1.1. Guideline aims

Clinical guidelines are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.(1) This guideline offers advice on the referral of patients with suspected cancer to specialist services. It updates previously published guidelines,(2) following a commitment in the NHS Cancer Plan(3) that these guidelines would be reviewed by NICE. The new guideline takes account of new research evidence and the findings of audits{969] undertaken since the publication of the previous guideline.

1.2. Referral of patients with suspected cancer

A key aim for the NHS is improvement in the care of people with cancer, including a reduction in mortality by 20% in people under 75 by 2010 in comparison with a 1995–97 baseline. Progress is being made towards this objective, and death rates are falling.{970} In England and Wales in 2003, 136,030 people died from cancer(4). The cancers causing most deaths are shown in Table 1.

Table 1

Deaths from cancer males and females, all ages, in England and Wales(4).

Five-year survival rates for some cancers are increasing. For example, rates for breast cancer rose from 72.8% in the period 1991–5 to 77.5% in the period 1996–9; for colon cancer the improvement was from 42.1% in men and 42.8% in women to 46.9% in men and 47.9% in women over the same period. However, in cancers survival rates have been relatively unchanged, for example certain types of cancers of the bladder, brain, and cervix.(5)

Early referral has a role to play in the improvement of care for people with cancer, and in some cancers early referral may improve survival rates. In addition to its roles in prevention, support and long-term management of people with cancer, primary health care has particular responsibility for the early detection of cancer and the initiation of speedy referral to specialist services. To assist primary healthcare professionals identify people with suspected cancer as early as possible, the Department of Health issued guidelines on the topic in 2000.(2)

A recent report by the National Audit Office(6) on cancer services in England observed that patients in England tended to have more advanced cancer at the time of diagnosis than some other countries, at least for breast and bowel cancer. Older people and those from deprived areas were more likely to be diagnosed with cancer at a more advanced stage.

The national Audit Office accepted that more action was needed to reduce delay in the presentation of patients for treatment. Delay may be explained by the failure of some patients to seek help quickly, and by the difficulties general practitioners can face in identifying people with cancer. An electronic survey was circulated to the several thousand subscribers of a general practitioner information network. The survey attracted 814 responses, just under half of whom had read the Department of Health guidelines published in 2000 and found them useful. Some respondents reported that the guidelines had not added to their existing knowledge. A survey of consultants indicated that respiratory physicians reported that 80% of referrals from general practitioners were appropriate, but colorectal surgeons reported 50% that only were appropriate. The National Audit Office recommended that the updated guidelines should be widely disseminated and acted upon, and that stronger joint working relationships between general practitioners and hospitals should be encouraged through the continued development of standardised referral procedures and feedback to general practitioners on appropriateness of referrals.

1.3. Principles underlying the guideline development

The key principles behind the development of this guideline were that it should:

• take full account of the perspective of the person with suspected cancer and their family and/or carers
• consider all the issues that are important in the primary care assessment and referral of people with suspected cancer
• base the recommendations on the published evidence that supports them, with explicit links to the evidence
• be useful and usable by all health care professionals dealing with people with suspected cancer
• indicate areas of uncertainty requiring further research.

1.4. Who should use this guideline

The guideline is intended for use by individual healthcare professionals in primary care, people with suspected cancer and their carers, the wider general public, and health care commissioning organisations and provider organisations.

Separate short form documents for people with suspected cancer and healthcare professionals are available without details of the supporting evidence. The guideline does not consider health promotion or education of the public about cancer.

1.5. Structure of guideline documentation

The guideline is divided into sections which cover in detail specific topics relating to twelve groups of cancers:

• lung
• upper gastrointestinal cancers
• lower gastrointestinal cancers
• breast cancer
• gynaecological cancers
• urological cancers
• haematological cancers
• skin cancers
• head and neck including oral cancers
• brain/central nervous system cancers
• bone and sarcoma, and
• children’s and young people’s cancers.

In each section, the symptoms, signs and risk factors relevant to initial assessment in primary health care are considered. The role of investigations in primary care is then addressed, and the sections conclude with consideration of factors related to delay and difficulties in diagnosis.

Two additional sections are included at the beginning of the guideline. The first deals with the needs of patients with suspected cancer at the time of referral. The second considers the process followed by healthcare professionals in reaching an initial diagnosis, and interventions to help healthcare professionals improve their ability to identify patients who should be suspected of having cancer.

Important general methodological issues are flagged up as appropriate. Where appropriate, full details of the papers reviewed are presented in the evidence tables (see Appendix A and B).

1.6. Guideline limitations

The guideline documentation and recommendations are limited to the detection of people who may have cancer in primary care, and do not address the assessment or investigation of patients after referral. The guideline will be relevant to professionals in general practice, walk-in centres, accident and emergency departments and other open access services that may be consulted by patients with symptoms or signs caused by undiagnosed cancers.

1.7. Scope