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NICE two-week cancer advice 'is delaying diagnoses', claim surgeons

Fast-tracking GP cancer referrals through the two-week wait pathway has overloaded clinics and caused delays in diagnosis of head and neck cancers, a group of surgeons have warned.

Experts from the British Association of Oral and Maxillofacial Surgeons (BAOMS) said the recently updated NICE guidelines – which lowered the risk threshold for referral – had ‘tipped the balance’ too far in favour of GP referrals for investigations, and called for an ‘urgent review’ of the referral criteria.

NICE denied the claims, arguing that its guidelines are supported by the latest evidence, while GP leaders said an increase in the number of referrals was ‘unavoidable’ under current guidelines supplied to GPs.

It comes as a study in the British Journal of Oral and Maxillofacial Surgery showed that the proportion of people who end up with a diagnosis of head and neck cancer has fallen markedly over the years since the introduction of the two-week wait pathway in 2008 - from around 11% to just 7%.

Although more cancers are being diagnosed via the two-week wait, as more people are referred, the experts said that half of cancers are still diagnosed through ‘conventional’ pathways, and that overall, the increasing number of people in the system was delaying the diagnosis and treatment of those patients who really need to be seen.

David Mitchell, a consultant oral and maxillofacial surgeon at Mid-Yorkshire Hospitals and editor of the journal, said: ‘An urgent review is needed now to stop this target-driven system delaying the treatment of patients who actually have mouth cancer.’

Former BAOMS president and consultant surgeon at Sunderland NHS Foundation Trust, Mr Ian Martin, told Pulse there ‘has been a big increase in referrals where there isn’t cancer’ and that ‘this latest change to the guidelines has tipped the balance too far’.

He added: ‘You have to question whether this is the right approach because it has the potential to actually, paradoxically, mean those who actually have cancer are going to be treated more slowly.’ 

Mr Martin said there ‘already huge pressure in the system, the 62-day treatment targets are already being missed in a lot of places’ and that ‘resources have to be diverted to dealing with people, who are understandably worried because they have been sent in on the two-week wait pathway… rather than getting on and treating those who do actually have cancer.’

Professor Willie Hamilton, clinical chair on the guidelines, said the BAOMS had presented ‘no evidence’ that the guidelines had introduced a delay for patients and defended the referral criteria.

He said: ‘The simple truth is that with patients and symptoms it is impossible to investigate “smarter”, giving surgeons their desired high conversion rate. We have to investigate “more” (but within reason).’

He added that the review showed ‘more patients are being seen, and the “new” patients are at slightly lower risk, but overall more patients are being diagnosed’.

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said: ‘Individual generalists will come across a new specialist case so rarely that it must be accepted that there will be a large non-conversion rate. This is not due to a deficiency in the guidance or in the knowledge of the referrer, but is an unavoidable consequence of policies designed to avoid diagnostic delay.’

Why have GP cancer referrals risen? 

NICE guidelines were recently updated to encourage GPs to refer at lower, roughly 3% risk of cancer, as part of NHS England’s drive to improve on early diagnosis and treatment of cancer. At the time, NICE experts said it was not possible to predict the impact on diagnostics.

GP leaders have welcomed the general shift towards more GP referrals, but also warned the system might not cope with them  - and that some cases of cancer may even end up being delayed, at least in the short term, while CCGs and providers work out new pathways and set up new clinics.

The Government has committed to training up more clinicians in endoscopy, as part of a new target to guarantee patients get cancer diagnosed or ruled out within four weeks of referral, but Cancer Research UK has warned more investment across the whole workforce is needed, particularly for training more radiographers.

Readers' comments (11)

  • Great, even more tension between primary and secondary care.

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  • Some of the 2ww referrals need to be looked at. Raised PSA in elderly men, microscopic haematuria etc which could be seen routine in some cases. It would be nice if it could be left to the clinical instinct of GPs but this is gone.

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  • It's all gone!

    Why will any student pick the medical profession as a career choice in the future? It's even becoming stressful in the US.

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  • In the early preamble NICE says it is "guidance" and allows for clinical judgement. Try telling that to a lawyer when your being sued.

    While at it add DVT Mx too as spoke to NICE regarding what to do in the week between scans in patients who are Wells Score +ve D Dimer +ve USS -ve too me that smacks of just not found clot yet. NICE guidance is we dont recomend anti-coagulation in that week but defer to clinical judgement.

    Crystal Clear!!!

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  • When NICE changed its 2ww guidelines it adopted a a threshold of relative risk of 3% ( unfortunately this is based on symptoms/tests rather than individual calculation from clinical scores such as Qcancer which is more accurate. This leads to vast over referral that will smother the system- incidentally most GP`s don`t use the the new threshold and hence system has not collapsed YET!
    Although improving this threshold would improve cancer diagnosis this is assuming an *unlimited amt of resources* to meet the 2ww wait referrals.
    A quick run through of Qcancer risk on existing EMIS system reveals about 6% of adults have higher than 3% Qcancer risk which will be higher if all relevant symptoms were read coded rather than in free text!
    GP`s have a 15-20% conversion rate for 2ww to actual cancer diagnosis over the years which kept the system running, aiming to improve on this is good but will need additional resources which do not exist.

    A very learned professor who is an expert in statistics once mentioned to me in a meeting (when I specifically asked about the new NICE cancer guideline) that NICE seems to have gone in "evidence free zone" on this one!
    Also at some point the the NNH (number needed to harm) will start climbing as radiating procedures (CXR, CT scans) and invasive diagnostic procedures are done more frequently.

    Many of our local Trusts are falling behind in cancer 31/62 day targets and routine appointments now are several months later as more resources are diverted to 2ww clinics!!!

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  • I wonder if PULSE editor could ask Prof. Julia Hippisley-Cox who is the developer of Qcancer risk score regarding the statistical evidence for the NICE cancer guidelines.

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  • This is the conclusion from the paper: "There is evidence that two-week referral conversion rates are falling, while detection rates are rising because of an increased number of referrals."

    So, rising cancer detection rates is a good thing. What we need is a system that can cope with more referrals and better access to appropriate investigations.

    And, the QCancer data is included in the 2015 NICE guidance, and they base their recommendations on Positive Predictive Values (not relative risks).

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  • Dear registrar at 11.53 am,
    Apologies, yes NICE threshold is based on PPV of 3% ( error on my part).
    Rest of the msg is my opinion still stands - increasing detection overall is good only if it doesn`t impact on other problems. there is indirect evidence that waiting times for routine and urgent appts have worsened after lower 2ww thresholds.
    PULSE maybe able to obtain the no of 2ww referrals since the New NICE criteria and compare to same period previous 2-3 years. IS it increasing and if yes is it increasing faster than it has been over the last few years?
    Given less resources in NHS is is the best way to spend taxpayers money.

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  • Samuel Lewis

    You cannot win. Lower ing the threshold to 3% log means you will refer 97 cases without cancer, for every three with. If you miss a case, someone might sue you. You will be blamed anyway, and all the patients you referred will all be asking you to expedite..

    Stop worrying, and refer if the patient is worrying.

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  • The idea that we can't help our GP colleagues to investigate "smarter": in this case listen, look and feel a persisting unusual lump or ulcer and refer appropriately and that the only solution is to flood grossly overstretched secondary care with 97% worried well (the DH target being 3% cancer diagnosis) is surreal. Worse than that the obsession with the USC system means real people with real cancer get a lesser degree of access. 50% of cancers being diagnosed via a conventional pathway and 6.6% via the USC system equals a system that doesn't achieve what it needs to do. These are not rare cancers 8-9000 new diagnoses, they are demanding to treat but can be treated. They can also be prevented - smoking cessation, reduced alcohol and being vaccinated against oncogenic HPV could prevent 75% of them at a quarter the cost of treatment.
    A polio analogy would be the government is making more calipers instead of implementing a gender neutral and comprehensive catch up vaccination program.
    There is plenty of evidence if only those at the coal face who treat these patients were actually engaged.

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