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


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


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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Endocrine &

metabolic

12527 12416

5749

3025

2850

2100

1798

1486

858

551

Causes of death SW Cancer Network

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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.


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

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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


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.


Risk Factors


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


Layout of Guidance

Cancer Site

Patient support

Symptoms


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


Symptomatic Layout


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


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.


Primary Care Investigations

• PSA

• Ca125

• Ca+

• Leucopenia

• Anaemia

• Iron deficiency


Thrombocytosis

40% risk of cancer

Lung – CXR

Endometrial – USS

Oesophagus/stomach - endoscopy


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


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


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


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.


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?


Macmillan


CRUK


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.


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.


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



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