Viewpoint: NICE referral advice helps GPs catch cancer earlier, says Dr Richard Roope

Updated NICE guidance that lowers the referral threshold for suspected cancer will not be easy for busy GPs to take on board, says Hampshire GP Dr Richard Roope - RCGP and Cancer Research UK clinical lead for cancer. But the profession should be confident about referring at the new level, and be aware that doing so could improve cancer survival.

Dr Richard Roope: NICE cancer advice welcome
Dr Richard Roope: NICE cancer advice welcome

Like many GPs, I welcomed the changes in the NICE referral guidelines for suspected cancer (CG27). It is hoped the new Suspected Cancer: Recognition and Referral guidelines (NG12) will help reduce excess deaths attributed to diagnosis delays.

Providing recommendations by symptom in addition to cancer type should result in easier and timelier referrals and consequently better outcomes. However, it will take a little time to implement the changes and it won’t always be a smooth journey. As some of my RCGP colleagues have recently highlighted, the financial and capacity challenges that may be incurred will need careful review and assessment.

The reality for most GPs is the everyday workload and amount of reading we have, on a multitude of disease areas, may prevent us from immediately absorbing all 94 pages of the new guideline summary, let alone the 378 pages of the full guideline. It will take some time before we can fully assess the implications to our locally agreed pathways and changes that may be needed to our approach to diagnostic testing.

Be clear on cancer campaign

On 13 July, the next Be Clear on Cancer adverts go live. It is a re-run of the campaign which explains that older women are at greater risk of getting breast cancer. Adverts will appear on TV, leaflets in our surgeries and pharmacies, and newspaper articles exploring other non-lump symptoms that women should be aware of.

Following the last ‘breast cancer over 70’ campaign (Feb-March 2014), the number of breast cancers diagnosed via an urgent GP referral[1] increased by 25%. So we may see more women with breast symptoms in the coming months.

Two breast pathways remain: The two-week urgent referral for suspected breast cancer and the more general breast symptom referral.

GP cancer advice

For this specific tumour site, the changes in the new cancer guidelines haven’t been that significant. But, there are a few updates that may influence our clinical decisions.

Throughout the guidance, the referral threshold falls to a positive predictive value (PPV) of  3%. For breast cancer specifically, the guideline changes include:

  • The inclusion of age for nipple change symptoms (discharge, retraction, other changes of concern) - which is 50 years and over. The description for discharge has been widened and is no longer just bloody discharge
  • Features of a lump, such as being fixed or hard, are no longer detailed, allowing GPs to use their clinical expertise
  • Lumps in women aged 30+ warrant urgent referral, with a ‘consider non-urgent referral’ for women under 30
  • Eczematous skin changes have changed to ‘skin changes that suggest breast cancer’ therefore broadening the definition
  • The guideline for pain has changed and is now ‘breast lump (with or without pain)’
  • The addition of ‘unexplained lump in the axilla’ for women aged 30+
  • Family history is no longer a determining factor of symptomatic diagnosis

Read the new breast guideline in full

In practical terms what does this mean for us GPs? We need to work with our practice colleagues, CCG leads and commissioning teams to prepare for referral pathways changes.  It is not yet clear whether this guideline will increase referral numbers, or merely enable earlier referral, which may produce a short lived increase in referrals.  We should be confident about referring those with a 3+% PPV and remember that we have the potential to improve breast cancer survival for women across England.

[1]  Statistically significant. Comparing  Feb- April 2012 with Feb-April 2014 for suspected breast cancer referrals and breast symptom referrals.

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