral for colorectal cancer would normally be the first direction of investigation for these symptoms. They therefore agreed not to make any recommendations for these symptoms related to renal cancer. The GDG noted the absence of evidence for investigations for renal cancer in primary care. Based on their clinical experience they considered that whilst ultrasound is an investigation commonly used to diagnose renal cancer in secondary care, it could have value as an investigation in primary care. The GDG considered that the clinical benefits of renal ultrasound performed in primary care would be to expedite renal cancer diagnosis in people whose symptoms may otherwise not be investigated. However, the GDG recognised that it was difficult to define exactly which symptoms should prompt an ultrasound and consequently some people without renal cancer may also be investigated unnecessarily. The GDG therefore felt unable to make any recommendations on primary care-based investigations for renal cancer. |
| Trade-off between net health benefits and resource use | The GDG noted that no relevant, published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. The GDG noted that the recommendation for a suspected cancer pathway referral for visible haematuria is likely to result in a cost decrease because of the introduction of an age limit. However, the recommendation to refer if there is persistent/recurrent urinary tract infection is likely to represent a small to moderate increase in costs. Overall the GDG agreed these were likely to balance each other. |
| Other considerations | The GDG noted that visible haematuria is a symptom which is common to cancers of the urinary tract. It was therefore, agreed that recommendations for referral of haematuria would need to be consistent for these cancer sites. |
From: 12, Urological cancers
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