1. Referral guidelines for suspected cancer
NICE Clinical Guideline
Issue date: June 2005
Review date: June 2009
NOTES FOR PRESENTERS
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
HEADER SLIDE – ALL
You can add your own organisation's logo alongside the NICE logo if you want. 1

2. NICE clinical guidelines
Recommendations for good practice based on best available evidence
DH document ‘Standards for better health’ includes expectation that organisations work towards implementing clinical guidelines
Healthcare Commission will monitor compliance with NICE guidance
NOTES FOR PRESENTERS
SLIDE FOR COMMISSIONERS AND MANAGERS
This slide sets the context on what NICE guidelines are, what the expectation is for compliance, and how this will be monitored. 2

3. Top 10 cancer killers Lung Pancreatic Colorectal Stomach Breast
Prostate
Oesophageal
Pancreatic
Stomach
Non-Hodgkin’s lymphoma
Ovarian
Leukaemia
NOTES FOR PRESENTERS
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Rationale for this guideline (Refer to full guideline Section 1.2)
Improving care for people with cancer is a key aim for NHS; includes reduction in mortality by 20% in people under 75 years by 2010 compared to baseline.
National Audit Report on cancer services in England shows that patients tended to have more advanced cancer at time of diagnosis compared to other countries. Older people and those from more deprived areas more likely to be diagnosed with cancer at a more advanced stage.
Therefore early referral important. For example, delays of 3 to 6 months between the onset of symptoms and diagnosis are associated with worse survival rates in breast cancer. In a study of time between presentation and treatment of six common cancers in general practice, the median number of days between presentation of the 1st symptom and initiation of referral was 0 days for breast, 28 days for large bowel, 31 days for lung, 84 days for oesophageal, 20 days for prostate and 66 days for stomach cancer. 3

4. Rationale for this guideline
Recent improvements seen in diagnosis and treatment of cancer patients
Still some patients not being referred urgently, leading to a delay in treatment
This guideline helps practitioners distinguish between common symptoms associated with common illnesses, and those that might indicate cancer
NOTES FOR PRESENTERS
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Refer to the National Audit Report: Tackling Cancer: Improving the Patient Journey March 2005
Four cancers looked at: breast, lung, bowel and prostate 4

5. What this guideline covers
Referral processes for the following cancers
- Lung - Upper and lower GI
- Breast - Gynaecological
- Urological - Haematological
- Skin - Head and neck including thyroid
- Brain and CNS - Bone cancer and sarcoma
Cancers seen in children and young people
Support and information needs
Key priorities for implementation
NOTES FOR PRESENTERS
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Refer to Scope: referral guideline for suspected cancer Section 4.1 5

6. What this guideline does not cover
Screening programmes for cancer
Tests undertaken after referral
Referral for suspected recurrence in previously diagnosed cancer patients
Referral for palliative care
NOTES FOR PRESENTERS
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Refer to Scope: referral guideline for suspected cancer Section 4.1.2 6

7. Cancer referral timelines
Immediate referral
Acute admission
or referral
within a few hours
Urgent referral
Patient seen within
2 weeks
(national target)
NOTES FOR PRESENTERS Refer to QRG Page 4
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NICE GUIDELINE SAYS:
Referral timelines
The referral timelines used in this guideline are as follows:
immediate: an acute admission or referral occurring within a few hours[A1], or even more quickly if necessary
urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks)
non-urgent: all other referrals.’
Current DH target is 17 weeks (4 months). By December 2005 – 3 months.
Some recommendations refer to the appropriateness of non-urgent referrals for e.g. breast cancer (QRG page 19), penile cancer (QRG page 23), basal cell carcinomas (QRG page 28), head and neck cancer (QRG page 31) and brain and CNS cancer (QRG page 34).
NICE guideline recommendation – investigations should not delay referrals.
Non-urgent referral
All other referrals 7

8. New in the NICE guideline…
This NICE guideline updates previously published Department of Health guideline 2000, as indicated in the National Cancer Plan
The NICE quick reference guide provides signs and symptoms indicating urgency of referral
NOTES FOR PRESENTERS
SLIDE FOR ALL
When viewing the following slides (10- 22) please ensure participants have a copy of the quick reference guide (QRG) and /or NICE guideline 8

9. Lung cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 9 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Asbestos exposure is included as a risk factor
Refer to full guideline Table 1: In 2003 cancer of the trachea, bronchus and lung accounted for the highest number of deaths from cancer (17,141) Separately identified was mesothelioma which accounted for 1,373.
For an explanation of ‘risk factors’ refer to full guideline 2.8.3 9

10. Upper GI cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 10 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Refer urgently adults with persistent vomiting and weight loss without dyspepsia to specialist
Refer urgently for endoscopy patients over 55 years with unexplained and persistent recent-onset dyspepsia alone
H. pylori status should not affect decision to refer
Stop acid-suppressing medication for 2 weeks minimum if referring for endoscopy
In obstructive jaundice consider urgent ultrasound
Patients with new onset dyspepsia should have FBC to detect iron deficiency anaemia. Get FBC done before outpatient appointment
FBC= full blood count
Definition on dyspepsia is taken from the NICE guideline on Dyspepsia: ‘Management of dyspepsia in adults in primary care’ ( Dyspepsia in unselected patients in primary care is defined broadly to include patients with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting.
In this guideline ‘unexplained’ is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations. In context of this recommendation the PCP should confirm that the dyspepsia is new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion of NSAIDS. ( taken from QRG Pg 10) 10

11. Lower GI cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 11 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Exclude positive family history as risk factor
Ulcerative colitis is a risk factor
Do DRE for unexplained lower GI symptoms
Do FBC to check for iron deficiency anaemia
Refer urgently patients over 40 years reporting rectal bleeding and change in bowel habits lasting over 6 weeks
‘Treat, watch and wait’ when equivocal symptoms but patient not anxious
DRE = digital rectal examination
FBC= full blood count 11

12. Breast cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 11 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Descriptions of the features of lumps
Family history as a risk factor
Urgent referral for lumps persisting after menstruation
Breast cancer in men
Not allowing investigations to hold up referral 12

13. Gynaecological cancer
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
Ask participants to refer to Pg 13 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
No lower age limit in cases of post-menopausal bleeding
Tamoxifen as a risk factor in endometrial cancer
Symptoms of ovarian cancer
Indications for full pelvic examination
Advice that smear is not needed if cancer is suspected
Ultrasound for checking abdominal or pelvic mass not obviously uterine fibroids, or of GI or urological origin
Urgent referral to specialist team if urgent ultrasound not available 13

14. Urological cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 14 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Indications for PSA and DRE
But exclude UTI before PSA
How to deal with haematuria with UTI
Testing for proteinuria and creatinine in cases of microscopic haematuria
Urgent ultrasound when scrotal masses do not transilluminate and/or when the body of the testis cannot be distinguished
PSA = prostate-specific antigen
DRE = digital rectal examination 14

15. Haematological cancer
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
Ask participants to refer to Pg 16 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Investigating unexplained fatigue
Lymphadenopathy and bruising
Indications for FBC
Investigating persistent bone pain
FBC = full blood count 15

16. Skin cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 17 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
7-point check list to assess pigmented lesions
Photographs to monitor growth 16

17. Skin cancer – 7-point check list
Major features Minor features
Change in size Largest diameter 7mm+
Irregular shape Inflammation
Irregular colour Oozing
Change in sensation
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
For checklist refer to QRG Pg 17 17

18. Head and neck cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 19 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Hoarseness persisting more than 3 weeks as an indication for X-ray (DH says over 6 weeks)
Urgent referral for persistent unexplained parotid or submandibular masses
Section on thyroid cancer
Advice on dental check-ups 18

19. Thyroid cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 20 in QRG 19

20. Brain and CNS cancer NOTES FOR PRESENTERS SLIDE FOR CLINICIANS
Ask participants to refer to Pg 21 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Progressive cognitive impairment and personality change
Past history of cancer as a risk factor
Indications for examination
Discussion with specialist if in doubt
Need to reassess if progress unsatisfactory 20

21. Bone cancer and sarcoma
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
Ask participants to refer to Pg 23 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Investigate unexplained or persistent bone pain
Consider metastases, myeloma, lymphoma and sarcoma in older people 21

22. Children and young people
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
Ask participants to refer to Pg 24 in QRG
NICE ADDITIONS TO DH 2000 GUIDELINE
Repeated presentation with same problems, parental concerns and persisting symptoms as triggers for referral
Down’s and other syndromes as risk factors
History of injury does not exclude bone sarcoma
Urgent referral for lymph nodes over 2cm
Recommendations on retinoblastoma
Indications for FBC
Imaging should be performed by specialist paediatricians 22

23. So key priority is:. education for healthcare professionals
So key priority is: education for healthcare professionals to ensure that
all indications for referral are picked up
timely and appropriate investigations are ordered
patients and carers get appropriate support and
information
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
Refer to QRG Pg 5 – Key priorities for implementation 23

24. Support and information for patients
NOTES FOR PRESENTERS
SLIDE FOR ALL
This slide is intended as a discussion tool
Refer to NICE guideline section –
When referring a patient with suspected cancer to a specialist service, primary healthcare professionals should assess the patient’s need for continuing support while waiting for their referral appointment. The information given to patients, family and/or carers as considered appropriate by the primary healthcare professional should cover, among other issues:
where patients are being referred to
how long they will have to wait for the appointment
how to obtain further information about the type of cancer suspected or help prior to the specialist appointment
who they will be seen by
what to expect from the service the patient will be attending
what type of tests will be carried out, and what will happen during diagnostic procedures
how long it will take to get a diagnosis or test results
whether they can take someone with them to the appointment
other sources of support, including those for minority groups.
The primary healthcare professional should be aware that some patients find being referred for suspected cancer particularly difficult because of their personal circumstances, such as age, family or work responsibilities, isolation, or other health or social issues.
Primary healthcare professionals should provide culturally appropriate care, recognising the potential for different cultural meanings associated with the possibility of cancer, the relative importance of family decision-making and possible unfamiliarity with the concept of support outside the family Discuss with patients (and carers as appropriate) their preferences for being involved in decision-making about referral options and further investigations (including risks and benefits).
Take into account personal circumstances, such as age, family or work responsibilities, isolation, or other health or social issues.
Provide culturally appropriate care.
Be aware that men may have similar support needs to women, but may be more reticent about using support services. 24

25. Breaking ‘bad news’
Effects of inappropriate giving of bad news can be profound but good techniques can be learnt
Recognise the changing expressions of grief: despair, denial, anger, bargaining, depression and acceptance (not always in that order!)
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
The guideline refers to the document below. While a primary healthcare professional (PCP) may be imparting the news that the referral is to ascertain whether or not the patient does have cancer this is still bad news for the patient and the principles on how to handle this remain the same.
Taken from ‘Improving communication between doctors and patients' A report of the working party of the Royal College of Physicians (1997)
Changing Expressions of Grief: Kubler-Ross E. On death and dying. New York: Macmillan, 1970 25

26. Key factors for implementation (1)
Training and education to ensure practitioners are:
familiar with typical
presenting features of
cancers
alert to unusual
symptom patterns or
unexpected failure
to recover
alert to parental
concerns when
dealing with
children
NOTES FOR PRESENTERS
SLIDE FOR PCPs (Primary healthcare professionals) OR COMMISSIONERS, PRACTICE MANAGERS
Primary healthcare professionals must be alert to the possibility of cancer when confronted by unusual symptom patterns or when patients who are thought to not have cancer fail to recover as expected. In such circumstances, the primary healthcare professional should systematically review the patient’s history and examination, and refer urgently if cancer is a possibility.
Discussion with a specialist should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical.
Cancer is uncommon in children, and its detection can present particular difficulties. Primary healthcare professionals should recognise that parents are usually the best observers of their children, and should listen carefully to their concerns. Primary healthcare professionals should also be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected. 26

27. Key factors for implementation (2)
Systems in place so that practitioners can:
refer urgently and
discuss referral
with
specialist
start
investigations
without
holding up
referral
provide
appropriate
support and
information
SLIDE FOR PCPs (Primary healthcare professionals) OR COMMISSIONERS, PRACTICE MANAGERS 27

28. Implementation for clinicians
Be familiar with new guideline
Address changing roles of primary care health professionals
Review current referral and investigation procedures
Consider implications and consequences of ‘support and information needs’
Find opportunities for collaboration and joint training between primary and secondary care
Link with your cancer network
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS, COMMISIONERS AND MANAGERS
Guideline refers to ‘primary health care professional’ not specifically GP. Organisations need to interpret this in the light of their own local arrangements
Refer to The NHS Cancer Plan: A progress report 28

29. Implementation for managers
Disseminate guidance effectively
Review current practice, protocols and referral processes
Develop and implement an action plan
Check capacity, schedules and waiting times for access to specialist teams and investigations
Establish collaborative working across primary/ secondary care and links with the cancer network
Consider workforce planning and training issues
Monitor, audit and review progress
NOTES FOR PRESENTERS
SLIDE FOR COMMISSIONERS AND MANAGERS
This slide is intended as a discussion tool
It starts with internal dissemination but moves on to undertaking a gap analysis
Dissemination – Have the right people received the guidance?
Consider what are the actions for those receiving the guideline?
Monitoring and audit: Consider a baseline assessment and plan change against this. Plan for audit
Action planning: Use local action planning templates, consider how progress is fed back into the organisation 29

30. Assessing cost locally
NICE is developing a costing tool for this guideline
A national costing report and local costing templates will be available on the NICE website from August 2005
SLIDE FOR COMMISSIONERS AND MANAGERS
Costing templates will be available on the Implementation section of the website from August 30

31. What services are provided in your area
What services are provided in your area? Create your own local services list!
Consultant Specialist
Oncology team
Oncology Clinics
Clinical Nurse Specialist
Counsellor
Radiology
Voluntary organisations
SLIDE FOR PRESENTER TO COMPLETE
This slide allows you to add your own local information. It helps identify what services exist within your area. You can use this slide to update teams on individuals and teams providing cancer services, you can include contact details etc 31

32. Audit against recommendations
Audit criteria
Immediate referral
Acute admission
or referral
within a few hours
Audit against recommendations
Urgent referral
Patient seen within
2 weeks
(national target)
NOTES FOR PRESENTERS
SLIDE FOR CLINICAL EFFECTIVENESS, AUDIT LEADS
Refer to NICE guideline Appendix D Technical detail on the criteria for audit
Non-urgent referral
All other referrals 32

33. Further information
Quick reference guide: summary of the recommendations for health professionals
NICE guideline: all of the recommendations
Full guideline: all of the evidence and rationale behind the recommendations
Information for the public: plain English version for patients, carers and the public
SLIDE FOR ALL
The slides do not replace the full version of the guideline and should be used in conjunction with the Quick Reference Guide or Full Guideline – links displayed above 33

34. www.nice.org.uk SLIDE FOR ALL
You can find more information on NICE and our work by visiting the website at 34