NICE launches new cancer strategy

NEW guidance to help GPs diagnose cancer earlier could save thousands of lives, says NICE.

NICE has updated and redesigned its 2005 guidelines to support GPs in recognising the signs and symptoms of 37 different cancers and refer people for appropriate tests more promptly.

The updated guidelines use a new approach focusing on the symptoms that a patient might experience and go to their doctor with. Tables linking signs and symptoms to possible cancers are included with simple recommendations about which tests to perform and the type of referrals to specialist services.

The guidance also sets out timeframes for specialist referrals, ranging from 48 hours to two weeks depending on urgency.

In the previous guidelines, few recommendations corresponded with a positive predictive value (PPV) below 5 per cent. In order to improve the diagnosis of cancer, the updated guideline uses a 3 per cent PPV threshold value to underpin the recommendations for suspected cancer pathway referrals and urgent direct access investigations, such as brain scanning or endoscopy.

NICE states that the lower threshold should not overwhelm clinical services, nor greatly increase the possible harms to patients from over-investigation.

Today around one in two people will be diagnosed with cancer in their lifetime and the disease is responsible for more than a quarter of all deaths in the UK. It is estimated that around 5,000 lives could be saved each year in England with earlier diagnosis.

Dr Steve Hajioff, a director of public health, who chaired the independent group of experts which developed the guidance for NICE, said: "Traditionally, cancer referral guidelines have presented their evidence on a cancer by cancer basis because that’s the way the research is done. However, that does make them very difficult to use if someone has a symptom that’s related to multiple cancers.

"A symptom-based approach, in effect, takes a symptom, for example abdominal pain, or a set of symptoms, and brings them together to identify the potential cancers that it could be. The purpose of this approach is to make it easier to use by primary care clinicians in a busy consulting room so that they don’t have to wade through documents. They can look very quickly at the information to help them make an appropriate decision and so potentially fewer things are missed."

Professor Willie Hamilton, a GP and Professor of Primary Care Diagnostics at the University of Exeter who helped to develop the updated guideline, said: "This guideline is about getting the right patients to the right tests at the right time.

"Traditionally, GPs have always had some tests available such as blood tests, X-rays and some scans. This guidance expands this by bringing some tests that have been traditionally thought to be hospital tests under the wing of GPs. It will open the door for smarter testing so that people with cancer will receive their diagnosis much earlier. There is no doubt in my mind that this guideline will help to save lives."

But the RCGP has responded to the new guidance by questioning the potential for increased volume of referrals. Dr Maureen Baker, Chair of the RCGP, said: "At face value, this appears to be very good news that patients will find encouraging and reassuring.

"However, we query whether NICE has assessed the potential volume of patients that will be affected by this change and are worried that the system overall may well not be able to cope with the increased volume of referrals.

"We support moving to 3% thresholds, but only if local services can accommodate such a change in practice.

"If there is sufficient diagnostic capacity, such as scans and imaging, in secondary care then that works to everyone's advantage. But if the onward services cannot cope with the work, we run the risk of patients actually having to wait longer for investigations and diagnosis, causing them further anxiety and stress."

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