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NICE Suspected Cancer Guidelines

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NICE Suspected Cancer Guidelines

The NICE guidance NICE NG12 from 2015 is already having a major impact on primary care, with urgent referral pathways being radically changed.

It has had a significant update in July 2017 related to using faecal immunochemical tests (FIT) to guide referral for colorectal cancer in primary care.

The 2017 update of the guideline now advises the new FIT test is used as the preferential test (these are more sensitive than the older tests and only one test is needed) for occult blood in faeces. The original 2015 NICE guideline had a rather confusing list of criteria for when we should test for occult blood. NICE guidance is now much more general. They now advise that the FIT test should be used in primary care to guide referral for suspected colorectal cancer in patients with symptoms without overt bleeding but who do not meet the urgent cancer referral criteria.

In Scotland, the Scottish referral guidelines for suspected cancer have been published by Health Improvement Scotland, which we cover separately.

NICE Suspected Cancer: recognition and referral NICE 2015, NG 12

These guidelines are already having a major impact on the NHS and how we work. The government has committed to an extra £300M per year over the next 5 years to help implement them. They were summarised in BMJ2015;350:h3044 and BMJ2015;350:h2418 and discussed in a wise and thought provoking BMJ editorial by GP Kevin Barraclough BMJ2015;351:h3640. These ‘game changing’ guidelines, he states, are a major overhaul and ‘reflect monumental scholarship and are unique in the world’. They should be welcomed, not least because they are more nuanced and less didactic than previous guidelines. They were also discussed, and broadly welcomed, in a BJGP editorial BJGP2015;65;446

When considering the guideline, a crucial point is that all the included evidence came from primary care studies. Patient selection, clinical responsibility and setting should all have been conducted in primary care to be eligible for inclusion, which makes it (the authors believe) the most evidence-based primary care applicable guideline. Key points from the guideline:

  • Recommendations are organised both by cancer site (as is traditional) but also, for the first time, by presenting symptoms.
  • The guideline explicitly encourages GPs to use their clinical judgement. They state: ‘these recommendations are recommendations, not requirements, and they are not intended to override clinical judgement’. The guideline asks clinicians to continue to trust their clinical experience and it assumes a full history, examination and primary care appropriate initial blood tests have been done. Recommendations are for symptoms or signs, which are ‘persistent and unexplained’ i.e., you have been unable to make a diagnosis after your initial primary care assessment.
  • The positive predictive values (PPV) referral threshold for cancer, has been lowered from 5% to 3% (less for children). The authors trawled through the primary care literature to find which clinical features are associated with a >3% positive predictive value (PPV) of cancer and recommends that these should be referred urgently. A 3% threshold will obviously lead to many more referrals.
  • There will be more direct access to investigations for GPs, such as scanning and endoscopy (including brain MRI and abdominal CT).
  • We are encouraged to consider using a wider range of diagnostic tests in certain clinical situations (e.g. faecal occult blood testing as a diagnostic test, PSA tests with LUTS) and to re-consider how we interpret some tests (e.g. platelet counts)
  • Safety netting and referral. The guideline makes these points, which have important implications:
    • The healthcare professional who orders the investigation takes responsibility for reviewing and acting on the results appropriately, or of passing on responsibility for this
    • Be aware of the possibility of false negative results (e.g. for CXRs and faecal occult blood tests) and refer if symptoms continue
    • Discussion with specialists is recommended when there is uncertainty about symptoms, signs, results or urgency of referral
    • Once a decision to refer has been made, make sure that the referral is made within one working day

So, what are the recommendations?

There are recommendations for 37 different cancer types and well over 100 different symptoms over 378 pages! The quick reference PDF is nearly 100 pages long. (NB a criticism of the guideline is therefore its complexity, compared to a single electronic tool such as QCancer ). The recommendations can be viewed and used on-line on the pathways pages:

By Symptoms: NICE pathways

By Cancer Site or Type: NICE pathways

NICE & Cancer Research UK have also produced an Interactive Desk Easel you can download to help navigate the guidance

To make it easier for you, we have synthesised the site and symptoms pathways into a single KISS guide to the most common presentations and cancer sites and highlighted some of the clinical implications.

The words used in the guideline have specific meanings:

  • Unexplained means that a diagnosis has not been made in primary care after appropriate history, examination and primary care investigation.
  • Offer denotes a stronger level of recommendation than consider, based on stronger evidence.
  • Patient values and preferences should of course be taken into consideration when discussing referral options
  • Urgent means within 2 weeks (i.e. consistent with 2 week wait, 2WW), very urgent within 48 hours and immediate is what it says on the tin!
  • Children and young people means birth to 24

Quality Improvement Ideas: Early diagnosis of cancer

  • Include some recent cancer diagnoses as significant events. Could any have been diagnosed at an earlier stage?
  • Organise some in-house training based around these new guidelines
  • Are FIT (faecal immunochemical tests) available to you? Do you have direct access to abdominal CT or brain MRI? Liaise with your local providers and commissioning group to make these investigations available.
  • Do you need to revise local referral pathways?

Learning Points: Early diagnosis of cancer

  • We really do have a problem with late diagnosis of cancer...it is estimated implementation of these guidelines will save 5,000 lives per year
  • Improving early diagnosis via earlier and more streamlined referral is a key part of Achieving World Class Cancer Outcomes 2016 Report in England
  • New guidelines from NICE and in Scotland encourage earlier referral across a broad range of different cancers and symptoms. These introduce some key changes to practice and contain multiple learning points.
  • Testing for faecal occult blood as part of the clinical assessment of patients presenting with abdominal symptoms but without overt bleeding should now be routine. NICE now advise using the newer FIT test to help aid colorectal cancer referral decisions in patients presenting with abdominal symptoms but without overt rectal bleeding.
  • Consider a DRE and PSA for all men presenting in primary care with LUTS or erectile dysfunction, with appropriate patient counselling. DRE is a useful examination in primary care to distinguish between prostate cancer and BPH.
  • NICE criteria:
  • Scottish Guidelines

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