NICE guidance on referring for nasties
The huge media interest in new guidelines from The National Institute for Health and Care Excellence (NICE) on cancer referrals has certainly kept me busy in the last few days. The gist of the stories have ranged from a move towards a symptom, rather than individual cancer based approach; through new resources for GPs to refer directly for investigations usually only available through the hospital; to an attempt to stop GPs missing tens of thousands of cancers. So does a 'crib sheet' for GPs mean we're just not very good at spotting obvious signs of cancer?
Of course, any GP worth their salt can spot an obvious 'red flag' such as a new breast lump or coughing up blood. But many cancers don't come with such obvious clues, and for every patient I see who is convinced they have cancer and turns out to have it, there are scores who think they have cancer but turn out not to. The average GP sees about eight patients with a new cancer each year, compared to thousands who don't. Sorting out the few from the many without harming patients by over-investigation, but still making sure that cancers are pick up early enough to give the best chance of cure, is a much bigger challenge than you might imagine.
Firstly, many patients bury their heads in the sand and don't see a doctor until they can't put it off any longer, because they're so terrified of being given bad news. Secondly, many cancers at a very early stage cause very few, very vague symptoms, which are identical to those of more common non-cancerous conditions. Thirdly, some cancers don't show up on routine tests and need invasive procedures to confirm them.
I would suggest that every GP needs to read the new guidance, no matter how up to date they are. In essence, the guidelines have shifted the goalposts in terms of who GPs should refer and what investigations they should offer them. It's also important to realise that diagnosing every single cancer at the earliest stage is impossible.
GPs can't refer absolutely everybody for invasive tests every time they come in with the first hint of a condition which has a one in 1,000 chance of being cancer. If they did, the NHS would buckle under the strain and thousands of people would be exposed to high levels of radiation from repeated scans. What's more, patients who did have cancer would face unacceptable delays, lost among all the 'worried well'. However, the new guidelines have lowered the threshold at which we refer for investigation from an estimated risk of cancer of one in 20 to one in 33. As one spokesperson put it, these guidelines will allow doctors to target patients at 'low risk but not no risk' of cancer.
For some cancers, we know more about possible early warning signs than we did when the last NICE guideline was published 10 years ago. For some of the 37 cancers it covers, NICE recommends that initial investigations are done by the GP rather than waiting for a hospital appointment. For instance, we know that ovarian cancer can cause a cluster of symptoms including persistent bloating, feeling full early after eating, loss of appetite, urinary symptoms and pelvic or abdominal pain, especially if they're present for more than 12 days in a month. Rather than referring everyone with these symptoms to hospital, the new guidelines recommends that GPs carry out a blood test called Ca125 straight away; refer her for ultrasound if this is raised; and if the Ca125 is normal, they stress the importance of telling the patient to come back if symptoms get more frequent or severe.
The guidelines also focus on nonspecific signs of possible cancer, such as:
- Unexplained weight loss, which can be a sign of cancer of the stomach,oesophagus, lung, prostate, pancreatic or urinary tract
- Unexplained loss of appetites, which could signal cancer of the lung, oesophageal, stomach, colon, pancreas, bladder and kidney
- A DVT, or deep vein thrombosis, which has lots of non-sinister causes but can be a sign of breast, colon, lung, ovarian and womb cancer
- Tiredness, which in primary care often doesn't have a physical cause but which if often one of a cluster of symptoms (including loss of appetite, weight loss, cough, shortness of breath etc) in a variety of cancers.
There's no doubt that the UK has a long way to go to close the reported gap of 10,000 more patients a year dying from cancer than in other European countries of a similar size. These guidelines should help doctors get the right patients seen more quickly - as long as patients too know the symptoms they should be sharing.