NICE (NG12) Suspected Cancer: Recognition & Referral guidelines
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The NICE NG12 guidelines make recommendations on how to manage children, young people and adults with potential cancer symptoms that present to primary care. They set out;
- Potential cancer signs and symptoms;
- Recommendations on the appropriate diagnostic tests for patients;
- How soon diagnostic tests or a consultation should be carried out depending on the signs and symptoms (e.g. within 48 hours, 2 weeks etc);
- Recommendations for ‘safety netting’ patients;
- Recommendations on the information and support to provide to people with suspected cancer and their families and/or carers.
NICE outline a number of benefits that the referral guidelines, in particular lower referral thresholds, may bring to both patients and NHS services;
- Earlier diagnosis of cancer, leading to increased survival;
- A reduction in cancers diagnosed via an emergency route;
- Optimised diagnostic processes;
- More appropriate referrals to secondary care for suspected cancer.
Read the NICE (NG12) Suspected Cancer: Recognition & Referral guidelines, 2015, updated January 2021
More information on the impacts of specific guidelines are detailed in a costing statement from NICE along with a wider assessment for bowel cancer highlighting the varying impacts of the guidelines on different NHS service.
NICE produced a number of resources(link is external) to help local teams understand and evaluate the impacts and costs of implementing the guidance.
NICE Implementation Roundtable – January 2016
Cancer Research UK brought together a team of health professionals from across the cancer pathway to reflect on the NICE suspected cancer recognition and referral guidelines and share their tips for local implementation.
Click below for a helpful summary of the key actions you can take in managing people who present with non-specific signs or symptoms of cancer.
GP perspective
Dr Anant Sachdev, Cancer Research UK GP highlights in this video, the importance of routinely using suspected cancer referral guidelines despite current complexities around the management of cancer referrals.
Dr Neil Smith, Cancer Research UK GP highlights in this video, key considerations when managing people who present with non-specific symptoms.
Translating cancer guidelines into practice can be challenging, especially when people present with non-specific symptoms. If this happens, as well as using NICE (NG12), there are some key actions you can take.
Considerations for managing patients with non-specific symptoms
| Urgently refer people at a positive predictive value threshold of 3% or higher and at an even lower threshold for children, young people and for primary care tests. | |
| Use primary care investigations where available at point of care, to triage and manage the appropriate routes to send people. Chest X-rays, CT scans and blood tests are usually easily accessible and can help speed up cancer diagnosis. If you’re unsure of what’s available to you, contact your CCG or Health Board. | |
| Don’t be reassured by negative test results. Chest X-Rays, PSA and CA125 blood tests have false negative rates of 15-25%. | |
| Take advantage of Advice and Guidance to inform decision-making and assessment of suspicion of cancer prior to referral. | |
| Implement robust and consistent safety netting to help manage diagnostic uncertainty. Safety netting is vital for all patients, whether they’re being referred for tests, or specialist advice or not and recorded on the clinical system. | |
| Ensure you safety net patients who are not referred for suspected cancer until the symptoms are explained, resolved or the patient is referred. Patients should be given information about any tests they need to have, the next steps and follow up whether they are referred or not. | |
| Use tools to make following the guidelines easier (see below) and be aware of local guidance. | |
| Use non-specific symptom pathways (i.e. Rapid Diagnostic Centres (RDCs)), in some parts of England and South Wales, which provide alternative routes for patients when GPs are unsure which site-specific route would be appropriate. | |
| Remember to act on clinical suspicion if you still have concerns. |
Patient case study: test your NICE knowledge
Developed with Dr Tina George, Cancer Research UK GP & Clinical Lead for Early Diagnosis, Kent and Medway Cancer Alliance.
Tony is 72 years old and presents to his GP with appetite loss. He has diabetes and arthritis in his hands, which often makes it difficult for him to sleep and eat. Tony is a non-smoker and has had no exposure to asbestos.
The GP enquires if there are any additional symptoms, to understand if the appetite loss is related to Tony’s difficulty sleeping or not.
- If chest pain, cough, fatigue, shortness of breath or weight loss is present then NG12 recommends offering an urgent chest X-ray
There are no additional symptoms, but the GP decides to request several blood tests for additional reassurance that nothing serious is going on.
Which blood tests would you order?
- Several tests could be done at this stage given the non-specificity of Tony’s presentation, but the GP includes: FBC, haematinics, U&E, LFT, TFT, HBA1C, bone profile & ESR
The GP asks Tony to book another appointment in five day’s time, when his blood test results are due back. Tony returns in five days and says he is becoming increasingly tired. The blood tests show iron deficiency anaemia, but everything else is normal.
What would you do next?
- Ask Tony to return for another anaemia blood test in a week’s time?
- Refer on to an urgent suspected colorectal cancer pathway?
- Complete a Faecal Immunochemical Test (FIT) and wait for the result to determine whether to make a colorectal urgent referral?
Having discussed the options with Tony, the GP refers him to the urgent referral pathway for suspected colorectal cancer without doing a FIT, as this is the NG12 recommendation for people over 60 with iron deficient anaemia.
Use tools to make following the guidelines easier. Find your preferred tool.
Cancer decision support tools can be used to calculate risk and may aid with decision making.
CRUK Tools and resources
We have produced an interactive desk easel for GPs which summarises the NICE NG12 guidelines. Designed as a pdf document, GPs can access the summary from their computer and click through to the recommendations for each symptom group. Recommendations for adults, children and young people are covered, as well as primary care investigations. There’s also some additional advice on diagnostic tests and safety netting.
Download the interactive desk easel
If you have any feedback or comments about the easel please get in touch at earlydiagnosis@cancer.org.uk
Cancer Research UK NICE (NG12) Symptom Reference Guide Infographic
We have developed a symptom-led summary of the NICE (NG12) guidelines. This was updated in March 2020 to reflect the NICE (DG30) guidelines: Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care (2017)
Download the infographic here:
- CRUK NICE (NG12) Symptom Reference Guide Infographic style– Symptoms are grouped according to organ system, with a key directing you to NICE’s recommendations.
Or order physical copies of the infographic, for free, from the CRUK publications website.
Further learning and development for health professionals
We are keen to hear your views on these resources. If you have any feedback, you can get in touch at earlydiagnosis@cancer.org.uk.
Other Tools and resources
NICE
NICE have provided their guidance organised by cancer site(link is external) and by symptom and findings of primary care investigations. They have also provided a pathway tool which is searchable by cancer site or symptom.
British Medical Journal (BMJ)
The BMJ have published two summaries of the guidance from W Hamilton, et al;
- Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance
- Suspected cancer (part 2—adults): reference tables from updated NICE guidance
Macmillan Cancer Support
Macmillan Cancer Support have produced an update to their “Rapid Referral Toolkit” summarising the recommendations in the guidelines.
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