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NG12 | Suspected cancer: recognition and referral

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Ceri Lumb

on 18 October 2015

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Transcript of NG12 | Suspected cancer: recognition and referral

NG12
Suspected cancer:
recognition and referral
Published May 2015

Update from the 2005 guidelines
What's new?
Incorporation of evidence of how cancers present in primary care

Symptom thresholds lowered

Guidance ordered by signs and symptoms

GPs recommended to refer patients directly for tests

Introduction of different referral categories

Specific recommendations on safety netting
Main changes to guidelines
What potential problems can you foresee with the new guidelines?
Access to the suggested services - in particular imaging and endoscopy

?Increased patient anxiety

?Increased GP workload - dealing with the results of investigations
Professor Mark Baker,
NICE’s clinical practice director
"The problem is that a lot of cancer symptoms can be very general and similar to those of other conditions."
NG12 | Suspected cancer: recognition and referral
Earlier detection and better treatment for cancer would cut death rates from the disease by around a third, saving the lives of nearly a million people in the developed world every year.

(Report by the OECD 2013)
Concept of a 'risk threshold'
If the risk of symptoms / signs being caused by cancer is above a certain level then action (investigation or referral) is warranted

3% positive predictive value
Lower for children and young adults
"Systems" based referrals


What percentage of '2WW' referrals are diagnosed with a cancer?

What percentage of cancers in the UK are diagnosed through the '2ww' route?
2WW Guidelines - 2005
Increased emphasis on abnormal blood test results
Thrombocytosis
Anaemia
Leucocytosis
PSA
Ca125
New onset diabetes
Consider urgent CXR if >40y (Respiratory)

Consider non-urgent direct access OGD if >55 and nausea/vomiting/wt loss/reflux/dyspepsia/upper abdo pain (Upper GI)

Consider direct access USS if >55y with unexplained vaginal discharge or visible haematuria (Endometrial)
Thrombocytosis
Anaemia
Refer via cancer pathway >60y with iron def. anaemia (thresholds at GPs discretion) (Colorectal)

Consider cancer pathway referral if <50y with rectal bleeding and iron def. anaemia (Colorectal)

Offer FOB testing if <60y and iron def. anaemia (Colorectal)
Leucocytosis
Refer via cancer pathway >60y with unexplained non-visible haematuria and leucocytosis (Bladder)
PSA
Refer via cancer pathway if PSA above age-specific ranges

Consider checking PSA and performing DRE in men with:
Erectile dysfunction
Visible haematuria
CA125
Consider the possibility of ovarian cancer in the following situations and perform CA125:

Persistent / frequent, especially if 50y
Persistent abdo distension
Early satiety and / or loss of appetite
Pelvic or abdo pain
Increased urinary urgency or frequency

Unexplained weight loss / change in bowel habit / fatigue

New onset of IBS symptoms >50y
If CA125 >35: arrange urgent USS abdo / pelvis

If CA125 <35 or USS normal: reassess and safety net carefully
Consider urgent direct access CT scan (or USS if CT not available) if >60y with new onset diabetes


New onset diabetes
*USS only images the head of the pancreas
Immediate: acute admission

Very urgent: within 48 hours

Refer via cancer pathway: 2WW

Consider: evidence of benefit is less clear cut, use clinical judgement
Symptoms / signs
Unexplained weight loss

Unexplained loss of appetite

DVT
https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-symptom-and-findings-of-primary-care-investigations#urological-symptoms
https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer

Organisation for Economic Co-operation and Development
1 in 2 people in the UK can expect to have cancer

On average GP will only see 8 or 9 new cases of cancer per year
Background...
Putting the guidelines into practice
What is the lifetime risk of developing cancer?

On average how many patients will a GP diagnose with cancer each year?

11% conversion rate

43% of cancers in UK diagnosed through this route
Which non-specific signs have a positive predictive value of >3%?
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