P01.21.A Testing Semantic Verbal Fluency (SVFT) in patients with headache suspicious of cancer helps predict those with tumour on imaging

Background

Differentiating secondary headache from primary headache on history alone can sometimes be difficult. Headache “plus” other subtle cognitive features improves prediction. Patients and relatives may attribute subtle cognitive or behavioural changes to other causes (e.g. anxiety, low mood). Sematic verbal fluency - “how many animals can you think of in a minute” is commonly impaired on admission in patients with headache harbouring a tumour. We were interested whether SVFT at point of referral for scan would help predict a tumour and requested GPs report the SVFT on electronic referral for direct access scanning in cases with a history of headache suspicious of cancer. The aim of the pilot study was to establish if the SVFT was a “red flag” for secondary causes of headache. We report the results of a 20-month audit of cases.

Material and Methods

An electronic Protocol Based Referral (PBR) was developed for Headache Suspicious of Cancer to expedite scanning. 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 for scanning. Other data were gathered: PMH cancer; other symptoms/signs; co-morbid conditions and medications.

Results

GPs submitted requests for ePBR scanning in 669 cases over 20 months (62% females; Mean age 53: 60% <60 years). SVFT was completed on the request form in 381 (57%) cases. In these cases median SVFT was 17 animals. 11/381 cases were found to have cancer on scanning (2.9%): 10/188 cases with intracranial tumours had a SVFT <17 (5.32%) compared with one with a SVFT >=17. The median SVFT in cases with cancer was 10 animals. 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

A SVFT result <17, at the point of referral for brain imaging, in patients with headache suspicious of cancer was associated with intracranial cancer in more than 1:20 cases, whereas a SVFT of >=17 was associated with cancer in 1:200 cases. SVFT may be an additional useful “red flag”. The most appropriate SVFT cut-off requires more research in a larger study. Low SVFT in headache patients may inform Cancer Referral Guidelines, improve the identification of secondary headache and help expedite cases.

Selection of headache cases for expedited scanning to assist prompt diagnosis of brain tumour

Aims

Patients with brain tumours and headache commonly have poorer cognitive skills, either overtly or covertly, when cognitively tested. Cognitive changes reflect, tumour mass, fronto-temporal location or hydrocephalus, Previous work has demonstrated that the “semantic Verbal Fluency Test (SVFT) -“How many animals can you think of in a minute?” is a useful fast screening test for cognitive issues. Median SVFT in patients with brain tumour on admission is 10 animals.

Most GPs can now order “direct access cerebral imaging (DACI)” in patients with headache suspicious of cancer. The waiting times for scanning can be many weeks. The aim of this study was to determine whether low SVFT scores: might be useful to help stratify or expedite DACI. We present data from referrals through and electronic Protocol Based Referral (PBR) pathway for CT scanning over 3 years, to determine whether SVFT might be a useful adjunct to history and examination.

Method

From 2017, in Edinburgh/Lothians, Scotland, an electronic PBR was developed with involvement of Primary Care Cancer Lead, PBR lead, Neurology, Neurosurgery and Neuro-Imaging for outpatient imaging of patients in the community with Headache Suspicious of Cancer, to expedite their scans. The PBR sat alongside the routine outpatient DACI system. If the forms were correctly filled in Neuro-Radiology prioritised their appointments. The referrer (GP) was asked to complete the ePBR form and SVFT at the time of referral. Other data were also gathered, including: Past Medical History of cancer; other symptoms/signs; and co-morbid conditions and medications filled automatically from the GP system. This formed the dataset. We also retrospectively assessed a) whether English was first language b) past history of Pain Clinic Attendance or Functional Illness and subsequent final diagnosis of headache/condition, through evaluation of electronic GP referral letters through SCI Gateway system of those cases where SVFT was recorded.

Results

Between March 2017 - November 2019, 669 scans through PBR pathway. (62% females; Mean age 53 years: 60% cases <60 years). SVFT was completed in only 381/669 (57%). Median SVFT was 17. Eleven of 381 cases had cancer (2.9%). 10 cases with cancer had SVFT <17 animals (median 10) (5.32%). One case had SVFT >=17 (35 animals) (0.5%) - CT scan showed small multiple intra-cerebral calcified and non-calcified lesions, consistent with metastases. 12% with PMH cancer had a tumour.

Other possible reasons for low SVFT were: co-existing presumed dementia/mild cognitive impairment (19); non native English speakers (12); headache after traumatic brain injury (5); significant small vessel disease/vascular(5); intracranial cysts (4)(pineal / arachnoid, Giant Cell Arteritis (4) (all new - symptomatic); Chiari 1 malformations (2), PMH – encephalitis (1). Interestingly, there were 53 cases with known psychiatric/pain conditions on drugs (e.g. codeine/antidepressants/antipsychotics) with SVFT < 17 words/min.

Conclusion

People with Headache "Suspicious of Cancer" + SVFT <17 words in a minute are more likely to have a tumour (5.32% vs 0.5%) or other secondary cause for poor cognition.

Other probable causes /associations, with SVFT <17 are age, poor English skills, co-existing dementia. SVFT score may be a useful adjunct or “red flag,” to consider, to expedite DACI scan in patients with “Headache Suspicious of Cancer”. A SVFT >=17 in those with Headache Suspicious of Cancer, does not exclude the possibility of an intracranial tumour. Excluding cases with recognised causes for low SVFT e.g. dementia and those with existing chronic pain/psychiatric disease further increases the likelihood of a secondary cause for headache. SVFT should be tested in the persons native language.

A larger prospective study is required to establish whether these pilot study data and to examine whether chronic pain, functional neurology are negative predictive factors for secondary headache.

Developing facilitation skills amongst undergraduate nursing students to promote dementia awareness with children in a higher education institution (innovative practice)

Final year students on a BSc Hons Nursing programme in Scotland were supported to become Dementia Friends facilitators and develop interactive dementia awareness sessions for children from local schools. The children were invited to indicate phrases and images they associated with 'dementia' at the outset and end of the session. Analysis of the responses suggested that there were positive changes in the children's values and beliefs when thinking about a person living with dementia during the sessions. We suggest that peer learning is a valuable strategy to increase public and professional awareness about dementia and supports the development of graduate attributes.