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last updated: Fri, 21 Nov 2014 11:46:05 GMT

 Thu, 20 Nov 2014 13:00:00 GMT Cancer guidelines may improve diagnosis rates

“Doctors to get more help to spot cancer early,” The Guardian reports. The National Institute for Health and Care Excellence (NICE) has produced new revised draft guidelines that may help GPs pick up on possible early warning signs of cancer. 

The aim of the draft guidelines is to improve early cancer diagnosis in children, young people and adults of all ages. The draft guidelines have been primarily written for GPs and are an update of the 2005 guidelines that were last partially updated in 2011.


What are the possible early warning signs of cancer?

It is misguided to think of cancer as a single disease. Cancer is an umbrella term for a wide range of different conditions, in the same way as the term “infection”.

With that in mind, specific cancers can present with a wide range of symptoms, most of which are similar to trivial conditions, such as indigestion or a sprained joint.

What you need to watch out for are symptoms that are:

  • persistent – last for more than two weeks
  • unexplained – there seems to be no logical reason why a symptom(s) develops

Specific red flags you need to watch out for include:

  • cough that lasts longer than three weeks
  • unexplained and persistent changes in bowel habits, such as chronic diarrhoea or constipation
  • unusual bleeding, such as noticing blood in your stools or urine
  • you notice an unusual, irregular and possible itchy mole on your skin
  • unexplained weight loss

Read more about possible early warning signs and symptoms of cancer


What has prompted the recommendations?

All NICE guidelines are updated every few years to ensure the recommendations have taken into account the latest evidence and any improvements in diagnostic techniques and treatments.

Additional reasons for these particular guidelines to have been updated are that, as the media has pointed out, the UK is just missing its target of treating 85% of people with suspected cancer within 62 days (current reported figures are 82.5%). NICE reports that signs and symptoms of cancer can often be non-specific and overlap with other less serious conditions. They also say that each GP only sees, on average, eight new cases of cancer each year out of 6,000 to 8,000 appointments. As the appointments only last 10 minutes each, NICE wanted to provide practical guidelines for GPs to use to help them spot when to initiate further tests.


What are the new recommendations and how do they differ from existing ones?

The draft guidelines give clearer and updated information on the recognition of early signs and symptoms of over 200 different types of cancer and the criteria that warrant further investigations or referral to specialists. The threshold for whether a sign or symptom could indicate cancer has been lowered compared to the previous guidance.

The main difference from before is that the information in the guidelines has been presented in a new format to make it easier to find the relevant recommendations. The information is laid out in tables according to particular symptoms, such as fatigue, cough or rectal bleeding, and tables according to the site of possible cancer, listing the typical signs and symptoms to look for. In each case, the next steps, such as investigations and referral thresholds, have been provided.

The timing of referrals has been updated to include situations that warrant “very urgent” referrals, where a person should be seen within 48 hours. This is in addition to the previously described referral timings, such as “urgent” referrals, where a person needs to be seen within two weeks, and immediate referrals.

Finally, there is a new section that covers patient information, support and safety netting.


How accurate is the reporting?

The Daily Telegraph’s rather alarmist headline that “tired patients should be fast-tracked for cancer tests” is not related to any new guidance. Persistent or unexplained fatigue has long been a recognised symptom of a number of cancers, including leukaemia in children and adults, lung cancer and ovarian cancer, and this recommendation was present in the original 2005 guidelines.

In general, the media focussed on reporting the number of people who have not met the government target of treating 85% of people with suspected cancer within 62 days. NICE reports that research has estimated that late diagnosis contributes to between 5,000 and 10,000 deaths within five years of diagnosis per year.

Somewhat tellingly, all of the UK media ignore the issue of overdiagnosis, which is where people undergo tests or diagnostic procedures that they don’t actually need. The natural assumption is probably to think “better safe than sorry”, but many diagnostic procedures themselves carry small risks of complications. For example, current evidence suggests that a colonoscopy (used to diagnosis bowel cancer) carries a one in 150 chance of causing excessive bleeding, a one in 1,500 chance of creating a hole in the wall of the bowel and a one in a 10,000 chance of causing death.

Therefore, it’s important to be sure that the potential risk of a suspected disease is high enough to justify the risks associated with diagnosis.


What happens next?

The draft guidance is out for public consultation until Friday 9 January 2015. This means that any relevant patient groups, organisations, Clinical Commissioning Groups (CCGs) and other GP-led bodies can register and then comment on the:

  • new recommendations 
  • old recommendations that have been reviewed but remain unchanged
  • recommendations that are due to be removed

These comments can then be taken into account before the final version of the guidelines are published, which is anticipated to be May 2015.

The NICE draft guidelines are free to access online. After the consultation period, when the full guideline is published, it should guide patient care.

Though it will give recommendations for which signs and symptoms should warrant further investigation or referral, NICE clearly states that “the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer”.

Analysis by
Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Doctors to get more help to spot cancer early. The Guardian, November 20 2014

GPs urged to double cancer referrals in NHS guidelines. BBC News, November 20 2014

GPs told tired patients should be fast-tracked for cancer tests. The Daily Telegraph, November 20 2014

Doctors to get fresh guidelines to help spot cancer early. ITV News, November 20 2014

GPs To Get Better Cancer Diagnosis Guidelines. Sky News, November 20 2014

GPs can't be expected to know every cancer symptom, Government says. The Independent, November 20 2014

Doctors urged to test patients with coughs for cancer: GPs given guidance over fears they are dismissing early warning signs. Daily Mail, November 20 2014

 Thu, 20 Nov 2014 11:10:00 GMT Is growth in ADHD 'caused by marketing'?

"The global surge in ADHD [attention deficit hyperactivity disorder] diagnosis has more to do with marketing than medicine, according to experts," the Mail Online reports.

But these experts are sociologists, not clinicians, and they present no new peer-reviewed clinical evidence.

That said, they do highlight some interesting interconnected trends about ADHD that are worth attention.

The principal concern of the authors is that ADHD is being medicalised – that is, for a variety of reasons, children who may be simply "naughty" and high spirited are being misdiagnosed with ADHD, and are wrongly being treated with powerful medications such as methylphenidate, better known as Ritalin.  

This study concludes that the "global expansion" of ADHD and its subsequent medicalisation has been driven by five major causes:

  • drug industry lobbying
  • the influence of US-based psychiatry
  • the adoption of looser criteria for diagnosis
  • the influence of ADHD patient advocacy groups
  • the growth of information on the internet

This is a well-researched and interesting article which reflects current concerns about the medicalisation of symptoms that might be viewed as part of the human condition, rather than a disorder that needs drug treatment.

However, this is an opinion piece and is not the last word on this controversial subject.

If you are worried about a child or other relative's behaviour, it is important to see a health professional such as a GP.

Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD.


Where did the story come from?

The study was carried out by researchers from Brandeis University in the US. There is no information about external funding.

It was published in the peer-reviewed journal Social Science and Medicine.

The Mail Online's coverage was reasonably accurate, but it used the old journalistic cliché "experts say", implying there is a single expert opinion on a subject.

This is very rarely the case, especially when you are dealing with a subject as controversial as ADHD.


What kind of research was this?

This was a narrative review that looked at the evidence for an increase in ADHD across the globe. The authors say how in the US, ADHD has been medicalised for 50 years, but this approach is now being applied internationally.

They document the growth of ADHD diagnosis and treatment in the UK, Germany, France, Italy and Brazil, and look at the possible causes of this expansion.

This article was a narrative review, which means it is subject to selection bias, and is not a systematic review, which looks at all of the available evidence on a topic and uses this information to draw conclusions.

This potential selection bias means the authors may have selected articles to fit their theory.

ADHD is defined as a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.

There is a school of thought that the diagnosis of ADHD can be prone to medicalisation, where normal human behaviour is defined and treated as illness. 

But others argue this condition is being picked up more frequently as a result of better education and recognition of symptoms.


What does the study say?

The study looked at evidence for the "globalisation" of ADHD and the increase in the use of ADHD medication, such as methylphenidate (Ritalin).

In particular, it examined the prevalence and treatment of ADHD in five countries – the UK, Germany, France, Italy and Brazil.

In the UK, the authors state ADHD is now the most prevalent behavioural disorder, with an estimated 3-9% of children and adolescents having the condition.

Drug treatment for ADHD has also been on the rise here, with one recent report suggesting methylphenidate (Ritalin) prescriptions rose by 11% in GP practices, and by 24% in private practice from 2011-12. 

The authors partly ascribe this increase to changes in diagnostic criteria used in the UK. In the past, the UK adopted criteria from the World Health Organization (WHO) for a condition then called hyperkinetic disorder.

But there is now a greater use of US criteria globally, which uses different terminology and provides a lower threshold for diagnosis.

The article goes on to look at what it says are the major trends behind this rise in diagnosis and treatment in some countries.

Influence of drug companies

In the past, drugs for ADHD were heavily marketed in the US, but as this market has become saturated, the industry has expanded into international markets and promoted ADHD drug treatment around the world – first in western Europe, but also in other countries such as Brazil, Mexico and Japan.

Influence of US psychiatry

There has especially been a move towards "biological" psychiatry, where mental and behavioural disorders are treated with drugs rather than psychotherapy. More psychiatrists across the globe are now trained in the US and import US practices into their countries of origin.

Recent growth in the adoption of different criteria for ADHD

The authors say until the 1990s, many countries used the International Classification of Mental and Behavioral Disorders (ICD), published by WHO, which has strict criteria for ADHD. But since then, other countries have adopted the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, which has a lower threshold for diagnosis of ADHD.

Wide availability of information on the internet

The authors say there is "endless information on various sites about ADHD from numerous sources, including pharmaceutical websites". In particular, they point out the availability of ADHD checklists based on US screening devices. These allow internet users to "measure" certain behaviours that could lead to a possible ADHD diagnosis, prompting more consumers to ask for drug treatment.

Influence of ADHD advocacy groups

These groups often work closely with drug companies and promote drug treatments. The authors point out how in some countries, such as France and Italy, ADHD rates are lower. This is thought to be a result of a cultural tradition of using psychoanalytic rather than drug-based approaches for behavioural problems, and restrictions on the use of ADHD medication.


How did the researchers interpret the results?

The authors predict the medicalisation of ADHD will expand further to cover more countries.

This could also happen to other conditions, and divert attention away from "important social and structural approaches" to global health, they argue.



This is an interesting paper that shows there has been an increase in ADHD diagnosis and treatment in several countries, including the UK, and examines the reasons why this may have occurred. The possible "medicalisation" of ADHD has been an issue of concern and debate for some time.

As the authors note, the paper has some limitations. They selected countries where there is available published literature on ADHD, so their conclusions may not be generalisable to other countries.

Further research is needed to explore the approaches to ADHD in parts of the world that have received less attention, such as Asia, eastern Europe, the Middle East and Africa.

The authors used research on ADHD to support their opinion about the medicalisation and globalisation of this disorder. Others might disagree, arguing that more awareness has led to an increase in diagnosis, and drug treatment can be helpful in many cases.

If you are worried about a child's or other relative's behaviour, it's important to see a GP or other healthcare professional. Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Rise in ADHD cases is 'due to marketing, not medicine': Study blames increase on drug companies, pushy support groups, and people self-diagnosing online. Mail Online, November 19 2014

Links To Science

Conrad P, Bergey MR. The impending globalization of ADHD: Notes on the expansion and growth of a medicalized disorder. Social Science and Medicine. Published online October 8 2014

 Wed, 19 Nov 2014 11:50:00 GMT Have antibiotic changes upped heart infections?

"Rates of a deadly heart infection have increased after guidelines advised against giving antibiotics to prevent it in patients at risk," BBC News reports. But there is no evidence of a direct link between the two.

In 2008, the National Institute for Health and Care Excellence (NICE) produced guidelines regarding the use of antibiotics to prevent infective endocarditis – a potentially fatal infection of the lining of the heart that comes after bloodstream infection.

Prior to this guidance, common practice was to give antibiotics as a preventative measure to patients undergoing invasive procedures who were at increased risk of infective endocarditis (for example, patients with certain heart conditions).

In the 2008 guidance, NICE recommended that people undergoing dental or invasive surgical procedures were no longer given antibiotics as prevention for endocarditis, as the overall risks outweighed the benefits.

The current study examined trends before and after the guidance to see what effect the advice may have had on both antibiotic prescribing and rates of endocarditis.

This study demonstrates that the number of antibiotic prescriptions prior to invasive dental work or surgery significantly decreased after 2008. The rates of infective endocarditis have significantly increased since 2008, with an estimated 35 additional cases per month.

This is a valuable study, although this analysis of trends does not prove causation – that is, that reduced antibiotic prescribing in light of the NICE recommendations has directly caused the increase in cases. 

NICE has announced a review of their guidelines, although current recommendations remain unchanged until the review takes place.


Where did the story come from?

The study was carried out by researchers from Taunton and Somerset NHS Trust, the University of Surrey, the University of Sheffield School of Clinical Dentistry, John Radcliffe Hospital in the UK, and the Mayo Clinic and Carolinas Medical Center in the US.

Funding was provided by Heart Research UK, Simplyhealth and the US National Institutes of Health.

It was published in the peer-reviewed medical journal The Lancet.

BBC News provides a good account of this study.


What kind of research was this?

This study aimed to examine the trends before and after the publication of NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures.

The researchers aimed to look at:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

Infective endocarditis means infection and inflammation of the inner lining of the heart chambers (endocardium).

People with existing conditions affecting their heart valves or the structure of their heart are most at risk, as they are more at risk of having existing blood clots (thrombus) present in the heart, in which an infection can start.

The infection is caused by bacteria that have circulated in the bloodstream and reached the heart, so any invasive surgical or dental procedures could potentially carry a risk.

The most common bacterial cause of infective endocarditis is Streptococcus viridans – bacteria that are naturally present in the mouth and throat.

Invasive dental work can therefore potentially lead to these bacteria entering the bloodstream.

Symptoms of infective endocarditis are variable, but commonly include fever and general symptoms of being unwell, such as flu-like symptoms, aches and pains, loss of appetite and weight loss.

A person may also present symptoms after a blood clot has travelled from the heart and lodged in another part of the vascular system (for example, with a stroke).

People also usually have new heart murmurs. The condition carries a fairly high mortality risk, and treatment usually involves intravenous antibiotics, and sometimes surgery.

Prior to 2008, a single dose of amoxicillin (or clindamycin for patients allergic to penicillin) was recommended before invasive dental work for people who were at moderate to high risk of developing infective endocarditis.

In March 2008, NICE concluded that antibiotic prophylaxis (prevention) for infective endocarditis for people undergoing invasive surgical or dental procedures was no longer routinely recommended.

This was generally because the benefits of prophylaxis were outweighed by risks associated with antibiotics – both to the individual and in terms of population health in general in contributing to antibiotic resistance.

Equivalent guidance produced in the US and Europe is said to have also reduced the number of people for whom antibiotic prophylaxis is recommended.

But the US and Europe have not recommended antibiotic use is stopped altogether, as we have in this country.

The researchers aimed to see what effect the NICE recommendations have had on the number of infective endocarditis cases.


What did the research involve?

The researchers aimed to look at the change in prescriptions for antibiotic prophylaxis from January 2004 to March 2013, and to look at hospitalisation for a main diagnosis of infective endocarditis from January 2000 to March 2013 in England.

The prescriptions data came from the NHS Business Services Authority, from where they also got data on the number of individuals accessing dental care services.

Data for incidence of infective endocarditis and its associated mortality came from national hospital episode statistics (HES) and used standard diagnostic codes to identify infective endocarditis.

The researchers carried out statistical analyses looking at changes in incidence of infective endocarditis before and after the introduction of the guidelines in 2008, accounting for changes in population size.

For each case they identified, they also looked back to see if this person had been "high risk" in terms of having a susceptible heart condition or a previous episode of infective endocarditis.


What were the basic results?

Before 2008, the prescribing of antibiotics for the prevention of infective endocarditis was fairly constant.

After the introduction of the NICE guidance, it fell significantly from an average of 10,900 prescriptions per month from January 2004 to March 2008, to only 2,236 prescriptions per month from April 2008 to March 2013. Most prescriptions were for amoxicillin, and 90% were issued by dentists.

There were 19,804 cases of infective endocarditis between 2000 and 2013. Prior to 2008, there had been a steady upward trend in the number of cases, but from March 2008 onwards there was a steep increase in the number of cases above the projected historical trend. This amounted to an additional 0.11 cases per 10 million people each month.

By March 2013, there were an estimated 35 more cases per month than would have been expected had the previous trend continued. This increase in the incidence of infective endocarditis was significant for both individuals at high risk of infective endocarditis and those not considered to be at risk.

The researchers calculated 277 antibiotic prescriptions would need to be issued to prevent one case of infective endocarditis (number needed to treat, or NNT).


How did the researchers interpret the results?

The researchers say: "Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased significantly in England since the introduction of the 2008 NICE guidelines."



This is valuable and timely research, which has looked at trends before and after NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures. This examined:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

NICE's recommendation was based on an examination of the evidence of the effectiveness of antibiotics in preventing infective endocarditis, weighing the benefits and health outcomes (such as reduction in illness and deaths), risks and costs.  

The data collected by this study comes from reliable data sources, and the researchers took various steps to make sure their data collection was as complete and accurate as possible.

The results demonstrate a clear decrease in antibiotic prescribing as the NICE guidance came in – as would be expected – but also a significant increase in the number of infective endocarditis cases diagnosed since then.

The increase in cases was seen both in those who would be considered to be at risk of the condition and those without risk factors.

As the researchers highlight, this analysis of trends cannot prove causation. It cannot prove that the decrease in the prescription of preventative antibiotics before invasive procedures was directly responsible for the increase in the number of cases of infective endocarditis that has been seen subsequently, even though this may seem the likely cause.

We only know the number of diagnosed cases – we do not know what the actual cause in the individual cases was, and whether the person had, or had recently had, any dental or surgical procedures.

As the researchers say, they did not have reliable data on specific bacterial causes, which would have been useful – for example, in indicating whether it was bacteria normally present in the mouth, and so may have followed dental procedures. 

Other factors may be responsible for the change in trends, such as a change in the number of high-risk invasive procedures performed, or a change in the number of people at high risk of infective endocarditis.

However, the researchers did look into this and did not find a significant enough increase in the number of high-risk people with mechanical heart valves, or those having procedures for congenital heart disease, that could account for the trend.

It's also of note that there was an increase in infective endocarditis in people who weren't considered to be at risk of the condition – these people wouldn't routinely have been expected to have been offered antibiotic prophylaxis before the 2008 guidelines.

In light of this study, NICE has announced they will now review their guidelines. Until the review takes place, however, current recommendation are unchanged.

Even if there is a direct link between the 2008 guidelines and the rise in the number of cases of infective endocarditis, there are still other issues to consider.

Could it be justified to issue 277 antibiotic prescriptions to prevent one case of infective endocarditis, given the unnecessary exposure of many individuals to antibiotics, and given what we know about the growing threat of antibiotic resistance?

As with many aspects of public health, issues are never as clear cut as some media reporting would lead us to believe.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Heart infection rates rise after antibiotic use cut. BBC News, November 18 2014

Links To Science

Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. The Lancet. Published online November 18 2014


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