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NICE’s woolly red flags for ovarian cancer

Pick apart the new guidelines aimed at helping GPs combat the ‘silent killer’ and they soon unravel, says Copperfield

Just in case you missed them, here, verbatim, are the suggestions contained in the hot-off-the-press NICE ovarian cancer draft guidelines:

‘Carry out tests in primary care (see section 2.2 on page 41) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

  • persistent abdominal distension (women often refer to this as “bloating”)
  • difficulty eating and/or feeling full (early satiety)
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency.

I read them because, although I do a good impersonation of being a clapped-out cynic, and 99% of the time I am, I retain just a flicker of interest in clinical medicine.

And when you hear about ‘red flags’ for what has traditionally been viewed as a ‘silent killer’, the old diagnostic juices start to flow. Just for a moment. Then they stop. And you go back to being a dessicated old git practitioner again.

Why? Just read the above again. And again. And again. You don’t know whether to laugh or cry, do you? Don’t worry. It doesn’t seem to make sense because of one very good reason. It’s nonsensical.

For starters, there’s the issue of ‘distension’. The guidance helpfully points out that this is often referred to as, ‘bloating’. I’d add ‘swelling’, ‘ballooning up’ and a myriad of other inflationary phrases too. The question is, though, what do NICE and patients actually mean? Genuine swelling? Or subjective swollen feelings? Or both? And what is ‘persistent’? Progressive? Intermittent but continuing? Constant but stable?

This isn’t nitpicking: in presentations as tricksy as ovarian cancer and its mimics, these nuances are the key to finding the needle in the haystack without freaking out large numbers of benignly bloated women.

But there’s worse. We’re supposed to prick up our ears if these symptoms occur ‘more than 12 times per month’. Yes, you read that correctly. That’s ‘12 times per month’. And who, other than a patient whose possible ovarian cancer is accompanied by a side-order of OCD, would be able to say whether they have the symptoms 12 or more times per month as opposed to the more reassuring 11? And what does 12 times mean, anyway? What constitutes 12 episodes of pain? How do you define a single episode of frequency given that the word itself implies ‘often’? And how can ‘persistent’ – suggesting continuous – occur a dozen times?

It’s tempting to make a joke about this being daft more than draft. But I won’t because a) it’s a crap line and b) it’s more serious than that. Because if this is the level of quality and clarity we can expect from NICE these days, then God help us GPs. And God help women with ovarian cancer.

‘Sick Notes’ by Dr Tony Copperfield is out now, available from Monday Books.

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