Presentation is loading. Please wait.

Presentation is loading. Please wait.

Referral guidelines for suspected cancer

Similar presentations


Presentation on theme: "Referral guidelines for suspected cancer"— Presentation transcript:

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 SLIDE FOR ALL 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 SLIDE FOR ALL 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 SLIDE FOR ALL 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 SLIDE FOR ALL 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 SLIDE FOR ALL 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’ (www.nice.org.uk/CG017). 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 2005 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


Download ppt "Referral guidelines for suspected cancer"

Similar presentations


Ads by Google