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Cancer in people presenting with back pain in Primary Care (CANBACK): A prevalence and diagnostic accuracy study

Musculoskeletal pain is a common presentation to NHS primary care in England, accounting for approximately 1 in 5 presentations, of which the majority are for back pain. Whilst most presentations can be managed conservatively, clinicians are confronted with the possibility that patients who present with a new episode of back pain may have cancer as an underlying cause. The majority of clinical features are too generic to be clinically useful when cancer-screening patients who present with back pain. 

This study will investigate the risk of cancer diagnosis when clinical features are associated with a new episode of back pain. 

AIMS

Musculoskeletal pain is a common presentation to NHS primary care in England, accounting for approximately 1 in 5 presentations, of which the majority are for back pain. Whilst most presentations can be managed conservatively, clinicians are confronted with the possibility that patients who present with a new episode of back pain may have cancer as an underlying cause.  

Currently to identify low back pain patients with a higher likelihood of cancer, clinicians use clinical experience and presence of clinical features from the history and physical examination. Despite their endorsement in clinical practice guidelines, the majority of clinical features are too generic and poorly specified to be clinically useful when cancer-screening patients who present with back pain. 

To select patients who may benefit from further investigation (e.g. blood tests, imaging, specialist referral), clinicians need access to an informative screening tool for patients who present with back pain. 

HOW ARE WE INVOLVING PATIENTS AND PUBLIC

A cohort analysis using primary care data from the UK Clinical Practice Research Datalink (CPRD) database will be undertaken. Cancer diagnoses will be obtained from the National Cancer Registration and Analysis Service (NCRAS), Hospital Episode Statistics (HES) database, and the Office of National Statistics (ONS) (if related to death). We will first describe how often people present with a new episode of back pain and of these, how often cancer is diagnosed within the following 12 months. We will then identify the diagnostic predictive value of additional clinical features for cancer. Finally, a 12-month cancer-risk prediction model will be developed and tested for patients with back pain using clinically relevant covariates and those with high predictive ability. 

We will include consumer advisors as a patient and public involvement (PPI) group, who will convene throughout the project to review progress, interpret findings, and contribute to study reporting. 

How we are planning to implement the research outputs

The main output from this study will be creation and validation of diagnostic screening models to identify risk of undiagnosed cancer in patients with a new episode of back pain, which is a common presentation to primary care.  

The screening model would identify high-risk patients to help GPs decide if the back pain can be managed conservatively or requires referral for cancer investigation, leading to increased cancer yield, timely intervention, and improved survival outcomes.  

We will advance on the knowledge of which clinical features (“red flags”) are beneficial in detecting cancer to endorse in future clinical practice guidelines for management of back pain. 

Project members: