New cancer referral guidelines – a chance to get the process right

New guidelines from NICE on cancer referral are due imminently. Here, Dr Steven Beaven and Dr Cathy Burton look at the need for change

Despite improvements in cancer survival in the UK, our rates remain below the average for Europe,1 and well below countries with comparable economies to our own, in western Europe and elsewhere.2 The “excess” mortality is largely attributable to higher mortality in the year after diagnosis. This suggests that UK patients tend to have more advanced disease at diagnosis than inother, comparable countries.

For the last 10 years, referrals for suspected cancers in England have been governed by the NICE guidelines published in 2005.3 The work of the guidelines development group was limited by the lack of evidence about how patients with cancer present to primary care.

This lack of evidence led to the creation of guidelines that, to some extent, reflect the symptomatology of patients presenting to secondary care. This is unhelpful when we aspire to make earlier diagnoses. Unsurprisingly, with the application of these guidelines, we continue to have relatively poor outcomes in our cancer care.

One of the three research recommendations of the group was a call for studies to examine the presenting features of cancer in large primary care populations. Since then much research about presentation of cancer in primary care has been conducted and published. Professor Willie Hamilton (University of Exeter) has published extensively4 and developed cancer risk assessment tools. Professor Julia Hippisley-Cox (University of Nottingham) has developed QCancer,5 aweb-based tool that calculates the likelihood of a patient having an as yet undiagnosed cancer. These, and other areas of research, have provided a wealth of data about symptoms, signs and laboratory findings that may be associated with an undiagnosed cancer. Macmillan Cancer Support has worked with both of these research teams to develop “cancer decision supporttools” to assist primary care teams.

NICE has undertaken a review of referral guidelines, making use of this new evidence. Draft guidelines were released for consultation in November 2014. The finished guidelines are due to be published in May 2015 and it is likely that there will be important changes in aspects of clinical practice, in both primary and secondary care. These changes pose a challenge.

For primary care, there will be a challenge about dissemination of the guidelines, education of the primary care workforce and changes to current investigation and
referral pathways.

For secondary care, there will be workload and organisational implications. Identifying cancers earlier will inevitably entail an increase in referrals and investigations.

Macmillan Cancer Support plan to develop a Referral Toolkit to assist GPs and others in the primary care setting to understand and readily access information about the new guidelines. We are also planning a series of articles in the BJFM about developments in specific cancers, including introducing the new guidelines.

Dr Steven Beaven and Dr Cathy Burton, GP Advisers, Macmillan Cancer Support

1 Interpretation of EUROCARE-5, Lancet Oncology, 2013
2 International Cancer Benchmarking Partnership
3 NICE guidelines (CG27) Referral guidelines for suspected cancer, 2005
4 The CAPER studies: ve case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients, British Journal of Cancer, 2009