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
  • When referring a patient with suspected cancer to a specialist service, primary healthcare professionals should assess the patient’s need for continuing support while waiting for their referral appointment
  • The information given to the patient, family and/or carers as considered appropriate by the primary healthcare professional should cover, among other issues:
    • Where the patient is being referred to
    • How long the patient will have to wait for the appointment
    • How to obtain further information about the type of cancer suspected or help prior to the specialist appointment
    • Who the patient will be seen by
    • What to expect from the service the patient will be attending
    • What type of tests will be carried out, and what will happen during diagnostic procedures
    • How long it will take to get a diagnosis or test results
    • Whether the patient can take someone with them to the appointment
    • Other sources of support, including those for minority groups
  • The primary healthcare professional should be aware that some patients find being referred for suspected cancer particularly difficult because of their personal circumstances, such as age, family or work responsibilities, isolation, or other health or social issues
  • Primary healthcare professionals should provide culturally appropriate care, recognising the potential for different cultural meanings associated with the possibility of cancer, the relative importance of family decision-making and possible unfamiliarity with the concept of support outside the family

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

Diagnosis

  • Diagnosis of any cancer on clinical grounds alone can be difficult. Primary healthcare professionals should be familiar with the typical presenting features of cancers, and be able to identify these features readily when patients consult with them
  • Primary healthcare professionals must be alert to the possibility of cancer when confronted by unusual symptom patterns or when patients who are thought not to have cancer fail to recover as expected. In such circumstances, the primary healthcare professional should systematically review the patient’s history and examination, and refer urgently if cancer is a possibility
  • Discussion with a specialist should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classic
  • Cancer is uncommon in children, and its detection can present particular difficulties. Primary healthcare professionals should recognise that parents are usually the best observers of their children, and should listen carefully to their concerns. Primary healthcare professionals should also be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected

Investigations

  • In patients with features typical of cancer, investigations in primary care should not be allowed to delay referral. In patients with less typical symptoms and signs that might, nevertheless, be due to cancer, investigations may be necessary, but should be undertaken urgently to avoid delay. If specific investigations are not readily available locally, an urgent specialist referral should be made

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
  • Primary healthcare professionals should take part in education, peer review and other activities to improve or maintain their clinical consulting, reasoning and diagnostic skills, in order to identify, at an early stage, patients who may have cancer, and to communicate the possibility of cancer to the patient
  • Current advice on communicating with patients and/or their carers and breaking bad news should be followed

Specific cancers

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

Referral

  • Refer a patient who presents with symptoms suggestive of colorectal or anal cancer to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements
  • In a patient with equivocal symptoms who is not unduly anxious, it is reasonable to treat, watch and wait

Refer urgently patients who are:

  • Aged 40 years and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting 6 weeks or more
  • Aged 60 years and older, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
  • Aged 60 years and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
  • Of any age with a right lower abdominal mass consistent with involvement of the large bowel
  • Of any age with a palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist)
  • Men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 g/100 ml or below
  • Non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100 ml or below

Investigations

  • Always carry out a digital rectal examination in patients with unexplained symptoms related to the lower gastrointestinal tract
  • Where symptoms are equivocal a full blood count may help in identifying the possibility of colorectal cancer by demonstrating iron deficiency anaemia, which should then determine if a referral should be made and its urgency
  • When referring, a full blood count may assist specialist assessment in the outpatient clinic
  • When referring, no examinations or investigations other than abdominal and rectal examination and full blood count are recommended as this may delay referral

Risk factors

  • Offer patients with ulcerative colitis or a history of ulcerative colitis a follow-up plan agreed with a specialist in an effort to detect colorectal cancer in this high-risk group
  • There is insufficient evidence to suggest that a positive family history of colorectal cancer can be used to assist in the decision about referral of a symptomatic patient

Conclusion

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

References

  1. Department of Health. The NHS Cancer Plan: three year progress report - maintaining the momentum. London: DoH, 2003.
  2. National Audit Office. Tackling cancer in England: saving more lives. HC 364. Report by the Comptroller and Auditor General. London: TSO, 2004.
  3. Department of Health. HSC 2000/013: Referral guidelines for suspected cancer. London: DoH, 2000.
  4. National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Clinical Guideline 27. London: NICE, 2005. www.nice.org.uk
  5. 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

Guidelines in Practice, July 2005, Volume 8(7)
© 2005 MGP Ltd
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