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. 2000 May 27;320(7247):1476.

New guidelines for urgent referral of patients with cancer

Patients will have a dignified end to life

Nick Summerton 1
PMCID: PMC1127656  PMID: 10877572

Editor—Any new policy initiative such as the Department of Health's new guidelines for urgent referral of patients with cancer is inevitably accompanied by the views of both iconoclasts and opportunists. Sikora has clearly expressed his view, but I believe he is wrong.1

As a general practitioner I am in a different position from Sikora. Patients do not arrive at my surgery with diagnoses and neatly typed referral letters; they arrive with often vague and undifferentiated problems. My task is to identify which patients with, for example, persistent cough warrant an urgent referral or radiography. Tertiary care specialists may often approach lymphadenopathy with biopsy; in general practice we need to adopt a watchful waiting approach.

Sikora may be correct in stating that there is no evidence that delay in diagnosis is a large problem in the United Kingdom. However, a lack of evidence is surely an opportunity for further research.

The guidelines are merely an attempt to identify evidence for the diagnosis of cancer that is applicable to primary care populations which have a low prevalence of cancer.2 As a member of the working group I accept the criticism that in many areas the evidence is inconclusive and consensus approaches have necessarily been adopted. However, a strong element of primary care has been and continues to be incorporated in the final output. Above all, the process of developing guidelines for referring patients with cancer must be seen as dynamic and evolutionary. It is an opportunity for us in primary care to encourage researchers and policy makers to focus on the clinical questions that matter most to us and not necessarily on populist or pharmaceutical priorities.

Correct and targeted referral should reduce patients' anxiety by ensuring that the right patients reach the appropriate specialist rapidly. When patients cannot be cured they and their general practitioner will have time to sort out benefits and develop a plan of shared care with the oncologist or palliative care specialists. It also allows patients to get their life in order. Aside from effects on mortality, I believe that many patients will be given the opportunity to end life in a more dignified fashion as a consequence of more rapid and appropriate referral by their general practitioner.

Acknowledgments

Competing interest: Dr Summerton is a member of the cancer referral guidelines group.

References

BMJ. 2000 May 27;320(7247):1476.

The initiative should not be dismissed

Elizabeth Davies 1,2, Beverley van der Molen 1,2

Editor—Sikora criticises the two week waiting initiative for patients with suspected cancer and the referral guidance from the Department of Health,1-1 arguing that these will not improve survival and that money is better spent implementing the Calman-Hine recommendations and buying new cancer treatments.1-2

We agree that the Calman-Hine report is only partially implemented, but we suggest a different perspective. Work so far has been the designation of cancer units and centres, although the report also saw primary care as the focus of care, recommended public and professional education to help early recognition, and detailed discussion between primary care, units, and centres to clarify patterns of referral.1-3

Sikora states that delay in diagnosis is not important in the United Kingdom, where a wide range of referral times is evident. For example, studies of colorectal cancer reviewed by the Clinical Outcome Group found median delays ranging from less than 1 month to more than 4 months before referral and 6-7 weeks before diagnosis.1-4 A recent audit in Merton, Sutton, and Wandsworth Health Authority found that such delays could occur and revealed the distress that this caused some patients. It is not “window dressing” to mind about this, nor “an obsession with waiting list targets” to turn attention from routine surgery to the second most common cause of death. Reducing referral times will avoid unnecessary distress for patients, may reduce morbidity, and may even have a small effect on survival.

Sikora describes the guidance as “a reasonable distillation of textbook knowledge” which is “patronising” to well educated doctors. In fact general practitioners worked on most tumour specific subgroups to collate a research and consensus view not found in textbooks.1-1 We have visited primary care group cancer leads and individual general practitioners to discuss the guidance and received no such negative feedback. Rather, doctors request simple practical guidance, not textbooks, and wish to know how it will relate to local services and whether it can be backed up by workshop teaching around case examples. However, the management of patients not meeting the guidance, but who are anxious or need referral, must be clarified to avoid overloading services.

Sikora is right that guidance sent out on its own may be binned. The key to local implementation is full discussion of shared guidelines, followed by relevant education.1-5 Now is the time to plan this and to earmark resources to assess the effect. “Access to a uniformly high quality of care” demanded by Calman-Hine must surely be equal in time as well as place.

Acknowledgments

Competing interest: Dr Davies was a member of the Department of Health guideline subgroup for brain cancer.

References

  • 1-1.Department of Health. Referral guidelines for suspected cancer. London: DoH; 2000. [Google Scholar]
  • 1-2.Sikora K. New guidelines for urgent referral of patients with cancer are a waste of energy. BMJ. 2000;320:59. . (1 January.) [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Expert Advisory Group. A framework for commissioning cancer services. London: Department of Health; 1995. [Google Scholar]
  • 1-4.Cancer Guidance Sub-group of the Clinical Outcome Group. Improving outcomes for colorectal cancer. London: NHS Executive; 1998. [Google Scholar]
  • 1-5.Getting evidence into practice. Effective Health Care 1999; 5(1). (February 1999.)

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