“Professor Willie Hamilton was involved in drawing up the NICE cancer guidelines which have caused controversy around the use of faecal occult blood testing in the pathway. Both sides of this debate can be read on pages 16 and 17 of the latest copy of the Digest.” Richard Stevens
Here are his views:
The NICE 2015 guidance was considerably different from the 2005 guidance. Firstly, it used only primary care evidence – as the clinical problem of whom to select for investigation is very much a primary care problem. Secondly it was restructured around symptoms, not cancer sites, on the reasonable grounds that patients present with symptoms, not with possible cancers. Thirdly, it was explicit in its rationale for which patients should be selected for urgent investigation, using a risk of 3% to underpin the recommendations. It also allowed lower risk profiles to be tested if it was possible to do so within primary care. Finally, it explicitly allowed GPs to use their clinical wisdom to override the recommendations where there was good reason to do so. With 350,000 new cancer diagnoses annually in the UK, it was utterly unrealistic to capture the nuances of each and every one in a ‘mere’ 176 recommendations.
One recommendation caused concern in the GI community: testing for blood in faeces (by faecal occult blood or by faecal immunochemical testing (we didn’t specify which). The patient group to be offered such testing are those who do not qualify for a colonoscopy, and did not qualify in previous guidance. Thus, more patients are being offered testing, which should reduce emergency admissions and deaths from colorectal cancer.
GPs have largely welcomed the guidance; probably this is because it matched their clinical experience. Indeed, there has been a relentless rise in cancer diagnostic activity between the 2005 and the 2015 guidance, which probably reflects GPs liberalising their own personal thresholds for investigation. Oddly, this means the guideline may have less impact than expected/feared (delete as appropriate) – as much of the change has already happened. Even so, it will be good to get the right patients having the right tests at the right time.
Willie Hamilton, MD, FRCP, FRCGP
Professor of Primary Care Diagnostics, Peninsula College of Medicine and Dentistry
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