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At the heart of general practice since 1960

NICE has missed a key opportunity to improve early cancer diagnosis

Professor Julia Hippisley-Cox argues that the new cancer guidance is flawed

It’s a step forward that NICE are recommending better access to diagnostic tests for GPs and have moved to a more symptom-based, rather than cancer-based approach. But while they acknowledge that multiple symptoms map to multiple cancers, it’s a shame they haven’t been able to understand and use results of the key multivariate analyses available, such as those used within QCancer, which is more efficient at identifying the patients most likely to have cancer.

Also, it is disappointing that NICE has not addressed the concerns raised by many stakeholders about the draft version. These include multiple concerns around age cut-offs – for example, that the guidelines will miss significant numbers of lung cancers in people under the age of 40 and breast cancers in women under 50.

Concerns over the removal of established risk factors, such as family history of breast cancer and intermenstrual and post-coital bleeding for cervical cancer, have also been dismissed. The guidelines panel has not presented a cogent argument for adopting a 3% threshold using positive predictive values based on simple combinations of symptoms, rather than a more sophisticated risk assessment approach that combines multiple symptoms with key risk factors such as age, smoking and family history to calculate a validated measure of absolute risk. This means we have no idea of the sensitivity of the approach (for example, how many patients at risk will be correctly picked up and how many will be missed).

In other words, we may be missing high-risk patients while putting too many low-risk patients through tests.

The panel also does not appear to have addressed the large number of concerns raised by stakeholders including NHS England, Cancer Research UK and Macmillan about whether such long and complicated guidance could ever be implemented by GPs in everyday clinical practice.

In my view, they have missed a long awaited opportunity to improve early diagnosis of cancer.

Professor Julia Hippisley-Cox is professor of epidemiology and general practice at the University of Nottingham, lead researcher for the QCancer risk assessment tool and director of ClinRisk Ltd.

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Readers' comments (9)

  • Azeem Majeed

    Julia Hippisley-Cox makes some very good points.

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  • Vinci Ho

    When I said 2 weeks rule has its 'blind spots' in the past, I did not foresee NICE would eventually adopt a predominantly symptom based philosophy to 'encourage' clinicians , particularly GPs to go for a persuit of cancer at a very low threshold.
    If you still remember your medical school teachings in categorising causes of disease , they include infectious, inflammatory, auto-immune , trauma, degenerative , metabolic , endocrine , psychological etc in addition of malignancy .
    This knee jerk , politicised NICE recommendation comes in ironically at a time of austerity (hence drastic cut of resources), bottom low morale in all NHS frontline workers and over-regulation of all clinicians.
    The bottom line is self preserving , shameless and shallow politicians trying to squeeze every drop out of an under pressure NHS so as to earn more credits for themselves and their party.
    I totally agree to a more sensible and evidence based approach to detect cancer as early as possible but a senseless carpet screening of a symptom for cancer not only neglects other causes of the same symptom , but can also harm physically as well as mentally some patients unnecessarily.

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  • I've had a quick rummage through the guidelines and they're just too unwieldy for day to day to use.A lot of it is just a case of sucking eggs.I wouldn't get too hung up on age cut offs for this or that.If someone presents with unexplained symptoms out of the norm then it needs a referral for further evaluation.

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  • Samuel Lewis

    The new NICE guidance essentially endorses our standard Red Flag approach to early cancer recognition. It adds tweaks like age cutoffs, and in-house tests, but itrreally isn't much different than standard.

    Julia, despite her QCancer interests, makes the point that red flags might be simple, but do not take account of Bayesian Prior risk.

    Example.
    A guy presents with a cough. You doubtless wait a bit, then offer an antibiotic, then think about a CXR, maybe weeks later...

    Unless he's over 60, or a smoker, or mentions blood in his hankie.

    Which of these contexts change your decision ?

    Does a percentage risk engine really trump a gut-feeling or worried patient ?.

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  • Very well written. I hope the mainstream media takes this up as the public have a right to know this information. As everyone will recall, NICE was not so nice when it tackled dementia. Campaigners had to challenge its guidance in court before they backed down.

    I believe every NICE guidance should be up for national peer review before being rolled out. This would be the right thing to do in terms of patient safety and may even prevent mortality. If the patient was its first concern, it would consider this carefully given the failings in its previous guidance.

    Dr Rita Pal
    www.ritapal.info

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  • I hate tick box medicine. It is time consuming and does no better then an experienced clinician with old fashioned history taking skills who knows his patients.

    The current young generation of doctors are being totally deskilled in the art of medicine and are taught to slavishly follow algorhythms.

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  • Maybe the poorer cancer survivals are down to the lifestyle choices made by the UK population, favouring smoking and alcohol (increasing drug use), with excess red meat, and ready made meals high in fat and salt, lacking home cooked meals with fruit and vegetables, and the Mediterranean diet favoured by our European Neighbours.

    Just maybe, its the above ,rather than the GPs are all needing a manual on how to organise a piss up in a brewery.

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  • In the absence of more machines, more Radiologists, more endoscopists, is this not all theoretical?

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  • Samuel Lewis

    dear anonymous,

    if we referred less wrong'uns, and more right'uns, we could improve survival without increased resources ?

    take the stroke/TIA example - they almost all get a scan, but too late for it to matter. but we could refuse all 'stroke' scans that are not day1 and would not change Rx, and release those scanner slots for cancer diagnosis ..

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