Guidelines or tramlines? Putting cancer guidance back on track.

By Brian Nicholson for the CEBM Blog.

Image source: David Davies

“Does this make them good doctors or bad doctors?” was my favourite response to thePulse article “GP’s are bending the rules on cancer guidelines to benefit their patients” that discussed our BJGP article on international variation in cancer guidelines and the differences in how GPs follow them. It’s a good question!

Margaret McCartney wrote a relevant viewpoint in the British Medical Journal back in 2014. She immortalised the words of David Haslam (then Chair of the guideline developers NICE) at the NICE conference. From the horse’s mouth, he said- they are “guidelines not tramlines”. You could feel the collective sigh of relief from all the GPs (including me) who had deviated (even slightly) from the NICE guidelines (once or twice).

You might, then, find it strange that in Oxford that we’ve been redeveloping the 2-week-wait (urgent referral) cancer pathways with the Oxfordshire Clinical Commissioning Group so that they match up with the suspected cancer guidelinesreleased by NICE in July 2015. This has been no mean feat! (and is not exclusive to Oxford). There were over 200 recommendations and each form requires sign-off from our hospital colleagues before being used by the 632 GPs working in the 72 practices across Oxfordshire. Hospital specialists have reservations about NICE, expressing concerns that tests being recommended inappropriately and too many patients being referred without cancer will further overwhelm their already overstretched clinics. So, if this is true, why bother at all?- specialists dislike the new guidelines and GPs don’t take any notice of them.

The 2015 guideline includes three major leaps forwards to overcome the fact their 10 year-old predecessor led to thedetection of under 50% of cancers: 1) they lower the risk of cancer at which GPs should refer or test their patients, meaning patients can be investigated earlier- something patients want; 2) they are based on research conducted on General Practice patients, as relying only on traditional “red flag” or “alarm” late symptoms seen in specialist clinics means that cancers may be caught too late or present as an emergency; 3) they are based on symptoms and not just cancer types, as some symptoms like weight loss and fatigue are common to many cancers and are missed by cancer based guidelines. So referrals may go up, but the previous system was not working.

Read the full blog post here

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