NICE’s New Symptom-based Guideline for Earlier Cancer Diagnosis

The National Institute for Health and Care Excellence (NICE) in England has updated and redesigned its guideline to support general practitioners (GPs) to recognise the signs and symptoms of 37 different cancers and refer people for the right tests faster. In a change to its 2005 predecessor, the updated guideline uses a new approach – focusing on the symptoms that a patient might experience - to make its recommendations easier for GPs to use. It sets out clear tables linking signs and symptoms to possible cancers and includes simple recommendations about which tests to perform and the type of referral to specialist services that should be made.

Why this update is important

The best way of tackling the disease is for patients to receive an early diagnosis, as this improves the chances of beating cancer. If cancer is caught at an early stage before the disease has spread treatment is more likely to be successful.

Often patients present at primary care with symptoms that are non-specific. Signs of cancer may also not be clear or obvious and GPs see, on average, only around eight new cases a year.
A full time GP will have between 6,000-8,000 appointments every year. And they will only have around 10 minutes per appointment to pick out warning signs that could be cancer, but equally may be a symptom of a less serious condition.

Guideline based on symptoms

In a change to its 2005 predecessor, the updated guideline focuses on the symptoms that a patient might experience and go to their doctor with - to make its recommendations easier for GPs to use.

Recommendations in the update are now organised by symptoms which should prompt a 2 week wait referral; further investigation in primary care; and safety-netting in primary care. They cover:

• Abdominal symptoms
• Bleeding
• Gynaecological symptoms
• Lumps or masses
• Neurological symptoms
• Pain
• Respiratory symptoms
• Skeletal symptoms
• Skin or surface symptoms
• Urological symptoms
• Non-specific features of cancer
• Primary care investigations

The guideline also outlines which tests should be performed according to the type of cancer suspected, and if they can be done in a GP surgery or hospital clinic, as well as the timeframe for which referral patients should be referred to a specialist. This ranges from 48 hours to 2 weeks, depending on urgency.

Threshold for referral lowered

In the previous guideline, few recommendations corresponded with a positive predictive value (PPV) below 5%. In order to improve the diagnosis of cancer, the updated guideline uses a 3% PPV threshold value to underpin the recommendations for suspected cancer pathway referrals and urgent direct access investigations, such as brain scanning or endoscopy.

The lower threshold should not overwhelm clinical services, nor greatly increase the possible harms to patients from over-investigation.

Certain exceptions to a 3% PPV threshold were agreed. Recommendations were made for children and young people at below the 3% PPV threshold, and for possible cancers where the test can be done by the GP, although no explicit threshold value was set for these groups.

Impact on workload

Traditionally, cancer referral guidelines have presented their evidence on a cancer by cancer basis because that’s the way the research is done. However, that does make them very difficult to use if someone has a symptom that’s related to multiple cancers. A symptom-based approach, in effect, 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. The purpose of this approach is to make it easier to use by primary care clinicians in a busy consulting room so that they don’t have to wade through documents. They can look very quickly at the information to help them make an appropriate decision and so potentially fewer things are missed.

If GPs are able to investigate and make cancer referrals earlier, the outcomes for patients will be better, GPs will have fewer consultations, and the treatment will cost less.

Some investigations recommended in the guideline may be performed in primary care, such as blood tests like prostate specific antigen or CA125. Imaging investigations, such as chest X-rays, or ultrasound, are generally available directly to GPs.

Conversely, some investigations are currently accessed through secondary care, and so require formal referral, for example colonoscopy, biopsy or more complex imaging. Specialist opinion also has value in making the diagnosis.

To ensure this update is workable and focused on the needs of primary care, the NICE Guideline Development Group included six GPs, a retired GP, and a professor of primary care diagnostics. The RCGP has also been a stakeholder throughout the guideline development process.

Case study: a symptom-based approach

If a patient presents with lumps or masses: