Pancreatic cancer in adults: diagnosis and management [NG85]

New: Nice Guideline


This guideline covers diagnosing and managing pancreatic cancer in adults aged 18 and over. It aims to improve care by ensuring quicker and more accurate diagnosis, and by specifying the most effective treatments for people depending on how advanced their cancer is.

1.1 Diagnosis

1.2 Specialist pancreatic multidisciplinary teams

1.3 Staging

1.4 Psychological support

1.5 Pain management

1.6 Nutritional management

1.7 Relieving biliary and duodenal obstruction

1.8 Managing resectable and borderline resectable pancreatic cancer

1.9 Managing unresectable pancreatic cancer

NIHR Signal A surgical procedure for shoulder pain is less effective than previously thought

An increasingly common surgical procedure for shoulder pain, subacromial decompression, was only slightly more effective than no treatment. In the first trial of this sort, improvements in pain and function following decompression or arthroscopy (a placebo surgery) did not reach a threshold of clinical importance compared with people allocated to no treatment at all.


This NIHR-funded study involved 313 people with shoulder pain that had not responded to physiotherapy and a steroid injection. The main intervention, decompression, involved removing any bony outgrowths that could have been causing the tendons around the shoulder to be “pinched”. This was compared with an arthroscopy used for investigation only; this did not include removing any bone or tissue. Those in the third “no treatment” arm did not receive any physiotherapy or advice.


From the NIHR Dissemination Centre

NIHR Signal Starting antiretroviral therapy immediately after HIV diagnosis reduces transmission of the virus

Giving antiretroviral therapy to people newly diagnosed with HIV may be an effective and cost-effective way of reducing new infections. Increased HIV testing in at-risk populations may identify more people for treatment and also reduce infection rates.


Using data from a number of sources including NIHR funded projects, researchers developed a computer simulation model. The model looked at the relationship between HIV infections, sexual risk behaviours and antiretroviral therapy over a 30 year period. Introduction of antiretroviral therapies and increased condom use were associated with lower rates of new cases. Most new HIV infections arose due to people not yet being aware of their HIV status. Modelling projections suggested that increasing the rate of HIV testing, and initiating antiretroviral therapy from diagnosis could both reduce the rates of new infections.


From the NIHR Dissemination Centre

New Getting It Right First Time leads announced

Clinical leads for three areas of the Getting It Right First Time programme have been announced.

The £60m clinical efficiency and safety programme is run by NHS Improvement and sees clinician led teams look at service lines in every trust in England to determine whether they are operating at sufficient scale, among other factors.

Some trusts change their practices or stop providing some services as a result of the subject area GIRFT reports published so far on orthopaedics and general surgery.

The programme announced clinical leads for endocrinology, rheumatology and stroke medicine last week.

To obtain this article copy and past it into an email and send to: librasryw@uhcw.nhs.uk

Use of resources assessment: a brief guide for acute non-specialist trusts

The Use of resources assessment framework aims to improve understanding of how effectively and efficiently NHS providers are using their resources. By the end of 2019, all acute non-specialist trusts will have undergone an assessment. This briefing from NHS Improvement provides an overview for non-specialist acute trusts on the agenda for the onsite visit and other useful information.

See also this consultation from the CQC on reporting and rating NHS trusts’ use of resources.

NIHR Signal Long-term antibiotics likely to reduce risk of recurrent cellulitis

Antibiotics may reduce the risk of leg cellulitis by about two thirds, in adults who have had at least two previous episodes, but only while they take the antibiotics. There is limited evidence measuring the efficacy of other forms of prevention
.
A review of five studies showed that the risk of developing repeated cellulitis was reduced in participants who were taking long-term (more than six months) penicillin or erythromycin, compared with a control group. Once the antibiotic course had finished, participants’ risk of recurrent cellulitis was no different from the control group.


Cellulitis is a bacterial skin infection that spreads and worsens quickly. Risk of recurrence is high in people with a predisposing condition such as poor leg circulation.


This review explored the effectiveness of various preventative interventions for recurrent cellulitis. It highlights the need to explore non-pharmacological options, such as compression stockings, moisturisers or exercise. These could be cheaper and avoid the risk of increasing antibiotic resistance, but few studies of these options were identified.


From the NIHR Dissemination Centre

RCOphth welcomes EU Court of Justice Advocate General’s new opinion on the use of ‘off-label’ drug Avastin

The Royal College of Ophthalmologists (RCOphth) believes that ophthalmologists should have the discretion to prescribe Bevacizumab (Avastin) or alternatives such as Ranibizumab (Lucentis) or Aflibercept (Eylea), whichever is the most appropriate treatment of age related macular degeneration (AMD) for the patient, and provided the patient gives informed consent.

The RCOphth has long petitioned a review on Bevacizumab being available for wider use for AMD in the NHS. Not only does this cheaper alternative to Ranibizumab or Aflibercept potentially save the NHS over £100million a year, as identified by the IVAN study in 2012 but is clinically proven as safe and as effective by two major studies, CATT and IVAN, and the Cochrane review in 2014.

RCOphth Statement on Ethambutol Toxicity

NHS Improvement has highlighted two recent incidents of severe visual loss due to delayed diagnosis of optic neuropathy from ethambutol.

In 2015, 5758 cases of tuberculosis were notified in England and ethambutol is frequently prescribed in its initial phase of treatment

Although ethambutol optic neuropathy is rare, members are strongly reminded of the possibility of this cause of preventable sight loss and to ensure that current guidance is followed.

Dementia assessment and improvement framework

An evidence-based framework from NHS Improvement to support and enable directors of nursing and medical directors to achieve ‘outstanding’ care standards for those living with dementia during their stay in hospital.

Child weight management services: systematic review

This report, published by Public Health England, addresses the critical features of successful Tier 2 weight management programmes for children aged 0 to 11 years.

Vitamin D may prevent asthma worsening for some

"Vitamin D supplements protect against severe asthma attacks," The Daily Telegraph reports.

The headline was prompted by a review that pooled data from seven trials comparing taking vitamin D supplements with a placebo in people with asthma.

The researchers wanted to see whether vitamin D reduced the risk of severe asthma episodes that needed hospitalisation or treatment with oral steroids, referred to as "asthma exacerbations".

Overall, the researchers found vitamin D supplements reduced the risk of asthma exacerbations by 26%. Further analysis found the protective effect was only seen in people who were vitamin D deficient to start with.

But the main limitation of this evidence is the small number of exacerbations that occurred. For example, in two trials there were no asthma exacerbations, in another only a single event.

Many new cancer drugs show 'no clear benefit', argues review

"Over half of new cancer drugs 'show no benefits' for survival or wellbeing," The Guardian reports. That was the finding of a study looking at the evidence supporting new cancer drugs approved between 2009 and 2013 by the European Medicines Agency (EMA).

The study found only half of drug approvals had clear evidence showing they either prolonged people's lives, or improved their quality of life. That's not the same as saying these drugs would not help anyone. But research presented at the time of the drugs' approval, and gathered in the three to eight following years, did not show that they worked better than existing treatments in terms of prolonging or improving quality of life.

The study raises questions about whether medicines regulators should be stricter about the type of evidence they accept when allowing drugs to be marketed. This is especially relevant in the field of cancer treatment (oncology) where a course of treatment with new drugs can cost tens of thousands of pounds.

Safety and quality of emergency care

Chief Inspector of Hospitals Prof Ted Baker has written to England’s NHS trusts to highlight good practice from successful emergency care departments.

The examples came from discussions at a recent CQC event attended by senior clinical and nursing staff from 16 trusts rated good or outstanding for urgent and emergency care services.

The key themes identified in Prof Baker’s letter to trusts were:

• Ambulance arrivals
• First clinical assessment
• Use of inappropriate physical spaces
• Specialist referrals
• Escalation
• Deteriorating patients
• Patient outcomes
• Staff.

Are services well-led? Continuous improvement

Sets out how providers should carry out developmental reviews of their leadership and governance using the well-led framework.

• Developmental reviews of leadership and governance using the well-led framework: guidance for NHS trusts and NHS foundation trusts
• Well-led framework supplementary guide

NHS efficiency map

Healthcare Financial Management Association -
This map promotes best practice in identifying, delivering and monitoring cost improvement programmes in the NHS. It contains links to a range of tools and guidance to help NHS bodies improve their efficiency. The map is split into three sections: enablers for efficiency, provider efficiency and system efficiency. It highlights the successes some NHS providers have had in delivering specific efficiency schemes and provides sign-posts to existing tools and reference materials. It also includes updated definitions for different types of efficiency.

Hip fracture care still improving, but two in five patients still not receiving best practice care

The National Hip Fracture Database's (NHFD's) ninth annual report shows that while more patients are receiving early surgery and surviving a hip fracture, two in five are not receiving all of the recommended elements of a hip fracture programme that represent ‘best practice’.

The NHFD report analyses the process and outcomes of care of nearly 65,000 people who presented with a hip fracture across 177 hospitals. It reports much good practice within inpatient care, with the majority of patients getting prompt surgery, specialist geriatric assessment and consideration of their nutritional status.

GIRFT: national general surgery report

The report found that reducing unwarranted variations between hospitals in areas such as effective procedures, length of stay, infection rates and procurement costs will improve patient outcomes and help the NHS save £160 million in efficiencies each year.

Pancreatic cancer patients to have routine access to life extending drug after new deal

NICE has recommended nab-paclitaxel for routine NHS use after the company agreed a confidential price discount and provided more evidence on its effectiveness.

Nasogastric tube misplacement: continuing risk of death and severe harm

A stage two alert has been issued to support providers of NHS-funded care to prevent the risk of severe harm or death caused by the misplacement of nasogastric tubes (NG tubes).

Questions over advice to finish courses of antibiotics

"Should you finish a course of antibiotics?" asks BBC Online. The question is prompted by a new review suggesting concerns around antibiotic treatment are driven by fears of under-treatment, when we should instead be concerned about over-use.

This narrative review was written by researchers from several UK institutions, including Brighton and Sussex Medical School, the University of Oxford and the University of Southampton. It was published in the peer-reviewed British Medical Journal.

Generally the UK media's coverage was accurate and balanced. The majority of reporting referred to the review as an "opinion piece" and highlighted the importance of people continuing to follow doctors' advice to complete a prescribed antibiotic course.