1. Kevin Barraclough, general practitioner1
  1. 1Painswick Surgery, Hoyland House, Greenbank, Painswick, Stroud, GL6 6TY, UK
  1. k.barraclough{at}btinternet.com

Monumental, evidence based, but not “less is more”

It is difficult to recall the 1990s, when patients in the United Kingdom with suspected cancer sometimes waited months for investigation. In 2000 the Department of Health introduced guidelines for referral, structured pathways, and a waiting time target of two weeks for patients with suspected cancer. Fifteen years later guidelines published by the National Institute for Health and Care Excellence (NICE) represent an enormous overhaul, which reflect monumental scholarship and are unique in the world.1 2 3 This latest guidance differs greatly from its forebears in methodology, form, tone, and content.

The authors have painstakingly trawled the literature to pin down the positive predictive values of many of the presenting features of cancer. Adults with clinical features that are associated with a positive predictive value of 3% or more for cancer (less for children) should be referred urgently for investigation.

The wording is less prescriptive than in previous guidance. Many patients with cancer do not fit the classical referral criteria but still need easily accessible investigation—currently only about half of cancers are diagnosed via the suspected cancer pathway.4 The authors distinguish between advice supported by evidence and …

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