the new nice...the new nice suspected cancer guidance overarching principles • the 2005 tww...

Dr Alison Wint Macmillan GP and Clinical Lead for Cancer S. Glos CCG

The New NICE Suspected Cancer Guidelines

January 2016

Aims

• Background to the guidance • The new TWW Guidelines –

principles & overview. • What aids are available? • The Primary care role in

cancer diagnosis. • Consider follow-up actions

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 2

Cancer – always in the news

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 3

National Policy Documents

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better

Health 4

The New Cancer Story

• Public awareness of risk factors rising

• More cancers are being diagnosed, 300,000/yr

• Lifetime individual risk of cancer approaching 50%

• 200 different types of cancer

• New screening tests are being introduced

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The New cancer Story

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health

• Treatments are more effective

• More people are surviving.

• Cancer a new long term condition

• End of Life Care in UK exemplary.

Cancer is no longer a death sentence

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January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health

Endocrine &

metabolic

12527 12416

5749

3025

2850

2100

1798

1486

858

551

Causes of death SW Cancer Network

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January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 8

The primary care Challenge • Patients present with vague ill defined

symptoms.

• Increasingly dealing with an ageing population

• Frailty can mimic cancer

• Older patients more likely to have co-morbidities.

• The average GP diagnoses 8 cancers/year.

But a GP considers a cancer diagnosis several times/day.

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 9

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 10

Why New Guidelines

• It is now 10yrs since the initial TWW guidance was published.

• At that time it represented a cultural change in how GPs referred patients with suspected cancer.

• It was resisted at the time by GPs who were used to referring to a named clinician.

• It was a challenge for Secondary Care Consultants who thought GPs were referring inappropriate patients

• It was an administrative challenge as the CCGs were being rated nationally on their achievement of the 14day target.

Since then there has been a growing body of research evidence on the benefits of earlier diagnosis of cancer.

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 11

January 16 Dr A Wint: South Gloucestershire Clinical

Commissioning Group: - Leading you to Better Health

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January 16 Dr A Wint: South Gloucestershire Clinical

Commissioning Group: - Leading you to Better Health

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The New NICE suspected Cancer Guidance

Overarching Principles

• The 2005 TWW guidance was based on Secondary care data

• 2015 Guidance based on evidence from symptoms presenting to Primary Care.

• Positive Predictive Value of 3% for presenting symptoms is used to inform recommendations. 5% used in 2005

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 14

The Role of Primary care

• 90% of cancers are diagnosed based on presenting symptoms

• 85% are seen in Primary care

• Patients diagnosed via TWW pathway have better clinical outcomes.

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 15

Risk Factors

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health

Lifestyle, genetic and industrial exposure risk factors are important, and must be addressed, but do not affect how cancers present clinically.

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The new guidance provides

• Advice on when to refer urgently.

• When to use TWW referral process.

• The referral criteria for most clinical sites remains the same.

• Suggestions for investigations within Primary Care

• Emphasises that these are recommendations and not requirements and are not intended to override clinical judgement

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Layout of Guidance

Cancer Site

Patient support

Symptoms

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 18

What’s new in 2015

• For most of the sites the referral criteria remain the same

• For Upper GI & Colorectal, Primary Care will be asked to investigate speedily those symptomatic patients who do not meet the TWW referral criteria.

• Pathway & clinical responsibility changes

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 19

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 20

Symptomatic Layout

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 21

GPs Gatekeeper Role?

• GPs should no longer have a gate-keeper role.

• The presence of symptoms should trigger investigation rather than be a filter.

• Lower the threshold for investigation.

Diagnosing cancer earlier will lead to less invasive treatment and result in improved survival

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Primary Care Investigation

• The benefits of investigations performed in primary care would be to speed cancer diagnosis.

• To identify the groups of symptomatic people with greatest risk of cancer.

• To minimise the number of referrals for patients who do not

have cancer.

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Primary Care Investigations

• PSA

• Ca125

• Ca+

• Leucopenia

• Anaemia

• Iron deficiency

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 24

Thrombocytosis

40% risk of cancer

Lung – CXR

Endometrial – USS

Oesophagus/stomach - endoscopy

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 25

Investigation Cont’d

FOB – GI symptoms without rectal bleeding

New diagnosis diabetes with weight loss >60yrs – consider pancreatic cancer

Leucocytosis with non-visible haematuria >60yrs consider bladder Cancer

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Direct Access Investigation

Urgent direct access from Primary Care for investigation within 2 weeks is recommended in several cancer sites.

• CXR

• Endoscopy

• Non-obstetric USS

• MRI of brain

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Safety Netting

• Actively monitor symptomatic

patients who are do not meet the referral criteria.

“Low risk, but not no risk” • Ensure that there is a protocol for

results to be reviewed and acted on. • Be aware of false-negative results

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Patient Support

• Shared decision making & informed patients a key principle

• Information at the time of referral: on process, investigations, risks & likelihood of cancer.

• Reassurance and information for

patients with low risk symptoms.

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Primary Care Workload

Adherence to these recommendations

will lead to increased responsibility

and work for Primary Care,

in length & number of consultations.

What decision support tools or guides are there to help?

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Macmillan

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 31

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 32

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 33

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 34

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 35

CRUK

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 36

CRUK

January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 37

What can You do?

• Find a decision support tool you can work with.

• Familiarise Yourself with the layout of the new guidance.

• There is a lot that will stay the same.

• Be aware of the referral routes in your area.

• Availability of investigations may change.

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Action Plan Suggestions.

• Carry out a Significant Event Analysis of a cancer diagnosis.

• Take part in continuing education and Peer review.

• Do an audit of the outcomes of your TWW referrals.

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Remember: Medicine can be messy!

Cancer diagnosis is important, but -

• Things are never black or white.

• Every patient is unique

• Raise our index of suspicion

• Lower our threshold for investigation.

Think Cancer! January 16 Dr A Wint: South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health 40

January 16 Dr A Wint: South Gloucestershire Clinical

Commissioning Group: - Leading you to Better Health

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