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The New NICE...The New NICE suspected Cancer Guidance Overarching Principles • The 2005 TWW...
Transcript of The New NICE...The New NICE suspected Cancer Guidance Overarching Principles • The 2005 TWW...
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Dr Alison Wint Macmillan GP and Clinical Lead for Cancer S. Glos CCG
The New NICE Suspected Cancer Guidelines
January 2016
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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
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Cancer – always in the news
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National Policy Documents
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Health 4
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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
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• 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.
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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.
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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
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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.
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Risk Factors
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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
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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
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Symptomatic Layout
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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
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Thrombocytosis
40% risk of cancer
Lung – CXR
Endometrial – USS
Oesophagus/stomach - endoscopy
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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
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CRUK
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CRUK
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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.
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