Updated evidence-based guidelines will help GPs to identify those patients who need to be referred for cancer investigations, says Dr Tim Stokes
A key aim for the NHS is to improve the care of individuals with cancer and, by 2010, to reduce mortality in those aged less than 75 years by 20% compared with figures for 1995-97.1
A recent report from the National Audit Office highlights the fact that patients with breast and bowel cancer in England tend to have more advanced cancer at the time of diagnosis than patients in some other countries.2
Older people and those from deprived areas are more likely to be diagnosed with cancer at a more advanced stage. Delay may be explained by the failure of some patients to seek help quickly, and by the difficulties primary healthcare professionals can face in identifying people with cancer.
GPs must ensure that patients with symptoms that might indicate cancer are referred as quickly as possible to specialists for assessment, and yet they must not overload diagnostic services with large numbers of people who have a very low likelihood of having the disease.
Developing referral guidelines for suspected cancer
In 2000, the Department of Health issued guidelines to help in identifying individuals with suspected cancer as early as possible.3 The guidelines were widely disseminated in primary care and GPs have reported that they found them useful.
NICE has recently updated these guidelines,in line with a commitment contained in the NHS Cancer Plan.4,5 Referral guidelines for suspected cancer, which were developed by the National Collaborating Centre for Primary Care (NCC-PC), take account of new research evidence and the findings of audits undertaken since the previous guidelines were published.
The aim of the guidelines
A number of key principles underpin the guidelines. These include the need to:
- Take full account of the perspective of the individual with suspected cancer and his or her family and carers
- Consider all the issues that are important in the primary care assessment and referral of those with suspected cancer
- Base the recommendations on the published evidence that supports them, with explicit links to the evidence.
To achieve these aims, primary healthcare professionals and users were strongly represented on the multidisciplinary guideline development group.
The guidelines cover in detail specific topics relating to the following twelve groups of cancers:
- Lung cancer
- Upper gastrointestinal cancer
- Lower gastrointestinal cancer
- Breast cancer
- Gynaecological cancer
- Urological cancer
- Haematological cancer
- Skin cancer
- Head and neck cancer including thyroid cancer
- Brain and central nervous system cancer
- Bone cancer and sarcoma
- Cancer in children and young people.
Key priorities for implementation
The development group recognised the importance of the previous guidelines in setting out criteria for urgent referral from primary care of patients with suspected cancer, and these were updated as appropriate.
However, the new guidelines go further than offering a set of symptoms and signs that merit urgent referral. The sections on specific cancers address the role of investigations commonly requested in primary care (e.g. full blood count) and consider factors related to delay and difficulties in diagnosis (e.g. non-specific abdominal symptoms).
The guidelines also address two key areas not considered in the earlier guidelines. First, they deal in detail with the needs of patients at the time of referral and set out the information and support that should be given to the patient/family or carers by the primary healthcare professional (Box 1, below). A version of the guidelines has been published to provide information for individuals with suspected cancer, their families and carers and the public.
|Box 1: Key priorities for implementation: support and information|
Second, the guidelines consider the process followed by healthcare professionals in reaching an initial diagnosis, and offer guidance to help with those cases where this is difficult (Box 2, below).
|Box 2: Key priorities for implementation: diagnosis and investigations|
Some patients present with prominent classic symptoms or signs that clearly indicate a diagnosis of cancer. In others, however, the initial symptoms and signs are indistinguishable from those of less serious conditions. In such cases, the early detection of cancer can be the highest test of clinical skill. The guidelines stress the importance of continuing education for GPs so that they maintain their clinical consulting, reasoning and diagnostic skills to enable them to identify and manage patients who may have cancer (Box 3, below).
|Box 3: Key priorities for implementation: continuing education for healthcare professionals|
To illustrate the key areas covered in each section, Box 4 (below) lists the recommendations relating to an important cancer seen in primary care: lower gastrointestinal cancer.
|Box 4: Recommendations for referral of patients with suspected lower gastrointestinal cancer|
Refer urgently patients who are:
A key recommendation of the National Audit Office report is that the guidelines for referral for suspected cancer should be widely disseminated and acted upon.2
The report also recommended that stronger joint working relationships between GPs and hospitals should be encouraged through the development of standardised referral procedures and feedback to GPs on the appropriateness of referrals. Primary care teams should also consider the guidelines’ suggestion that they employ significant event audit to review and learn from their experience in detecting and referring patients with cancer. Referral guidelines for suspected cancer can be downloaded from the NICE website: www.nice.org.uk
- Department of Health. The NHS Cancer Plan: three year progress report - maintaining the momentum. London: DoH, 2003.
- National Audit Office. Tackling cancer in England: saving more lives. HC 364. Report by the Comptroller and Auditor General. London: TSO, 2004.
- Department of Health. HSC 2000/013: Referral guidelines for suspected cancer. London: DoH, 2000.
- National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Clinical Guideline 27. London: NICE, 2005. www.nice.org.uk
- National Collaborating Centre for Primary Care. Referral guidelines for suspected cancer. Royal College of General Practitioners and University of Leicester, 2005. www.rcgp.org.uk