Suspected cancer: recognition and referral

Changing context and service delivery

Stakeholders highlighted that NHS England published its Long Term Plan for Cancer in 2019. The NHS Long Term Plan includes, among other relevant areas, the introduction of new, faster diagnostic standards. The Rapid Diagnostic Centre (RDC) Vision and 2019/20 Implementation Specification outlines the introduction of new pathways in lung cancer, prostate cancer, colorectal cancer and oesophago-gastric cancer. The National Cancer Programme will evaluate the RDC programme with an initial evaluation expected by mid-2020. The implementation is in very early stages (it is estimated that the rapid diagnostic centres will be fully implemented by 2028), therefore it was considered that this change in the service delivery does not have an impact in the guideline now but it might have an impact in the future. We will monitor the progress of the initial evaluation and any further assessments of the RDC implementation and consider the results for impact on the guideline when available.

Stakeholders also commented that the National Cancer Programme is reviewing the Cancer Waiting Times Guidance v10, particularly the direct access to a suspected cancer pathway for those patients with abnormal test results. A further review is also underway as part of the Clinical Review of Standards. National best practice timed pathways in colorectal cancer, lung cancer, prostate cancer and oesophago-gastric cancer have also been published.

Furthermore, it was noted that the impact of the recent interim review of national screening programmes in England may need to be taken into account. Although there is a link between cancer screening at a population level, screening and surveillance of high-risk populations, and how general population (and high-risk patients) presenting with symptoms in primary care are referred onwards, it is not currently clear how this interim review impacts on NICE guideline NG12, which excludes screening. Nonetheless, we will monitor the progress of this review of national screening programmes as any changes to screening strategies could have a downstream impact on the context within which NICE guideline NG12 recommendations are implemented.

We will not update the guideline at this time because changes in service delivery are still being implemented into the system. We will monitor and track these areas and the results of the evaluations, so we can assess any impact on NICE guideline NG12 in future surveillance reviews (or before, if the results are published).

Symptoms of suspected cancer

Some topic experts noted new symptoms that could be included for particular cancers such as cervical or breast cancer. Information gathered during this surveillance review highlighted similar areas to those noted by topic experts, including new symptoms in some types of cancers such as throat pain in oral cancer, or new cancers such as hypopharyngeal or pharyngeal cancer that are not currently covered in the guideline.

Stakeholder feedback from consultation also noted that new symptoms or symptom combinations need to be added into recommendations for certain cancers such as pancreatic cancer, ovarian cancer, sarcomas, and head and neck cancers.

Overall, we did not identify new evidence to support the inclusion of new symptoms or cancers; or the evidence identified was considered limited in terms of the quantity and quality to warrant an update of the recommendations.

Family history and genetic test results were also mentioned as relevant factors to inform referral decisions in suspected cancer. It is known that there are genetic diseases such as Lynch syndrome, which increase the risk of developing certain type of cancers (such as colorectal cancer). However, we did not identify any evidence on risk factors different from those already included in the guideline (age and smoking) that have an impact on the predictive power of symptoms included in the guideline.

Additionally, genetic testing is currently a rapidly evolving area but no new evidence was identified through this surveillance review to inform an update to the guideline. Genetic testing will be noted for consideration again at the next surveillance review of the guideline, by which time there may be developments in the evidence base and service delivery in this area.

Colorectal cancer – symptom profile of low-risk patients

Topic experts and stakeholders highlighted the need to reinstate the colorectal cancer symptom profile in low-risk patients to improve implementation of recommendation 1.3.4. The symptom profile was removed following the introduction of NICE diagnostics guidance on quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care (DG30). We will amend the recommendation to reintroduce the symptom profile of low-risk patients.

Prostate cancer age-specific reference range for prostate-specific antigen levels

Stakeholders noted that recommendation 1.6.3 is challenging to implement because the age-specific reference range for prostate-specific antigen level included in the recommendation is not explicitly described. It was argued that this lack of clarity is causing variability in clinical practice and people are being treated differently depending on the age-specific reference range adopted by healthcare professionals. The Public Health England prostate cancer risk management programme recommends an updated referral value for men aged 50 to 69 of 3 ng/ml. However, this guidance covers an asymptomatic population so it is not currently known if the referral value is applicable to men who would be covered by NICE guideline NG12 (men with symptoms attending primary care). Given that the age-specific reference range is not explicitly described in the recommendation and that its use could be now inaccurate; we propose to address this issue through our refresh process.

Oral cancer

In recommendation 1.8.3, a referral from the GP to a dentist is considered in people with a lump on the lip or in the oral cavity consistent with oral cancer, or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. Stakeholders stated that there is no formal referral route from primary care to the dentist. They considered that this recommendation causes unnecessary delays and potentially limits the accessibility to services among people with fewer resources. When the recommendation was developed, the committee noted that the symptoms included in the recommendation did not have a positive predictive value (PPV) greater than 3% to recommend a suspected cancer referral for oral cancer. They considered that a PPV greater than 3% could be reached if these symptoms were assessed by a professional with expertise in this area. They also felt that the reduction of unnecessary referrals to secondary care services resulting from a lesion being seen by a more expert clinician balanced the risk associated with a short delay. In this surveillance review, no new evidence was identified to have an impact on current guideline recommendations. We considered the lack of formal referral from primary care to dentist as a service delivery issue. We will ensure that the information on implementation issues that we have identified in this surveillance review are disseminated via appropriate channels within NICE.

Primary care testing

Topic experts and stakeholders highlighted primary care testing as an area of interest. They were particularly interested in:

We identified new evidence on primary care testing around the role of inflammatory markers for cancer diagnosis in primary care, or the use of urinary biomarkers in patients with haematuria, and low-dose CT scans in lung cancer. However, the evidence was considered limited in terms of the study design, the number of patients included and conclusions to have an impact on current guideline recommendations.

The diagnostic process

We identified new evidence on several aspects of the diagnostic process including assessing the impact of the urgent referral pathway in primary care; evaluating the impact of undertaking additional primary care investigations in patients who do not fulfil the criteria for urgent referral, and the use of electronic health records and decision support tools. New evidence identified supports the use of the 2-week referral pathway for suspected cancer. The use of electronic health records and decision support tools is an emerging area of interest, but more research is needed to assess the effectiveness of those interventions in referral for suspected cancer.

For further details and a summary of all evidence identified in surveillance, see appendix A.