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GPs to refer more patients with low-risk cancer symptoms under new NICE guidance

GPs are being urged to refer and test thousands more patients for potential cancers under new guidelines rubber-stamped by NICE experts today.

The guidelines take a radical new approach, with the aim of giving GPs greater freedom to investigate patients with potential signs and symptoms of cancer and decrease the time before diagnosis.

The guidelines recommend GPs are able to request some ‘direct access’ tests urgently – within two weeks or even 48 hours for some rare cancers – which NICE advisors said would streamline the patient’s journey.

But GP critics said the guidelines risked referring too many patients at very low risk of cancer and missing those at the greatest risk because the new symptoms-based approach did not take into account patients’ baseline risk.

The guidelines are expected to lead to an increase in urgent referrals for potential lung cancer, upper gastrointestinal (GI) cancers, such as stomach cancer, and bowel cancer in particular – although NICE has not forecast exactly how many more patients would expect to go through these pathways.

Despite this, NICE said any increased costs would likely be evened out by savings resulting from diagnosing people earlier, so that their treatment is less complicated and more likely to be life-saving.

The main recommendations are largely unchanged from the draft guidelines published last November, and effectively lower the risk threshold at which patients are referred for cancer investigation – from a positive predictive value (PPV) of roughly 5% to 3% – as well as getting GPs to order tests for people with clusters of symptoms suggestive of potential cancer but with a lower PPV than this.

Professor Willie Hamilton, clinical lead for the guidelines development group and a GP in Exeter, told Pulse the guidelines should give GPs more flexibility to investigate when a patient’s presenting symptoms are only vaguely suggestive of cancer.

Professor Hamilton said: ‘GPs know the symptoms of cancer [but] what has been difficult up to now has been being able to act on that knowledge. There were patients with mild symptoms that just might have been cancer that it was more difficult to investigate.

‘So now that we have slightly increased both the types of tests and number of tests that are undertaken it is now easier for GPs to test.’

Professor Hamilton insisted the symptoms-based approach was not prescriptive and that he did not expect GPs to have to do much more work as a result of the recommendations to do more testing in primary care.

He said: ‘I don’t think it will be remotely unmanageable because some testing was already been going on, we’ve been doing blood tests, CA125 tests. We will have some responsibility for seeing the faecal occult blood test results, and making sure we act on the results. Similarly for gastroscopies.’

However, Professor Julia Hippisley-Cox, professor of epidemiology and general practice at the University of Nottingham, said it was ‘disappointing’ that the guidelines panel had not addressed concerns over the complexity of recommendations.

Professor Hippisley-Cox, who has been working on producing the validated QCancer risk tool that has already been adopted on GP computer systems, said: ‘They haven’t addressed the large number of concerns about whether such long and complicated guidance could ever be implemented by GPs in everyday clinical practice.’

The guidelines development group also faced criticism for not recommending GPs consider risk factors alongside symptoms in weighing up the patient’s risk of cancer.

Dr Nick Summerton, former NICE advisor and a GP in East Yorkshire, said it was ‘bonkers’ to ignore risk factors.

Dr Summerton said: ‘To ignore risk factors is – to be kind to them – bonkers. When any person arrives in the surgery they have a baseline risk of cancer – prior probability –  according to features such as age, gender, ethnicity, family history, lifestyle – for example, smoking – and co-morbidities.

‘We then collect other information on, perhaps, symptoms to enhance this probability. Thus to ignore baseline risk will mean increased referral of those at low risk and reduced referral of those at high risk – given the same symptoms. This is frankly stupid.’

However, Professor Hamilton said the addition of risk factors such as family history or smoking should not change the decision on whether a patient was investigated as the symptoms alone should be enough.

NICE - Suspected cancer: recognition and referral

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Readers' comments (32)

  • Russell Thorpe

    We are already suposed to have access to Brain CT for suspected brain tumour and tthat has never been made available in my area, although Blackpool to the North do have some access to this. Where is the investigation capacity to impliment this coming from?
    One ofthe problems with NICE has always been the disassociation between the guidance it puts out and any attempt to supervise and report on implementation.

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  • Access to imaging and the number of radiologist combined with GP workloads are the elephants in the room.Setting standards does not mean that the standard will be met with the lack of resources which should be a government responsibility.Sadly with the health and social care act the governemnt are not responsible for health care anymore.

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  • Ivan Benett

    Don't get me wrong, I'm a fan of early diagnosis and of NICE, but this time I think they've got it wrong. The delay in diagnosis is caused by a delay in presentation, not of referral time in Primary Care. It is this aspect of the pathway that we need to spend effort on. So we need to raise awareness of symptoms, make it easy to see their GP and reduce the bureaucracy of accessing investigations.
    With a PPV of 3%, that means 29 out of 30 people will be unnecessarily investigated. This figure doesn't tell us the number of false positives or false negatives there will be - the more tests, the more of both. Let alone the cost of tests, increased consultations, raised anxiety levels, and increased trained staff to make it work.
    No, make people aware of symptoms, and improve access to their GP...and encourage people to attend screening for conditions where it is effective, like bowel screening, and soon lung cancer screening (in Manchester)

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  • The usual culprits will be time and money to have access to resources.
    With CCG`s having budgets squashed and now NICE guidelines stating lower threshold for referral,
    perceived delay in diagnosis will lead to more lawsuits.
    The government is making it harder to practice Medicine in UK

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  • Doesnt this give primary care the weapon to murder the NHS in its current under resourced state.GPs to blame again,GPs ideally placed again.Why is is always us!

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  • As a clinician I have concerns about effect of this on my patient.

    But the devil in me tells me to forget all that good nature and just refer everyone with minor symptoms as the guidance suggests. After all, the country has decided to embrace NICE and pile work on primary care to the point we no longer have time to deal with patient in sympathetic and individual manner. it's easier (for me, not to my secondary care colleagues) to follow guideline and blindly refer.

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  • More access to MRI/ CT would be v useful . Also referral targets from CCG should be amended

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  • Oh for goodness sake, just refer refer refer. When secondary care gets swamped the govt will finally get the message to kick NIHCE up the backside and tell it to live in the real world of finite resources. Until you do that, GPs will continure to get the blame. I am coming to the conclusion that GPs have a victim mentality and keep deliberately doing things that get them blamed, instead of doing the bleeding obvious which is follow the rules and expose the inadequate system.

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  • If you check out the headlines it's all the fault of lazy incompetent GPs that patients are not being referred earlier.The guidelines are necessary to educate these overpaid "fools"
    "About 5,000 lives could be saved each year in England if GPs follow new guidelines on cancer diagnosis"

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  • Russell Thorpe

    In my view NICE should be compelled to include a cost analysis of implementation in all of their published guidance.

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