Suspected Lung Cancer in Primary Care

Suspected Lung Cancer in Primary Care (2021), available at www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/lung-cancer [10], provides recommendations for primary care providers for the investigation and management of adult patients (19 years of age and older) who present with signs or symptoms suggestive of lung cancer. Recommendations include the clinical assessment and appropriate referral of patients to a specialist. This guideline was developed in collaboration with the BC Cancer Primary Care Program (Family Practice Oncology Network) and was based on a guideline adaptation approach, including a recent systematic search of the evidence.

Highlights and key recommendations include:

• Tobacco remains the most significant cause of lung cancer.
• Smoking after a cancer diagnosis increases the risk of all-cause and cancer-specific mortality, adverse effects on treatment outcomes, and recurrence or secondary cancers. Efforts should be focused on supporting patients to quit smoking and to reduce exposure to secondhand smoke.
• Although smoking represents the largest risk factor, there is increasing recognition of the rise in cases of lung cancer in people who have never smoked.
• When communicating with patients with lung cancer, health care providers should avoid bias based on assumptions about smoking history.
• Regardless of smoking history, patients with persistent, atypical, or otherwise unexplained cough or chest infection should be sent for a chest X-ray. If the chest X-ray is negative but symptoms persist, additional investigations, including contrast-enhanced CT scan of chest to include adrenals, should be ordered.
• Long-term exposure to high concentrations of radon is a risk factor for lung cancer, particularly in smokers. Radon is found in outdoor air in low concentrations. In indoor environments, radon levels can be much higher. Radon levels in BC are variable but may be higher in some communities east of the Coast Mountains.
• The following require an urgent referral to the emergency department: stridor, massive hemoptysis, new neurological signs suggestive of brain metastases or cord compression, superior vena cava syndrome or obstruction, or a large unilateral pleural effusion.

Cataract—Treatment of Adults

The scope of the guideline Cataract—Treatment of Adults (2021), available at www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/cataract [11], is to provide recommendations for primary care providers in the prevention, diagnosis, management, and postoperative care of cataracts in adults (19 years of age and older).

Highlights and key recommendations include:

• The following are recommended to delay the onset and progression of cataracts: smoking cessation, reduced UVB exposure (hats, sunglasses with UVB protection), and safety eyeglasses during high-risk activities to avoid eye trauma.
• Patients who are long-term users of corticosteroids (by any route) should be informed of the increased risk of cataract formation.
• Indications for cataract surgery are not limited to Snellen visual acuity alone, and referral for cataract surgery consultation is indicated in the setting of glare, monocular diplopia, and other nonvisual functional impairment.
• Cataract surgery may be indicated in other ocular diseases for reasons independent of vision rehabilitation.
• When a cataract lens is surgically removed, it is replaced with a synthetic intraocular lens (IOL). There are many types of IOLs available. IOL technologies and choices continually evolve, as does MSP coverage of IOLs. Patients can be reassured that MSP-covered monofocal lenses provide fully satisfactory visual correction in the vast majority of patients. Glasses are usually required after surgery for near and sometimes also distance vision. Non-MSP-covered lenses may lessen dependency on glasses postsurgery but may not be appropriate for all patients due to individual suitability or side effects. IOL selection evolves out of a comprehensive discussion with the surgeon.
• Primary care practitioners should be aware of postoperative red flags. Postoperative patients should be urgently assessed (within 24 hours) by their surgeon or an on-call ophthalmologist in the case of increasing eye redness, pain, or a decrease in vision (see Table 4 at www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/cataract [11] for more details).

Fall Prevention: Risk Assessment and Management for Community-Dwelling Older Adults

The scope of the guideline Fall Prevention: Risk Assessment and Management for Community-Dwelling Older Adults (2021), available at www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/fall-prevention [12], is to address the identification and management of adults aged 65 years and older living in the community with risk factors for falls. It is intended for primary care practitioners. The guideline facilitates individualized assessment and provides a framework and tools to manage risk factors for falls and fall-related injuries. Hospital, facility-based care settings, and acute fall management are outside the scope of this guideline, although some of the principles may be useful in those settings.

Highlights and key recommendations include:

• Annually, or with a significant change in clinical status, ask patients 65 years of age and older about their fall risk using simple 1-minute screening tools:
  • Three-question approach.
  • Staying independent checklist.
• Recommend exercise to improve strength, balance, and safe mobility. This is the most effective fall-prevention intervention. See the “Exercise Prescription and Programs” section for more information.
• For those evaluated as “at risk” or who have had a fall, a multifactorial risk assessment is recommended over multiple visits (see the “Multifactorial Risk Assessment, Fall History and Intervention” section) to review:
  • Medications.
  • Medical conditions (including common geriatric conditions).
  • Mobility (endurance, strength, balance, and flexibility).
  • The home environment.
  • Osteoporosis risk and risk management (increases the risk of a fracture from a fall).
• After a fall, interdisciplinary assessment and care planning can reduce the risk of future falls. A team-based approach, when available, is recommended (see the “Referral Options” section).

Other updates

To stay up to date with BC guidelines, visit the “What’s New” section of the home page at www.bcguidelines.ca [13] and subscribe to the e-bulletin.