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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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  • Has anyone really looked at the implications of this? Refer every patient over the age of 40 who has ever smoked for a chest X-ray if they have a cough or feel fatigue? That's half my morning surgery.

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  • Anonymous | Practice Manager | 23 June 2015 11:06am

    Spot on!

    I will stop raging against the machine and just REFER anything that meets criteria, won't lose any sleep over it.

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  • And remember to refer anyone over the age of 60 with new onset of diabetes to rule out pancreatic cancer

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  • Do not worry about the minutiae - just refer it ALL into secondary care and swamp them. They are indefinitely protected.
    Only then will someone ever realise what collapse actually means.

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  • Anonymous | GP Partner | 23 June 2015 12:16pm my thoughts initially as well - but thank fully the word unexplained is included in the guidance - and most of your / mine morning surgery with their cough will be explained.

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  • Am I the only person who heard the NICE expert say on the Today programme that he wanted to "eliminate " the extra 5,000 cancer cases?
    Is this the new cost cutting exercise ?

    Sorry have now lost it.....

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  • Russell Thorpe

    I just cant see this happening has anyone bothered to talk to a radiologist or endoscopist?

    In my view we should have a requirement to perform Significant Event Analysis on all cases of delayed diagnosis / late presentation of cancer. That would improve the use of the exicting pathways.

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  • Russell Thorpe

    oops that existing

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  • Vinci Ho

    Has NICE 'responsibly' estimated how many more GPs (not PAs,not nurses)this will be required to ensure success with this guideline ?

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  • Lets not beat around the bush. when patients come to see us, all of this nice/government rhetoric means they will come with the agenda of knowing if they have cancer or not because their little finger hurt in the night time.

    "can you order those special tests I saw on the news please doc"

    Unfortunately in my experience, people are no longer reassured by clinical skill of a doctor and want a machine and radiologist to reassure them.

    I say just scan everyone all the time. I have gone beyond the point of trying to protect nhs budgets from the fools at the top.

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  • This is GREAT news. REFER it all!!! ? cancer

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  • Recently attended Colorectal meeting and consultant expressed quite clearly what she thought of new NICE guidance which appears to allow referral of almost anybody with abdominal pain, was rightly worried 2ww system is going to be swamped which means delay for the patient with yet to be diagnosed with Cancer.

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  • So the era of the "inappropriate referral" is behind us then is it? I well remember having to argue the toss with consultant radiologists about patients with headaches pushing for scans and having to justify referral of patients with equivocal lower bowel or abdo sympts who were not found to have Ca after Ix - all in the pursuit of cost reduction & chasing some target or other!

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  • Dear GP,
    Your contract of work is not with the patient, it is with the Govt. Your GMS contract does not state that part of your job is protecting the Govt from the consequences of its actions. It's action is to create and impose NIHCE upon you. Therefore comply with your contract of work and refer refer refer. If that swamps the hospitals and causes massive delays that becomes a problem for hospitals and Govt.

    Please stop being so precious about your self-anointed role as gatekeeper. You are not. Protecting people from the consequences of their actions merely teaches them to do it again, and do it worse. You keep bringing Govt inspired problems onto your own heads by trying to protect Govt from the results. STOP IT. Refer refer refer and let Govt suffer the consequences of its actions.

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  • Certainly not just us in the pooh. We have no local breast cancer service due to shortage of radiologists. Talking to a local senior radiologist very few want to work outside of teaching centres, with large numbers of newly qualifieds that do not end up in such centres moving to Aus/Can/NZ like the rest of us.

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  • 1. I don't understand why people are worried about nhs budget or spend as well publicised we spend less then any other country (the benefits bill is double the nhs budget)

    2. We peobably should be investigating more. Someone mentioned doing CXR on 40 year old smoker with a cough. I always do cxr for cough lasting 3 weeks before trying antibiotics and then may be able to avoid them if normal. ITS ONLY A CHEST XRAY THIS IS THE 21ST CENTURY!
    I work in Canada asd much better access to investigations(imaging not endoscopy) whats the problem with imaging vague symptoms if they are persistant even if you think its IBS or fibromyalgia or whatever. Imaging can be just to rule things out perhaps we should be imaging things more routinely in the UK, patients often expect it in the modern world and why not. If we stop acting like we have the budget of a third world country perhaps more funding will be allocated or people will have to co-pay. The problem is we all get second ratre service in some ways at the moment.

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  • ok so refer everyone, just in case

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  • Full body MRI scans for everyone every 12 months
    YAY!!

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  • Lets get access to testing sorted whilst we are at it. The ICE e-request system won't allow non GP clinicians to order investigations which has potential impact on timely referrals, and so disables ANPs who are seeing the same patient groups and also trying to make sense of the guidelines.sigh

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  • Rather scary as locally our referal rates for CT and MRI up by 30% and now serious capacity issue, and thats before NICE!

    Also looked at my practice data for over 6 years. Emergency admissions and then Dx as cancer usually because its a subsidiary diagnosis or they were refered appropriately for the origional problem.

    Delays usually are patient led not Primary care led, I struggle to accept the blame in delay for a metastatic prostate cancer # who hasnt seen GP for 5 years.

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  • How many extra cancers will be caused by X -radiation?

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  • Martin Harris

    I heard about this on Radio 4 Today programme while driving in to work last tuesday morning. The following day at the BMA ARM in Liverpool I met Dr Steve Hajioff who was the Chair of the independent group of experts which developed the guidance for NICE. he enthusiastically showed me the diagrams of his symptom-base system.approach.

    Steve told me: “a well informed patient with an educated doctor will mean that all benefit from this NICE guidance”

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