In June 2016 NICE issued a new quality standard, NICE Pathway on Suspected cancer recognition and referral [QS124]. This quality standard covers recognition of suspected cancer in adults, young people and children, and referral to specialist services.
NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.
Why this quality standard is needed?
Cancer has an enormous impact, both in terms of the number of people affected by it and the impact it has on people with cancer and those close to them. Approximately one‑third of the population will develop a cancer in their lifetime and more than 300,000 new cancers (excluding skin cancers) are diagnosed annually in the UK. Each cancer type can have different presenting features, though they sometimes overlap. There is considerable variation in referral and testing rates for suspected cancer, which cannot be fully explained by variation in the population.
The identification of people with suspected cancer usually happens in primary care, because most people first present to a primary care health professional. Some investigations for suspected cancer can be performed in primary care, for example, blood tests such as prostate-specific antigen tests for prostate cancer or CA125 tests for ovarian cancer. Imaging investigations, such as chest X-rays or ultrasound, are generally available by direct access from general practitioners (GPs). However, some investigations, such as colonoscopy and biopsy, can be accessed only through secondary care and so need formal referral.
This quality standard is expected to contribute to improvements in the following outcomes:
- time to cancer diagnosis
- cancer diagnosed at stage 1 or 2
- cancer-related morbidity
- cancer-related mortality.
NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE.
This quality standard is based on 4 quality statements.
Quality statement 1: Direct access to diagnostic tests
GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
People who visit their GP with symptoms that may suggest cancer are sent for diagnostic tests to confirm or refute a cancer diagnosis. Enabling GPs to use direct access for specific tests is cost effective and will reduce the time to reach a diagnosis.
Quality statement 2: Urgent direct access endoscopy for oesophageal or stomach cancer
People presenting in primary care with symptoms that suggest oesophageal or stomach cancer have an urgent direct access upper gastrointestinal endoscopy.
Urgent direct access for upper gastrointestinal endoscopy is cost effective and can lead to faster diagnosis of oesophageal or stomach cancer. Early detection and diagnosis is important to successfully treat and survive cancer, and to improve the quality of life for people with oesophageal or stomach cancer.
Definitions of terms used in this quality statement:
When a person is sent directly by their GP for a test in a specialist service, such as imaging or endoscopy, and the GP retains responsibility for the person's care, including following up and acting on the results.
The test should be performed and results returned within 2 weeks. When a person is sent for an urgent direct access test by their GP, the test (for example, an endoscopy) is performed and results returned within 2 weeks.
Symptoms that suggest oesophageal or stomach cancer
People should be referred for an urgent direct access upper gastrointestinal endoscopy (performed within 2 weeks) to assess for oesophageal or stomach cancer if they:
- have dysphagia or
- are aged 55 and over with weight loss and any of the following:
- upper abdominal pain
Quality statement 3: Testing for blood in faeces
Adults presenting in primary care with symptoms that suggest colorectal cancer, who do not meet the referral pathway criteria, have a test for blood in their faeces.
Many colorectal cancers leak blood into the bowel intermittently. Tests for the presence of blood in faeces are relatively easy, inexpensive and safe, and help to identify people at higher risk of having colorectal cancer. People at higher risk can then receive definitive investigation sooner, resulting in earlier treatment for those diagnosed with cancer.
Definitions of terms used in this quality statement:
Symptoms that suggest colorectal cancer
Adults should be offered testing for blood in faeces to assess for colorectal cancer if they do not have rectal bleeding but are:
- aged 50 and over with unexplained:
- abdominal pain or
- weight loss, or
- aged under 60 with:
- changes in their bowel habit or
- iron-deficiency anaemia, or
- aged 60 and over and have anaemia even in the absence of iron deficiency.
Criteria for suspected colorectal cancer pathway referral:
Adults should be referred using a suspected cancer pathway (for an appointment within 2 weeks) for colorectal cancer if they fulfil the following criteria:
- they are aged 40 and over with unexplained weight loss and abdominal pain or
- they are aged 50 and over with unexplained rectal bleeding or
- they are aged 60 and over with:
- iron‑deficiency anaemia or
- changes in their bowel habit, or
- tests show occult blood in their faeces.
Test for blood in faeces
A chemical test that can pick up the presence of tiny traces of blood in faeces. Current practice in the UK is to use the faecal occult blood test. However, the faecal immunochemical test is an alternative option.
Quality statement 4: Encouraging attendance at cancer services
People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.
Providing information to help people with suspected cancer to understand the importance of attending their appointment is critical to avoid delay due to missed appointments and ensure early diagnosis. People should be reassured that most people who are referred will not be diagnosed with cancer. This should help to alleviate any fears or concerns people may have about the referral.
Equality and diversity considerations
Information given to a person with suspected cancer should be appropriate in terms of language and culture, because there may be different cultural meanings associated with the possibility of cancer.
During the development of this quality standard, equality issues have been considered and equality assessment are available.
Good communication between health, public health and social care practitioners and people with suspected cancer is essential. Treatment, care and support, and the information given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with suspected cancer should have access to an interpreter or advocate if needed.
Commissioners and providers should aim to achieve the quality standard in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this quality standard should be interpreted in a way that would be inconsistent with compliance with those duties.
The whole text of this NICE quality standard is available here