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NICE guideline focuses on symptoms to diagnose cancer earlier
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The National Institute for Health and Clinical Excellence (NICE) has published a new guideline designed to achieve earlier detection of cancer in people in the UK by using a symptom-based approach to guide general practitioners (GP) when to take action and what action they should take. This includes referring patients directly for urgent diagnostic tests or further investigation without the need for specialist referral. With the development of the guideline, Suspected Cancer: Recognition and Referral, NICE has recognised that the first indications of a possible cancer are usually identified in primary care. The 2005 guideline on this topic is now completely updated and replaced, and focuses on the symptoms that cause a patient to consult their GP rather than specific cancers. It draws on evidence from primary care rather than secondary care with the aim of making it easier for GPs to consider the possibility of cancer sooner and refer people for appropriate tests more quickly. “This guideline, uniquely amongst guidelines of this type, presents the evidence on the way that patients present to their GPs. It reflects real life and we expect it to have a major impact on the success rate for cancer in England”, explains Mark Baker (Centre for Clinical Practice at NICE, UK). The institute estimates that earlier cancer diagnoses could save around 5000 lives each year in England. Recognising that GPs usually see an average of only eight new cases of cancer each year, the guideline links signs and symptoms to possible cancers with simple recommendations on which tests
are indicated and the type of referral to specialist services that is needed. Symptoms are arranged in alphabetical order so they are easy to find. For example, the guideline lists upper abdominal pain with weight loss in a person aged more than 55 as being linked to possible oesophageal or stomach cancer and recommends that GPs offer urgent direct access for gastrointestinal endoscopy to be undertaken within two weeks. The recommendations were developed using a risk threshold of the likelihood that a patient’s symptoms might be caused by cancer to determine the further action that GPs should consider taking. The previous 2005 guideline used a disparate range of risks but the guideline development group decided that a single threshold based on a positive predictive value of 3% for adults, and lower for children and young people, should be used to improve early diagnosis. With this lower threshold, the updated guideline will cause a major increase in the demand for investigations and imaging scans. GPs are already able to request X-rays, blood tests, and some scans, but the new guideline means that they can also send patients for urgent endoscopy, MRI, or CT brain scans. “Direct referrals from GPs for diagnostic imaging tests are a valuable way of improving the early diagnosis of cancer but these recommendations have major implications for radiology services”, says Giles Maskell (Royal College of Radiology, London, UK). He explains, “The stated aim of the new NICE guidelines is to reduce the threshold for testing people with symptoms such that instead of one in ten patients referred under the two week
rule being found to have cancer, the figure will be around one in thirty. This means potentially a three-fold increase in the numbers of patients referred for urgent testing.” Maskell warns that NHS radiology services are unable to cope with current levels of demand. A snapshot survey of English NHS trusts in February 2015 suggested that almost 330 000 patients wait more than a month for the results of x-rays and 8000 for results of CT and MRI scans. “As yet, no provision has been made to increase capacity in radiology services to cope with the increased volume of referrals”, he notes, adding that the college is continuing to lobby the Department of Health, NHS England, and Health Education England, as well as the devolved governments of Scotland and Wales, to put measures in place to increase capacity. Greg Rubin (Durham University, Durham, UK) is leading a Commission on the expanding role of primary care in Cancer control, due to be published in October 2015 in the The Lancet Oncology. The role of primary care in improving the detection of cancer will be part of a review of the evidence of innovative models of care in the diagnosis and ongoing management of people with cancer. Rubin says, “the driving aim is what works best for patients.” He adds, “the population is living longer and more people are developing cancer. The role of primary care is increasingly being recognised as an efficient and effective way of maximising health within a population. So this a timely opportunity to reconsider in what respects primary care can contribute to cancer control.”
AJ Photo/Science Photo Library
NICE guideline focuses on symptoms to diagnose cancer earlier
Lancet Oncol 2015 Published Online July 3, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00131-X For more on the NICE guideline see www.nice.org.uk/guidance/ ng12/evidence/ fullguidance-65700685 For more on The Lancet Oncology Commission see http:// www.thelancet.com/campaigns/ cancer/primary-care
Susan Mayor
www.thelancet.com/oncology Published online July 3, 2015 http://dx.doi.org/10.1016/S1470-2045(15)00131-X
1
The National Institute for Health and Clinical Excellence (NICE) has published a new guideline designed to achieve earlier detection of cancer in people in the UK by using a symptom-based approach to guide general practitioners (GP) when to take action and what action they should take. This includes referring patients directly for urgent diagnostic tests or further investigation without the need for specialist referral. With the development of the guideline, Suspected Cancer: Recognition and Referral, NICE has recognised that the first indications of a possible cancer are usually identified in primary care. The 2005 guideline on this topic is now completely updated and replaced, and focuses on the symptoms that cause a patient to consult their GP rather than specific cancers. It draws on evidence from primary care rather than secondary care with the aim of making it easier for GPs to consider the possibility of cancer sooner and refer people for appropriate tests more quickly. “This guideline, uniquely amongst guidelines of this type, presents the evidence on the way that patients present to their GPs. It reflects real life and we expect it to have a major impact on the success rate for cancer in England”, explains Mark Baker (Centre for Clinical Practice at NICE, UK). The institute estimates that earlier cancer diagnoses could save around 5000 lives each year in England. Recognising that GPs usually see an average of only eight new cases of cancer each year, the guideline links signs and symptoms to possible cancers with simple recommendations on which tests
are indicated and the type of referral to specialist services that is needed. Symptoms are arranged in alphabetical order so they are easy to find. For example, the guideline lists upper abdominal pain with weight loss in a person aged more than 55 as being linked to possible oesophageal or stomach cancer and recommends that GPs offer urgent direct access for gastrointestinal endoscopy to be undertaken within two weeks. The recommendations were developed using a risk threshold of the likelihood that a patient’s symptoms might be caused by cancer to determine the further action that GPs should consider taking. The previous 2005 guideline used a disparate range of risks but the guideline development group decided that a single threshold based on a positive predictive value of 3% for adults, and lower for children and young people, should be used to improve early diagnosis. With this lower threshold, the updated guideline will cause a major increase in the demand for investigations and imaging scans. GPs are already able to request X-rays, blood tests, and some scans, but the new guideline means that they can also send patients for urgent endoscopy, MRI, or CT brain scans. “Direct referrals from GPs for diagnostic imaging tests are a valuable way of improving the early diagnosis of cancer but these recommendations have major implications for radiology services”, says Giles Maskell (Royal College of Radiology, London, UK). He explains, “The stated aim of the new NICE guidelines is to reduce the threshold for testing people with symptoms such that instead of one in ten patients referred under the two week
rule being found to have cancer, the figure will be around one in thirty. This means potentially a three-fold increase in the numbers of patients referred for urgent testing.” Maskell warns that NHS radiology services are unable to cope with current levels of demand. A snapshot survey of English NHS trusts in February 2015 suggested that almost 330 000 patients wait more than a month for the results of x-rays and 8000 for results of CT and MRI scans. “As yet, no provision has been made to increase capacity in radiology services to cope with the increased volume of referrals”, he notes, adding that the college is continuing to lobby the Department of Health, NHS England, and Health Education England, as well as the devolved governments of Scotland and Wales, to put measures in place to increase capacity. Greg Rubin (Durham University, Durham, UK) is leading a Commission on the expanding role of primary care in Cancer control, due to be published in October 2015 in the The Lancet Oncology. The role of primary care in improving the detection of cancer will be part of a review of the evidence of innovative models of care in the diagnosis and ongoing management of people with cancer. Rubin says, “the driving aim is what works best for patients.” He adds, “the population is living longer and more people are developing cancer. The role of primary care is increasingly being recognised as an efficient and effective way of maximising health within a population. So this a timely opportunity to reconsider in what respects primary care can contribute to cancer control.”
AJ Photo/Science Photo Library
NICE guideline focuses on symptoms to diagnose cancer earlier
Lancet Oncol 2015 Published Online July 3, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00131-X For more on the NICE guideline see www.nice.org.uk/guidance/ ng12/evidence/ fullguidance-65700685 For more on The Lancet Oncology Commission see http:// www.thelancet.com/campaigns/ cancer/primary-care
Susan Mayor
www.thelancet.com/oncology Published online July 3, 2015 http://dx.doi.org/10.1016/S1470-2045(15)00131-X
1