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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.