Sir, I would like to draw your readers' attention to the updated National Institute for Health and Care Excellence (NICE) guideline on 'Suspected cancer: recognition and referral'.1 In a change to its 2005 predecessor, the 2015 guideline uses a new approach which focuses on the symptoms that a patient may experience.

For each cancer site (eg oral), the following two clinical questions were asked:2

  • What is the risk of (oral) cancer in patients presenting in primary care with symptom(s)?

  • Which investigations of symptoms of suspected (oral) cancer should be done with clinical responsibility retained by primary care?

The recommendations for oral cancer are:

  1. 1

    Consider a suspected cancer pathway referral (for an appointment within two weeks) for oral cancer in people with either:

  • Unexplained ulceration in the oral cavity lasting for more than three weeks or

  • A persistent and unexplained lump in the neck [new 2015].

  1. 1

    Consider an urgent referral (for an appointment within two weeks) for assessment for possible oral cancer by a dentist in people who have either:

  • A lump on the lip or in the oral cavity or

  • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia [new 2015].

  1. 1

    Consider a suspected cancer pathway referral by the dentist (for an appointment within two weeks) for oral cancer in people when assessed by a dentist as having either:

  • A lump on the lip or in the oral cavity consistent with oral cancer or

  • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia [new 2015].

The Guideline Development Group estimated that the recommendations would result in an increase in costs within the community dental service, and a decrease in the number, and therefore cost, of suspected cancer pathway referrals, but were uncertain over net effect.2

Although the authors state that they are making 'recommendations not requirements, and [they] are not intended to override clinical judgement', their advice often reads like requirements, and courts might interpret their advice this way.

This updated NICE guideline will have major implications for general practitioners in England, and most likely in Wales and Northern Ireland. In Scotland, similar referral guidelines for suspected cancer were updated by Healthcare Improvement Scotland in August 2014.3