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NICE Cancer Referral Guidelines 2015 FDA/Macmillan 5th November 2016

Brief notes from presentation – for full guidance go to

Drs Katy Gardner, Jill Kirkman, Cathy HubbertMacmillan GP Cancer Leads, Liverpool CCG

Key to guidelines

•Clinical Acumen: “While guidelines assist the practice of health care professional, they do not replace clinical knowledge and skills”

•History/examination vital (lessons from SEAs)

•Initial urgent investigations in Primary Care where appropriate

•Involve patient in decision making at all times

•Safety Netting

Overview of changes

  • Level of risk which triggers referral reduced – Positive predictive Value was 5%- Now = 3%
  • Layout by site of possible cancer but also by symptoms
  • Direct access investigations encouraged (OGD, USS, CT,)
  • Strength of recommendation (Refer, Offer or Consider – depending on strength of evidence)
  • PATIENT information, support and safety netting are emphasised
  • Timings - very urgent e.g. 48 hours for children
  • Age- In some cases reduced (e.g.colorectal 2ww unexplained rectal bleed ≥50 now )
  • Specific duration of symptoms have gone from some guidelines – clinical judgement instead

Non ‘site specific’ symptoms of concern:

  • Weight loss: many cancers,
  • Appetite loss: remember lung and ovary
  • DVT! Several cancers including urogenital, breast, colorectal, lung, pancreas
  • Fatigue: FBC, Ca125, CXR (≥40 ever smoked./ asbestos)
  • See BMJ symptom based spaghetti chart: bmj.com/content/bmj/suppl/2015/07/17/bmj.h3044.DC1/adult_cancer_NICE_graphic_v3.1.pdf

What’s new? Examples: urgent/ 2ww

  • ≥ 40 with jaundice: 2ww (unless unwell consider MAU)
  • Urgent U/S if abdominal mass consistent with enlarged liver or GB (however shortage of u/s - see Liverpool direct to CT pathway)
  • Hepatosplenomegaly-very urgent FBC (48hr)
  • New onset T2 diabetes with wt loss - think pancreatic cancer
  • ≥60- persistent bone pain, particularly back pain or unexplained fracture – myeloma

What’s new? Platelets

  • Up to 30% of patients with some cancers will have unexplained raised platelets at diagnosis
  • Lung: ≥40 consider CXR
  • Upper GI: ≥55 nausea/vomiting/wt loss/ dyspepsia/abdo pain: consider OGD
  • Endometrial: ≥55 haematuria/vaginal discharge consider US
  • Consider age/ and other risks

What’s new? Myeloma

  • Persistent bone pain
  • Especially back pain or unexplained fracture: do FBC, ESR, Ca
  • 60+ with hypercalcaemia/↓WBC:
  • do electrophoresis and BJP within 48hr
  • As well as myeloma think about bony secondaries

New in urol /gynae cancer

  • >60, Raised WCC + unexplained non-visible haematuria: 2WW urology
  • >60 recurrent /persistent UTI – routine urology

Male Consider’ PSA & DRE

  • in Erectile dysfunction,
  • LUTS ( local advice -if infection repeat PSA when infection settled)
  • Also u/s for some indications……..

When to request Ultrasound- urology /gynaecology

CONSIDER-Routine:

  • Female ≥ 55, Vaginal discharge first presentation and ↑platelets or haematuria
  • Female ≥55 haematuria + anaemia, or ↑platelets or ↑glucose

all can indicate uterine cancer, of course visible haematuria also requires 2ww urology

  • Male Unexplained or persistent testicular symptoms (BUT possible urgent!)

Other ultrasound URGENT: unexplained lump increasing in size (sarcoma)

When to check CA125 –Female(see local ovarian C and M pathway)*

  • Abdominal/ pelvic pain (persistent) ≥50
  • Abdominal distension (persistent) ≥50
  • IBS symptoms ≥50y
  • Change in bowel symptoms
  • Urinary urgency (persistent) ≥50
  • NICE: Do CA125/US
  • Examine patient if possible!

*If CA125↑ …... arrange US abdo/pelvis: mark “ URGENT”. Put CA125 result on form. Will be scanned within 2 weeks (see specific handout)

When to arrange urgent FBC (48h)

  • Unexplained bruising, bleeding, petechiae
  • Pallor
  • Persistent fatigue
  • Unexplained fever
  • Unexplained infection persistent/ recurrent
  • Hepatosplenomegaly

When to request urgent CXR

OFFER:

  • ≥40 ever smoked +1 unexplained symptom (2 if never smoked)
  • Symptoms: cough, fatigue, SOB, chest pain, weight loss, appetite loss
  • Asbestos exposure + 1 symptom

CONSIDER:

  • ≥40 persistent or recurrent chest infection, finger clubbing, LN supraclavicular or cervical, signs of pleural disease, thrombocytosis

NB 10% people with lung cancer had a non-suspicious Xray in previous 3months!

Haemoptysis ≥40 refer 2ww

When to request OGD

REFER URGENT

  • Dysphagia
  • ≥55 + weight loss + one of :
  • Upper abdominal pain/ reflux/ dyspepsia

CONSIDER URGENT OGD

  • Upper abdominal mass consistent with stomach cancer (consider CT aswell)

Liverpool - working with upper GI re this

CONSIDER ROUTINE OGD

≥55 with one of

  • Dyspepsia treatment resistant
  • Anaemia (normo/micro) + upper abdominal pain
  • Nausea or vomiting + any of: weight loss /reflux/dyspepsia/upper abdo pain
  • Raised platelets AND 1 of nausea, vom, wt loss /reflux/dyspepsia/upper abdo pain
  • Hematemesis (use clinical judgment as if active may need to admit!)

When to considerurgent CT (think pancreas)

≥ 60 + weight loss and one of:

  • diarrhoea, constipation,
  • back pain, abdominal pain,
  • nausea, vomiting,
  • new onset diabetes

Straight to CT pathways Aintree & RLBUHT (for wgt loss and vague symptoms that don’t fit other 2ww)

Weight loss: recap

In unexplained weight loss as well as usual hist/exam/bloods :-

  • Ever smoked/ h/o asbestos- cough/fatigue/SOB/chest pain/ appetite loss- CXR
  • Abdominal pain or rectal bleeding- lower GI
  • Upper abdo pain/ reflux/ dyspepsia (raised platelet/ nausea/ vomit)- OGD
  • Diarrhoea/ abdo/ back pain/ n/ v/ constipation/ new onset DM- CT
  • Splenomegaly/ lymphadenopathy/ alcohol induced lymph node pain-haematology
  • Don’t forget Ca125 in women
  • Also See CT pathway handout

Children & Young Adults (see BMJ chart)

  • Refer within 48 hr Abdominal mass /enlarged abdo organ/ unexplained visible haematuria, new cerebellar or neurological dysfunction
  • Refer within 2w – absent red reflex
  • FBC (48h) unexplained bruising/bleeding/pallor/lymphadenopathy/ fever/ infection/ fatigue
  • US (48h) lump unexplained/ increasing
  • X ray (48h) bone pain/ swelling

Faecal Occult Blood is NOT available locally at present: National debate is ongoing

FOB is in new NICE

  • ≥ 50 unexplained abdo pain or weight loss
  • < 60 change in bowel habit or IDA
  • ≥60 with anaemia not IDA

So Examine and do bloods. If IDA --˃ to IDA clinic RLUH /colorectal UHA. Also see Wgt loss

If you are thinking FOB and sx don’t fit other urgent pathways-consider Non 2ww GI referral.

Local (Merseyside) Colorectal and IDA – RLUH AUH -same standards different models

RLBUHT – Use Choose and book, document PR and abdo exam

Colorectal 2ww

Apts are TELPHONE SLOTS - triage so that people go straight to most appropriate test.

Hospital slots are only for frail/ people who require a face to face

IDA– specialist nurse face to face BLOODS MUST CONFIRM IDA(see bundle on ICE)

Aintree UH

2ww Colorectal and asymptomatic IDA - same clinic – Nurse specialist triages/arranges most appropriate tests

Walton Neuro

  • Progressive subacute loss of CNS function use 2ww referral CNS –or Consider urgent MRI Walton Neuro
  • Other concerns d/w neuro helpline 07860 481429. 11.30 – 12.30 Mon – Fri excl bank hols

Head and Neck

  • Mouth cancer becoming more common, although risks include smoking and alcohol it can affect younger people and non-smokers(HPV)
  • CRUK and Doctors Net have just released oral cancer toolkit for GPs
  • NICE includes advice to refer dentist, local advice is if patient has no dentist don’t delay 2ry care referral

Other Resources

  • BMJ Adult and Childhood cancers spaghetti charts
  • Macmillan rapid referral guidelines 2015 (search engine –“Rapid referral Guidelines”
  • Safety netting: CRUK
  • Desktop/mobile/tablet referral guidelines are free of charge at:

Tools, tips, what you can do:

  • Safety-netting, worried? BOOK follow up, have robust processes for dealing with investigation results and check referrals received. (Some negative tests – mean further investigation needed!)
  • RCGP audit of cancer diagnosis
  • Risk assessment tools
  • SEA
  • Ensure you use new referral proformas and directory of services reflecting NICE 2015
  • “GP UPDATE/ Red Whale” Cancer Course… very good value.

These are notes taken from various sources please consult definitive guidelines for more information

Refs: Macmillan, NICE, BMJ, CRUK

Thanks to Dr Sue Burke –GP cancer lead, Warrington CCG

For more information on early diagnosis contact the primary care cancer team:

Dr Katy Gardner –

Dr Cathy Hubbert –

Dr Jill Kirkman –

Tomas Edge –

Louise Roberts –