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Cancer guidelines may improve diagnosis rates

Thursday 20 November 2014

“Doctors to get more help to spot cancer early,” The Guardian reports. The National Institute for Health and Care Excellence (NICE) has produced new revised draft guidelines that may help GPs pick up on possible early warning signs of cancer. 

The aim of the draft guidelines is to improve early cancer diagnosis in children, young people and adults of all ages. The draft guidelines have been primarily written for GPs and are an update of the 2005 guidelines that were last partially updated in 2011.

What are the possible early warning signs of cancer?

It is misguided to think of cancer as a single disease. Cancer is an umbrella term for a wide range of different conditions, in the same way as the term “infection”.

With that in mind, specific cancers can present with a wide range of symptoms, most of which are similar to trivial conditions, such as indigestion or a sprained joint.

What you need to watch out for are symptoms that are:

  • persistent – last for more than two weeks
  • unexplained – there seems to be no logical reason why a symptom(s) develops

Specific red flags you need to watch out for include:

  • cough that lasts longer than three weeks
  • unexplained and persistent changes in bowel habits, such as chronic diarrhoea or constipation
  • unusual bleeding, such as noticing blood in your stools or urine
  • you notice an unusual, irregular and possible itchy mole on your skin
  • unexplained weight loss

Read more about possible early warning signs and symptoms of cancer

What has prompted the recommendations?

All NICE guidelines are updated every few years to ensure the recommendations have taken into account the latest evidence and any improvements in diagnostic techniques and treatments.

Additional reasons for these particular guidelines to have been updated are that, as the media has pointed out, the UK is just missing its target of treating 85% of people with suspected cancer within 62 days (current reported figures are 82.5%). NICE reports that signs and symptoms of cancer can often be non-specific and overlap with other less serious conditions. They also say that each GP only sees, on average, eight new cases of cancer each year out of 6,000 to 8,000 appointments. As the appointments only last 10 minutes each, NICE wanted to provide practical guidelines for GPs to use to help them spot when to initiate further tests.

What are the new recommendations and how do they differ from existing ones?

The draft guidelines give clearer and updated information on the recognition of early signs and symptoms of over 200 different types of cancer and the criteria that warrant further investigations or referral to specialists. The threshold for whether a sign or symptom could indicate cancer has been lowered compared to the previous guidance.

The main difference from before is that the information in the guidelines has been presented in a new format to make it easier to find the relevant recommendations. The information is laid out in tables according to particular symptoms, such as fatigue, cough or rectal bleeding, and tables according to the site of possible cancer, listing the typical signs and symptoms to look for. In each case, the next steps, such as investigations and referral thresholds, have been provided.

The timing of referrals has been updated to include situations that warrant “very urgent” referrals, where a person should be seen within 48 hours. This is in addition to the previously described referral timings, such as “urgent” referrals, where a person needs to be seen within two weeks, and immediate referrals.

Finally, there is a new section that covers patient information, support and safety netting.

How accurate is the reporting?

The Daily Telegraph’s rather alarmist headline that “tired patients should be fast-tracked for cancer tests” is not related to any new guidance. Persistent or unexplained fatigue has long been a recognised symptom of a number of cancers, including leukaemia in children and adults, lung cancer and ovarian cancer, and this recommendation was present in the original 2005 guidelines.

In general, the media focussed on reporting the number of people who have not met the government target of treating 85% of people with suspected cancer within 62 days. NICE reports that research has estimated that late diagnosis contributes to between 5,000 and 10,000 deaths within five years of diagnosis per year.

Somewhat tellingly, all of the UK media ignore the issue of overdiagnosis, which is where people undergo tests or diagnostic procedures that they don’t actually need. The natural assumption is probably to think “better safe than sorry”, but many diagnostic procedures themselves carry small risks of complications. For example, current evidence suggests that a colonoscopy (used to diagnosis bowel cancer) carries a one in 150 chance of causing excessive bleeding, a one in 1,500 chance of creating a hole in the wall of the bowel and a one in a 10,000 chance of causing death.

Therefore, it’s important to be sure that the potential risk of a suspected disease is high enough to justify the risks associated with diagnosis.

What happens next?

The draft guidance is out for public consultation until Friday 9 January 2015. This means that any relevant patient groups, organisations, Clinical Commissioning Groups (CCGs) and other GP-led bodies can register and then comment on the:

  • new recommendations 
  • old recommendations that have been reviewed but remain unchanged
  • recommendations that are due to be removed

These comments can then be taken into account before the final version of the guidelines are published, which is anticipated to be May 2015.

The NICE draft guidelines are free to access online. After the consultation period, when the full guideline is published, it should guide patient care.

Though it will give recommendations for which signs and symptoms should warrant further investigation or referral, NICE clearly states that “the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer”.

Analysis by Bazian
Edited by NHS Website