NICE summaries

The fact that the National Institute of Clinical Excellence has its own official biscuits does not bode well for the quality of its recommendations on obesity...

The purpose of this page is to allow you to quickly brush up on the relevant NICE guidance in common areas, split up by common topics body system/pathologies. Try to memorise them all in one sitting (really - don't do this)...

Cancer is a huge topic, affecting every organ system, so I've dropped the guidance into each sub section...

GI

Upper GI cancer

You will want to refer via 2WW anyone with an upper abdominal mass that suggests stomach cancer, or anyone over 40 with jaundice.

Send for urgent OGD

• Dysphagia
• 55+ with weight loss and pain/reflux symptoms.

Send for non-urgent OGD

• Haematemesis
• 55+ with:
  • Non resolving dyspepsia.
  • Upper abdo pain and anaemia
  • Raised platelets with any upper GI symptoms
  • Nausea and vomiting with weight loss/reflux/pain

Send for urgent CT

Anyone who is 60+ with weight loss and any of these:

• Diarrhoea or constipation
• Back pain
• Abdominal pain
• Nausea/Vomiting
• New diabetes

Some of these are a bit odd, because you would probably already be sending on a Lower GI cancer referral...

Consider urgent USS

Anyone who has a mass that feels like an enlarged liver or gallbladder mass deserves a cheeky USS.

Lower GI cancer

It's 2WW time for any of the following:

• Any age with unexplained anal mass or ulceration.
• 40+ with weight loss and abdo pain
• 50+ with unexplained rectal bleeding
• 60+ with iron deficiency anaemia or changes in bowel habit.
• Positive FOB test.

Consider 2WW referral

• Any abdominal mass
• Younger than 50 with rectal bleeding plus:
  • Abdominal pain
  • Change in bowel habit
  • Weight loss
  • Iron deficiency anaemia

Offer FOB testing

• 50+ with abdominal pain +/- weight loss.
• Less than 60 with change in bowel habit or iron deficiency anaemia.
• More than 60 with any anaemia.

Gynaecology

Ovarian cancer

You need to refer urgently if you suspect ascites, or find any unexpected pelvic/abdominal mass.

Consider ovarian malignancy and do CA125 if

• 50+ woman with bloating, early satiety, pelvic pain, or increased urinary symptoms.
• Any unexplained weight loss, fatigue or bowel habit changes.
• New onset of IBS in women over 50.

The key is that ovarian cancer is easily missed and diagnosed late, so always have it at the back of your mind.

Endometrial cancer

Send anyone 55+ with postmenopausal bleeding via 2WW. Consider it strongly in anyone under 55 too.

Go for an urgent USS if...

• 55+ with unexplained vaginal discharge for the first time, or with thrombocytosis, or with haematuria.
• Haematuria with anaemia, raised platelets or high blood sugars.

Other gynae cancers

If the cervix is abnormal in appearance, they are going to need an urgent referral. Same with any weird vulval lumps, ulcers or bleeding.

Haematology

Leukaemia

Do an FBC within 48 hours in any children or adults with one of these:

• severe pallor or tiredness
• generallised lymphadenopathy
• unexplained persistent infections
• bleeding or bruising issues
• hepatosplenomegaly

In children with these bleeding or bruising issues or hepatosplenomegaly, admit for an immediate specialist review - they coiuld have severe marrow suppression!

Lymphoma

Refer anyone with unexplained lymphadenopathy or splenomegaly for 2WW. Refer kids even more urgently. Especially think about fever, night sweats, SOB, itchiness, weight loss.

Myeloma

In patients over 60 with bone pain, particularly back pain or unexplained fractures do FBC, serum calcium and ESR/plasma viscosity.

If they have raised calcium, or raised viscosity, do protein electrophoresis and Bence Jones protein urine test within 48 hours. Refer with 2WW if these suggest myeloma.

Neurology

Brain and CNS cancer

Adults with a progressive loss of CNS functions, or any sign of intracranial lesion should have an urgent MRI. Children should have an urgent Neurology review.

Paeds

Childhood cancers

All the below need a 2WW referral to rule out neuroblastomas, retinoblastomas and Wilm's tumours...

• Palpable abdominal mass
• Absent red reflex
• Unexplained visible haematuria

Respiratory

Lung cancers

In

anyone with a suggestive CXR, or anyone over 40 with unexplained haemoptysis you need to refer them through 2WW.

Otherwise, consider:

Urgent CXR if over 40 and 2 of these:

• Significant smoking/asbestos history
• Cough
• Fatigue
• SOB
• Chest pain
• Weight loss or loss of appetite

Consider urgent CXR if over 40 and

Anything weird, such as recurrent chest infections, clubbing, neck or supraclavicular lymphadenopathy or weird chest findings on examination.

Sexual Health

Contraception

UKMEC guidance says the combined pill should be avoided in anyone:

• 35+ who smokes
• BMI over 35
• Breastfeeding, or within 3 weeks of giving birth.
• High blood pressure or vascular disease
• History of DVT (or high risk for one)
• With previous stroke
• Migraine with aura.
• Personal history of breast cancer, or BRCA1 positive.
• Diabetes with end organ damage.
• Liver cancer
• Current gall bladder disease.
• Lupus

Cancer risk

The Combined Oral Contraceptive increases risk of some female cancers. The easy way to remember risk: Oral = Oh no!

Oh no! Outermost, Improves Innermost:

• Increases risk of outermost female cancers - breast and cervical
• Decreases risk of innermost - ovarian and endometrial

Urology

Male Stuff

Refer any of the following via 2WW:

• Lumpy scary-feeling prostate on DRE.
• PSA above the age specific range (Generally anything much over 5).
• Painless enlargement or change in testicle shape.
• Firm penile mass or ulceration after STI excluded/treated.

Consider DRE and PSA test

• Any urinary symptoms, such as urgency, frequency, nocturia, etc.
• Erectile dysfunction
• Visible haematuria

Exclude UTI with these too.

Consider USS

• For any unexplained or unusually persistent testicular symptoms.

Bladder and kidney cancer

Two groups to look for:

• 45+ with visible haematuria without UTI as the cause
• 60+ with microscopic haematuria and dysuria or raised WCC.

Consider non urgent referral

Anyone over 60 with recurrent UTI with no obvious cause.

Women's Health

Breast cancer

Breast clinic under a 2WW for anyone:

• Over 30 with a concerning breast lump with or without pain.
• 50+ with nipple changes or discharge.

Consider 2WW referral for anyone

• With skin changes that suggest breast cancer
• 30+ with axillary lump with no obvious cause.

Clinical Genetics referral

Sarah has a rare X-linked allergy to Jaffa cakes, and has two 1st degree, 2 second degree and a 3rd degree relative suffering from this terrifying disease.

First step is to understand what a first, second and third degree relative is - its simply just the number of steps from you along a family tree:

1. First degree: parents, siblings, children
2. Second degree: grandparents, aunts, nephew, grandchild, half-sibling, etc
3. Third degree: great-grandparents, great aunt/uncle, first cousin, great grandchild, great niece or great nephew

Refer to Clinical Genetics if breast cancer in:

• any 1st degree female relatives under age of 40
• any 1st degree male relatives at any age
• any two 1st and 2nd degree relatives
• any three 1st, 2nd and 3rd
• any 1st or 2nd with breast plus any 1st or 2nd with ovarian cancer