What's the risk?
Appreciation of risk is a very personal characteristic. When I worked in obstetrics I frequently had conversations with anxious parents about the risk of their child having a problem - most frequently Down's syndrome. A woman who is 35 years old has a one in 350 risk of having a child with Down's syndrome, based on age alone. Some would elect (after detailed discussions) to have invasive testing such as chorionic villus sampling, with an average risk of miscarriage of one in 100. Others would take their 349 chances that the baby would be fine.
In June NICE released the updated guidance for referral of patients with suspected cancer. The update organises symptoms which should prompt a two-week wait referral, gives advice about further investigation in primary care, and safety-netting in primary care. The symptom-based approach takes a symptom, for example abdominal pain, or a set of symptoms, and brings them together to identify the potential cancers that it could be. GPs can look very quickly at the information to help them make an appropriate decision and so potentially fewer things are missed.
The guideline also says which tests should be performed appropriate for the suspected cancer, and if this can be done in a GP surgery or hospital clinic, along with the timeframe for referral, between 48 hours and two weeks, depending on urgency.
The threshold for referral has been lowered. The previous guideline had recommendations which corresponded with a positive predictive value (PPV) of around 5%. In order to improve the diagnosis of cancer, the updated guideline uses a 3% PPV threshold value. The threshold is even lower for children and young people.
New NICE criteria for an urgent cancer referral:
• Aged over 40 with unexplained weight loss and abdominal pain
• Aged 55 and over with weight loss and upper abdominal pain, reflux or dyspepsia
• Aged 55 or over with upper abdominal pain and raised platelet count
• Aged 60 and over with weight loss and new-onset diabetes
• Aged 40 or over with chest signs compatible with lung cancer
• Aged 40-55, have never smoked, have haemoptysis and appetite loss
• Women aged under 55 with post-menopausal bleeding
• Aged over 50 and have unexplained rectal bleeding
• Children with unexplained bleeding
• Unexplained ulceration in the oral cavity lasting for more than 14 days.
Although this move will lead to more people having earlier diagnoses, many have criticised it, as greater numbers will be investigated and have to manage their anxiety over a potential cancer diagnosis. There is also some debate about whether our already stretched health service can cope with the increase in demand.
The guidelines development group has also faced criticism for not recommending GPs consider risk factors alongside symptoms, when assessing the patient's risk of cancer, although the guideline development lead has said that 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.
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 the QCancer risk tool 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."
If you have concerns that you will not assimilate all the recommendations quickly and may miss potential cases, one option could be to try QCancer risk assessment (probably not with your patient present) and consider referral for anyone with a risk of around 3%, or greater. This is already fully integrated into EMIS Web systems.
What's your opinion of the new guidance?
How will you change your practice, if at all?