Delphi method to identify expert opinion to support children’s cancer referral guidelines

Abstract

BackgroundThe National Institute for Health and Care Excellence (NICE) guidance for referral of children with suspected cancer was first published in 2005 and updated in 2015. The updated version relied on sparse primary care evidence and published without input from key stakeholders, for example, acute general paediatricians and paediatric haematologists/oncologists. This led to a document that fell short as a practical guide for referring physicians managing children with potentially life-threatening conditions. Following discussions between the Children’s Cancer and Leukaemia Group (CCLG, the UK multidisciplinary professional body for healthcare professionals caring for children with cancer) and NICE, it was agreed that a practical supplement should be produced for the 2015 guidance. A prerequisite was evidence gathering from tertiary care to balance the existing primary care evidence, and a Delphi consensus method was therefore convened.MethodsA CCLG NICE Guidance Committee formulated 25 draft statements for review. The CCLG emailed its paediatric haematologist/oncologist membership (n=179) and 88 responded (49%). To achieve consensus, statements required ≥70% agreement from ≥60% of actual respondents, from the denominator (n=88).ResultsFifteen of 25 original statements were accepted at the first round of voting. Three of 25 statements where >50% did not support were rejected outright. One statement could not be revised without replicating a previously accepted statement. The six remaining statements were revised and a second round of voting undertaken; all six revised statements were accepted. Overall, 21 of 25 statements (84%) met consensus criteria.ConclusionsThis expert opinion should help streamline suspected cancer referral in children and help optimise subsequent outcomes.

Hodgkin Lymphoma Presenting With Spinal Cord Compression: Challenges for Diagnosis and Initial Management

“…For this reason, it is important to keep a very broad differential when a child or adolescent presents with back pain. For example, back pain in a child causing waking from sleep should result in urgent referral to pediatrics 15 and neurological deficits should also always be considered a ‘red flag’ and urgent imaging arranged. A study of patients presenting with a malignant cause for spinal cord compression found that neuroblastoma (29%), soft-tissue sarcomas (21%), neuroectodermal tumors (17%) and non-Hodgkin lymphoma (13%) made up the majority of cases.…”

Fifteen-minute consultation: A structured approach to the child with palpable cervical lymph nodes

“…The current National Institute for Health and Care Excellence (NICE) suspected cancer guidelines9 do not provide lymph node size criteria to help differentiate which children require referral from primary to secondary care. However, paediatric haematologists and oncologists in the UK consider small (<1 cm) palpable CLNs to be physiological, even if they are persistent 10. Those CLNs that are small and fluctuate in size are almost certainly benign and are likely to be reactive in nature 1.…”

“…Those CLNs that are small and fluctuate in size are almost certainly benign and are likely to be reactive in nature 1. Lymph nodes that continue to measure greater than 2 cm for longer than 6 weeks warrant referral to secondary care 10. The associated symptoms and signs which should also be considered alongside CLN size to determine which children require further investigation are discussed below.…”

“…Supraclavicular nodes specifically drain the thyroid gland, lungs, and the upper gastrointestinal and genitourinary tracts—their enlargement is more specific for atypical infection (non-tuberculous mycobacterial infection, cat scratch disease) or malignancy (lymphoma, thyroid cancer, neuroblastoma). While generalised small lymph nodes are rarely an indicator of malignancy, unilateral, asymmetric, posterior triangle or supraclavicular lymphadenopathy which is bulky or enlarging requires investigation in the majority of cases 1 10…”

Comment on Pediatr Blood Cancer. 2022;e29589. Standardizing the surgical management of benign ovarian tumors in children and adolescents: A best practice Delphi consensus statement.

“…The denominator (number of experts approached to be involved) and response rate is not stated. The standard thresholds for accepting Delphi statements is >70% votes in support from >60% of experts in each voting round [2], as used in Delphi studies undertaken by the authors here [3,4]. Furthermore, there is no indication of level of support for statement(s) not reaching the 70% threshold.…”