NICE NG12 Suspected Cancer Discussion

Dr Katie Elliott

GP Lead for Cancer

Northern England Strategic Clinical Network

Aims

Discuss the changes in the NICE guidance.

Agree any changes required to the 2ww referral criteria.

Discuss/ agree a standard referral form for urgent 2ww referrals for suspected cancer.

Discuss any amendments to local guidelines.

Issued in June 2015 Identify more cancer at an earlier stage Symptoms based Increased emphasis on early referral/ direct to test in primary care PPV 3%

Implications for referral pathways Impact on diagnostic services Cost

62 Day Cancer target Cancer Strategy

New NICE Guidance NG12

Benefits

o One form for all practices to all trusts o Up to date criteria. Only one form to change if guidance changes o Standard formatting to link with GP IT system o Move away from hand written forms/ fax o Concentrate on clinical narrative and criteria for referral o Reduce risk of delay due to wrong form/ wrong information

Disadvantages

o How to accommodate local variation in services o Local advice telephone contact numbers o Will the forms get changed anyway?

Opportunity to develop a standard, region wide referral form for suspected Upper GI cancer

Update from HPB NSSG

No direct access to the tertiary care HPB MDT

All suspected pancreatic/ liver/ gallbladder cancer will still go via the local Upper GI team.

Do not recommend USS in primary care for investigating suspected pancreatic cancer.

Consider a pathway from abnormal CT direct appointment with upper GI team.

Refer to clinic

The North of England NSSG for UGI OG cancers has adopted in their entirety the comprehensive national guidelines for UGI oesophago-gastric cancers; these are to be used in collaboration with NICE 2005 referral guidance. To support local implementation of these, each section included below provides the clinician with information on referral pathways and clinical team. GP referrals This flow chart illustrates the referral mechanism for GPs to use for patients with dyspepsia. Note that iron deficiency anaemia is <110g/l (men) and <100g/l (post-menopausal women). The presence of low ferritin and/or low MCV without anaemia does not warrant endoscopy. Dyspepsia: Epigastric pain, Heartburn, Bloating, Nausea With: Alarm Symptoms: Dysphagia/ Unintentional weight loss/ Epigastric Mass/

Recent Onset >55/ Persistent vomiting/ Iron Deficiency Anaemia >>>>2ww referral

OG Cancer Clinical Guidelines OG NSSG on behalf of NESCN June

2015

Refer urgently for endoscopy, or to a specialist patients of any age with dyspepsia and any of the following chronic gastrointestinal bleeding dysphagia progressive unintentional weight loss persistent vomiting Iron deficiency anaemia epigastric mass suspicious barium meal result

Refer urgently for endoscopy patients aged 55 years and older with unexplained and persistent recent-onset

dyspepsia alone.

Old CG27 Guideline 2005

Refer urgently patients presenting with:

dysphagia

unexplained upper abdominal pain and

weight loss, with or without back pain

upper abdominal mass without

dyspepsia

obstructive jaundice (depending on clinical

state) – consider urgent ultrasound if

available.

Consider urgent referral for patients presenting with:

persistent vomiting and weight loss in the

absence of dyspepsia

unexplained weight loss or iron deficiency

anaemia in the absence of dyspepsia

unexplained worsening of dyspepsia and:

- Barrett’s oesophagus

- known dysplasia, atrophic gastritis or

intestinal metaplasia

peptic ulcer surgery over 20 years ago

Old CG27 guideline 2005

Consider a suspected cancer pathway referral ( to be seen within 2 weeks) for an upper abdominal mass consistent with stomach cancer. [new 2015]

Offer urgent direct access UGIE (to be performed within 2 weeks) for assessment for oesophageal or gastric cancer in people:

With dysphagia

Aged 55 and over with weight loss AND any of the following

Upper abdominal pain

Reflux

Dyspepsia. [new2015]

Consider non-urgent direct access UGIE to assess for oesophageal or gastric cancer in people with haematemesis. [new 2015]

Consider non-urgent direct access UGIE to assess for oesophageal or gastric cancer in people aged 55 or over with:

Treatment-resistant dyspepsia OR

Upper abdominal pain with low HB levels OR

Raised platelet count with any of the following:

Nausea

Vomiting

Weight loss

Reflux

Dyspepsia

Upper abdominal pain OR

Nausea or vomiting with any of the following:

Weight loss

Reflux

Dyspepsia

Upper abdominal pain. [new 2015]

NICE NG12 Assessment for Oesophageal/Gastric Cancer

Pancreatic Refer people using a suspected cancer pathway referral (for an appointment

within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice.

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:

Diarrhoea back pain abdominal pain Nausea vomiting constipation new-onset diabetes.

Gallbladder Consider an urgent direct access ultrasound scan (to be performed within 2

weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder.

Liver cancer Consider an urgent direct access ultrasound scan (to be performed within 2

weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver.

NICE NG12 Assessment for Pancreatic/ gallbladder/ liver cancer

Previous guidance used a disparate range of percentage risks of cancer in their recommendations.

Few corresponded with a PPV of lower than 5%. The GDG felt that, in order to improve diagnosis of cancer, a PPV threshold

lower than 5% was preferable. The GDG aspired to broaden recommendations to try and improve the

timeliness and quality of cancer diagnosis. The lower the threshold could reasonably be set, the more patients with cancer would have expedited diagnoses, with accompanying improvements in mortality and morbidity.

GDG considered costs vs benefits and decided on PPV of 3%. Same criteria for referral and urgent direct access investigations except

where access to direct investigation would replace referral to a specialist.

How the NICE Guideline Development Group (GDG) decided

the PPV

These recommendations are recommendations, not requirements.

They do not override clinical judgement. This guidance seeks to assist primary care clinicians in selection of

patients, and seeks to help patients in expediting their diagnosis when they may have cancer.

It also helps secondary care in understanding what services to provide.

Exceptions will occur, however, and clinicians should trust their clinical experience where there are particular reasons that this guidance does not pertain to the specific presentation of the patient.

What these recommendations are and what they are not

Suspected Pancreatic Cancer Pathway (subset of UGI pathway 15/11/13)

Clinical Presentation suggests pancreatic cancer

Review against NICE criteria and Hamilton Risk Assessment Tool

Patient fulfils NICE criteria

Patient >40 yrs doesn’t fulfil NICE criteria, but has a RAT

score of 2 or above with 4/52 history

Patient doesn’t fulfil NICE criteria or have a RAT

score of 2 or above

Two week wait referral

Consider abdominal USS

Direct to CT scan of thoraxabdomen / pelvis

Consultant review

Symptoms resolved

Symptoms persisting

No further action

Routine referral

Meets Direct to CT test criteria Has one of following: • Upper abdominal pain and weight

loss • Obstructive jaundice • Upper abdominal mass

USS abnormal USS normal

Clinical responsibility transfers to secondary care Clinical responsibility within secondary care Red outline indicates urgent pathway

Pancreatic Cancer Risk Assessment Tool B

ack

pai

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New

o

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dia

bet

es

Dia

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oea

Co

nst

ipat

ion

Mal

aise

Nau

sea

or

vom

itin

g

Ab

do

min

al

pai

n

Loss

o

f

wei

ght

Jau

nd

ice

0.1

(0.1, 0.1)

0.2

(0.2, 0.2)

0.2

(0.2, 0.2)

0.2

(0.2, 0.2)

0.2

(0.2, 0.3)

0.3

(0.3, 0.4)

0.3

(0.3, 0.4)

0.8

(0.7, 1.0)

21.6

(14,52) PPV as a single

symptom 0.3

(0.2, 0.4)

0.2

(0.1, 0.3)

0.3

(0.2, 0.4)

0.3

(0.2, 0.6)

0.3

(0.2, 0.5)

0.4

(0.3, 0.5)

2.0

(1.0, 4.3)

8.9

- Back pain

0.4

(0.3, 0.5)

0.4

(0.3, 0.6)

0.5

(0.3, 0.9)

0.7

(0.5, 1.0)

0.9

(0.7, 1.1)

1.6

(1.0, 2.9)

22.3

- New onset

diabetes 0.2

(0.1, 0.3)

0.3

(0.1, 0.5)

0.2

(0.2, 0.3)

0.4

(0.3, 0.5)

2.7

-

>10

- Diarrhoea

0.3

(0.2, 0.5)

0.6

(0.4, 0.8)

0.5

(0.4, 0.7)

1.5

(0.8, 3.0)

>10

- Constipation

0.5

(0.3, 0.8)

0.6

(0.4, 0.8)

0.9

(0.4, 2.1)

>10

- Malaise

0.9

(0.7, 1.2)

2.2

(1.1, 4.6)

14.6

- Nausea or

vomiting 2.5

(1.5, 4.4)

15.0

- Abdominal

pain >10

- Loss of weight

32.3

- Jaundice

1. What will be the changes to the referral criteria on the 2ww forms?

2. If it is a non-urgent UGIE referral, what is the time scale?

3. What happens if GP orders an urgent 2ww CT/USS and it it is reported consistent with cancer?

4. What happens if a non-urgent UGIE is abnormal?

5. What happens if an urgent 2ww UGIE is normal but symptoms are suspicious?

6. Should we continue to recommend urgent 2ww USS

What should we advise GPs ?

Reference point using new NICE guidance

Formatting for demographics and practice details already agreed.

Clinical information to be agreed

Any additional info required?

What about direct to CT option for areas without access to urgent CT?

Any need for a separate suspected HPB cancer form ?

Sample form

Weight loss Upper

abdominal pain

Reflux Dyspepsia Low HB Nausea/

Vomiting

Raised platelets

Weight loss

2ww

UGIE

2ww

UGIE

2ww

UGIE

IDA in over 60

2ww LGIE

Non-urgent UGIE Non-urgent

UGIE

Upper

abdominal pain

2ww

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Reflux

2ww

UGIE

Treatment

resistant reflux

Non-urgent

UGIE (BSG)

Non-urgent

UGIE

Non-urgent

UGIE

Dyspepsia

2ww

UGIE

Treatment

resistant

dyspepsia

Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent UGIE

Low HB

IDA in over

60 2ww

LGIE

Non-urgent

UGIE

Assess for active

bleeding

Nausea/

vomiting

Non- urgent

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent UGIE

Raised Platelets Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Non-urgent

UGIE

Assess for

active bleeding

Non-urgent

UGIE

Any actions required?

Thank you

Cancer strategy recommendations relevant to

diagnostic pathways

Recommendations: 16 Implementation of NICE NG12 17 NHS should mandate GP direct access to investigations for suspected cancer : blood tests, CXR, CT, MRI, endoscopy – by end 2015 21 Pilot 5 Multi-diciplinary diagnostic centres. 22 Pilot patient self referral via nurse triage if they have a red- flag symptom that would always result in a test. 24 95% patients referred for testing to have either cancer diagnosis confirmed or excluded and communicated to the patient within 4 weeks by 2020. 50% within 2 weeks

62 Day Cancer target event Reduce lead time - <14 days Work with primary care Work with secondary care

Diagnostics MDT Capacity – diagnosis/ clinic/ treatment Process mapping for diagnostics agreed for:

Colorectal - Sunderland OG - South Tees HPB - Newcastle Lung – North Tees Urology – North Cumbria

Additional supporting work from the SCN and NSSGs