Monaz: Hello, I'm Monaz Mehta, editor in the Cochrane Editorial and Methods department. In March 2021, the Cochrane Neuro-Oncology Group published a series of eight new systematic reviews on priority topics for the brain tumour community. These were selected from the most important unanswered questions identified by people in this area, using James Lind Alliance Priority Setting Partnership methods, which bring together patients and the public with practitioners. In this podcast, one of the Group's consumer representatives, Helen Bulbeck, talks with lead author Robin Grant, a consultant neurologist involved in the Edinburgh Centre for Neuro-Oncology in the UK, which is one of the Tessa Jowell Brain Cancer Mission Centres of Excellence, about the recent review of interventions to reduce time to diagnosis of brain tumours.

Helen: Hello Robin, first of all, could you tell us a little about the importance of time to diagnosis for the brain tumour community?

Robin: Hello Helen. When someone is diagnosed with a brain tumour, it's common for them or their family to be concerned that either they should have approached health services sooner or that symptoms they were worried about were not taken seriously enough by clinicians, meaning that they did not receive a prompt diagnosis. They feel that if they had been diagnosed earlier, something more curative could have been done when the tumour was smaller.
However, this is not straightforward. Many symptoms of brain tumour are common to other conditions, such as simple headache and stress symptoms. For instance, a brain tumour may be the reason in only one in a thousand cases of a new headache and perhaps one in five hundred people who have cognitive issues that could be attributed to stress. If everyone with these types of symptom was referred for scanning to check for a tumour, there would have to be a massive increase in scanning and paradoxically, because of the huge waiting lists this would cause, a patient who actually has a tumour may have to wait much longer before diagnosis. 

Helen: This clearly makes it important to understand the effectiveness of different ways to shorten the time to diagnosis, which is where your review comes in.

Robin: Yes, absolutely. The two important things for patients and doctors to do are firstly recognise pointers in the patient's history that make a brain tumour more likely, we call these 'red flags' and secondly, patients and GPs need to find the best way to quickly get a diagnosis or scan and this is called 'the patient pathway'. It's this second part that we cover in the review, using the available evidence for things that might 'speed up' diagnosis.

Helen: With that in mind, what did the review look at? 

Robin: We looked at interventions that might reduce the 'patient interval' between first symptom and attending for medical help, the 'primary care interval' between the patient presenting to the GP and the GP referring them for a hospital opinion, and 'time to imaging diagnosis' from being first seen to having the diagnostic scan.
The interventions were those that might speed up the handling of 'neurology-specific' pathways or 'stroke-like' presentations; epilepsy-like presentations and other presentations, like headache and cognitive problems; 'cancer specific' pathways and policies to increase 'direct access cerebral imaging' from primary care, and fast access routes to clinical appointments or outpatient scans within the two weeks of referral for 'Suspicion of Cancer' that is recommended in guidelines. 

Helen: Did you find the evidence you needed?

Robin: We found 115 studies in these areas, but they were small audits or before and after studies without control groups. This means that they don't provide the quality of evidence needed to provide a reliable answer. This leaves us with a need for high quality, well designed research in this important area.

Helen: What types of research would you like to see?

Robin: One way to find interventions that reduce the time for people to present to clinicians, in other words to shorten the patient interval, would be for studies to compare an educational campaign in one region of a country with a different campaign in another region. 
To reduce the primary care interval, trials might test new pathways for fast access scanning in people with headache and memory problems by randomising patients to open access MRI versus a neurology referral, to see the effect on time to scanning diagnosis.
Moving onto the 'secondary care interval', randomisation might be used to refer some patients to new cancer rapid diagnostic centres while others follow a standard general imaging pathway. And, finally, to reduce the 'diagnostic interval', we'd like to see studies comparing the impact of adding a new service, such as an additional scanner or direct access cerebral imaging to current practice. 

Helen: Overall, what's your take-home message for reducing the time to diagnosis of brain tumours?

Robin: It's likely that more scanners and more scanning time will reduce the time to diagnosis, but there is a need to develop better expedited electronic pathways for patients with 'red flags', such as headache plus cognitive or behavioural symptoms to specialist services. Clinical research to find the effectiveness of these pathways needs to be given priority.

Helen: Thanks Robin. If people would like to read the review, how can they get hold of it?

Robin: Thanks Helen. The review's available online – just go to Cochrane Library dot com and type 'time to diagnosis of brain tumours' in the search box to find it.