This document provides a summary of updated guidance from the National Institute for Health and Care Excellence (NICE) on the recognition and referral of suspected cancers from primary care. It includes: 1) A poster with recommendations for assessing and referring children, young adults, and adults with suspected cancers across different symptoms and lesion sites. 2) Information that the poster visually summarizes the full NICE guidance in two parts, one for children/young adults and one for adults. 3) Details on organizations and individuals that supported the development and distribution of the poster.

1. Dr Will Stahl-Timmins
The Farr Institute
16 May 2016
INFORMATION GRAPHICS
at The BMJ

6. www.bmj.com/infographics

40. © 2015 BMJ Publishing group Ltd.
Childhood and adult cancers:
NICE guidance on assessment and referral
An infographic poster by Will Stahl-Timmins
24th
October 2015
Based on original article by:
The National Institute for Health and Care Excellence (NICE) has updated
its 2005 guidance on the recognition and referral from primary care of people
with suspected cancer. The full guidance is available on bmj.com. This poster
provides a visual summary of the full guidance, in two parts:
* In adults, the suspected cancer pathway should be used.
The production and distribution of this poster was supported by NICE.
Read the full
article online
http://bmj.co/adcan
http://bmj.co/chcan
Part 1 (overleaf)
Recommendations for children
(up to 15 years old) and young
adults (16–24 years)
Part 2 (centrefold)
Recommendations for adults
William Hamilton
University
of Exeter
Steve Hajioff
London Borough
of Hillingdon
John GrahamMia Schmidt-Hansen
National Collaborating Centre
for Cancer, Cardiff
Referral without
investigation
Colour key
Immediate Within 48 hours Within 2 weeks* Non-urgent
Investigation
required
Within 48 hours Within 2 weeks Non-urgent

42. Respiratory
symptoms
Abdominal
features
(discomfort
or pain)
Abdominal
features
(distension
or mass)
© 2015 BMJ Publishing group Ltd.
non-visible age 60+
persistent
Lumps or
masses
Oral lesions
Skin or
surface
symptoms
Hoarseness
Fatigue
Chest signs consistent with Lung cancer Pleural disease
Chest pain
age 30+
age under 30
Breast lump
unexplained
Neck lump
Soft tissue lump
Anal mass
Lymphadenopathy
generalised
supraclavicular persistent cervical
Ulceration in oral cavity
red red and white
Lip or oral cavity lump
Axillary lump age 30+
Vulval bleeding
Appearance of cervix consistent with cervical cancer
one nipple only discharge age 50+retraction
Skin changes that suggest breast cancer
Dermoscopy findings that suggest melanoma
weighted 7 point checklist score of 3 or more
Skin
lesion
Penile mass or lesion
Penile symptoms affecting the foreskin or glans
suspicious of a squamous cell carcinoma
Skin lesion
Nipple changes including:
+
+
Anaemia Thrombocytosis
No urinary tract infection (UTI) Persisting after UTIvisible age 45+
Urinary tract infection unexplained recurrent persistent age 60+
Haematuria
Dysuria Raised white blood cell count
Haematuria
Erectile dysfunction
Nocturia Frequency Hesitancy
Haematuria visible
Change in testis
Testicular symptoms unexplained persistent
unexplained
Women
Men
unexplained
unexplained
unexplained
unexplained increasing in size
Thyroid lump unexplained
Vaginal mass unexplained palpable in or at entrance to vagina
Vulval mass Ulceration
age 45+
age 40+
Fever Night sweats Breathlessness+
Alcohol induced lymph node painWeight lossPruritus
unexplained persistent age 45+
ever smoked exposed to asbestos
age 40+
Cough
2 or more of these symptoms
+ Weight loss Appetite loss
Breathlessness
unexplained
Chest infection persistent recurrent age 40+
: Finger clubbingage 40+
age 55+ Vaginal discharge
+
visible
Urgency Retention
enlargement change in shape change in texture
unexplained lasting 3+ weeks
Patch in oral cavity consistent with Erythroplakia Erythroleucoplakia:
Anal or vulval ulceration unexplained
suspicious of a basal cell carcinoma
suspicious
suggests nodular melanoma
pigmented +
ulcerated STI excluded persistent after STI treatment
unexplained persistent
Investigation / referral
Men
Version 4.1. Updated 10 September 2015.
Suspected cancers
Non-
Hodgkin’s
lymphoma
liver
stomach
Neurological
Non-specific
features
of cancer
Rectal bleeding
age 50+
+
+
age 60+ colorectal cancer excluded+
Upper abdominal pain
age 55+
Weight loss
+ Weight loss
+ Weight loss
+
Rectal or abdominal mass
Hepatosplenomegaly
Upper abdominal mass,
consistent with enlarged:
Splenomegaly
Women
Fever Night sweats Breathlessness Pruritus Weight loss+
Loss of central neurological function
Musculoskeletal
Diarrhoea Constipation Weight loss
Abdominal distension persistent frequent
Abdominal pain
esp. age 50+
Irritable bowel syndrome symptoms in last 12 months age 50+
Change in bowel habit unexplained age 50+
age 60+
age 60+
age under 60
+ Rectal bleedingChange in
bowel habit
Anaemia Thrombocytosis Nausea Vomiting
Dyspepsia
age 55+
treatment resistant
gall bladder
+ Thrombocytosis Nausea Vomiting
+Ascites pelvic/abdominal mass not obviously uterine fibroids
Weight loss age 40+
Weight loss
Fatigue Ever smoked Exposed to asbestosWeight loss Appetite loss
Deep vein thrombosis
Fatigue
unexplained
+
age 40+unexplainedHaemoptysis
Haematemesis
Rectal bleeding
Bruising Bleeding Petechiae
Abdominal pain Change in bowel habit
age 50+
unexplained
+
Weight loss Iron deficiency anaemia
Nausea Vomiting Weight lossThrombocytosis
+Reflux Weight loss
Reflux
Dyspepsia Upper abdominal pain age 55+
age 55+
Jaundice
Weight loss Diarrhoea Back pain Abdominal painage 60+
progressive sub-acute
Adult cancers:
NICE guidance on assessment and referral
persistent Fever unexplained Infection unexplained persistent Pallorrecurrent
+ + age 40+
unexplained
Appetite loss unexplained
age 40+
+
persistent Bone pain persistent Unexplained fractureBack pain
+ Weight lossage 60+
Nausea Vomiting Constipation New onset diabetes
unexplained
+
Dysphagia
Ultrasound
Chest x ray
Full blood count within 48 hours
Referral
Prostate specific
antigen test
Digital rectal
examination
within 2 weeks
within 2 weeks
Chest x ray within 2 weeks
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Dental referral within 2 weeks
CT scan Ultrasound within 2 weeks
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
non-urgent
Assess for additional
features to clarify most
likely cancers
Multiple
possibilities
Referral non-urgent
Referral non-urgent
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Postmenopausal bleeding
+ Thrombocytosis HaematuriaVaginal discharge age 55+unexplained
Ultrasound direct access
non-urgent
non-urgent
within 2 weeks
Ultrasound direct access
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
+
Urgent referral suspected cancer pathway
Upper GI endoscopy
direct access
non-urgent
within 2 weeks
Upper GI endoscopy
direct access
Testing for occult blood in faeces non-urgent
Measure serum CA125 non-urgent
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Ultrasound within 2 weeks
Ultrasound within 2 weeks
Urgent referral suspected cancer pathway
Full blood count within 48 hours
Urgent referral suspected cancer pathway
Urgent referral suspected cancer pathway
Testing for occult blood in faeces non-urgent
CT scan Ultrasound within 2 weeks
Nausea Vomiting Weight loss age 60++
Urgent referral suspected cancer pathway
Full blood count within 48 hours
Urgent referral suspected cancer pathway
Upper GI endoscopy non-urgent
Full
blood
count
Blood tests +calcium
erythrocyte
sedimentation rate
plasma
viscosity
+
CT scan Ultrasound within 2 weeks
CT scan Ultrasound within 2 weeks
MRI scan CT scan within 2 weeks
Chest x ray within 2 weeks
Urgent referral suspected cancer pathway
The production and distribution of this poster was supported by NICE
Gynaecological
symptoms
Urological
symptoms
Abdominal
features
(bowel transit
symptoms)
Abdominal
features
(upper gastro-
intestinal
symptoms)
Bleeding
Breast
Laryngeal
Soft
tissue
sarcoma
Thyroid
Vaginal
Vulval
Cervical
Testicular
Penile Anal Basal cell
carcinoma
MelanomaSquamous
cell
carcinoma
Oral
Lymphoma
Bladder
Suspected cancer
referral for concerning
lesion site or size
Colorectal
Gall
bladder
Liver
Pancreatic
Oesophageal
Stomach
Leukaemia
Ovarian
Lung Mesothelioma
Myeloma
Prostate
Brain/
CNS
Endometrial
Renal
Lift for
childhood
cancers

57. POTENTIAL MECHANISMS OF CHANGE / PROCESS
OUTCOMES
SPIRITUALITYCHANGE IN PERSONAL / SOCIAL IDENTITY
SOCIAL CONTACT
BEING
AWAY FROM STRESSORS
RESTORATION / RECUPERATION
AC
HIEVEMENT / CONTRIBUTION
KNOWLEDGE ACQUISITION
SELF-CONFIDENCE
ENJOYMENT/PLEASUREGOING INTO NATURE
PHYSICAL ACTIVITY
WELLBEING AND THE ENVIRONMENT:POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
ENVIRONMENTAL MODERATORS
ACTIVITY MODERATORS
MECHANISM MODERATORS
PERSONAL MEDIATORS
CHANGE IN
SOCIAL / GROUP
COHESION
TYPE OF
ENVIRONMENTAL
CHANGE
ENJOYMENT
ACHIEVEMENT(S)
DEVELOPMENT
OF SOCIAL
CAPITAL
ACTIVITY TYPE /
INTENSITY
TYPE
DEGREE OF
ENVIRONMENTAL
CHANGE
QUIETNESS
FEATURES
CONTEXT
(AWAY / NEAR)
TYPE OF
ENGAGEMENT
OTHER
PARTICIPANTS
TYPE OF PROGRAMME
(AIMS, OBJECTIVES, ETC.)
ENGAGEMENT
ROUTE(S)
EXPECTATIONS
FULFILMENT
MOTIVATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONS
OF SELF
SOCIAL
IDENTITY
PHYSICAL
ABILITY
EXPECTATIONS
MENTAL
HEALTH
SOCIAL
FUNCTION
PHYSICAL
HEALTH
QUALITY
OF LIFE
OTHER
ACTIVITIES

59. Nature of programme
E.g. GG VS Branching out
ENVIRONEMTAL
ENHANCEMENT ACTIVITY
...
OUTCOMES
Physical
health
Mental
Health
Social
function/
health
MODERATORS
(e.g. personal/physical/environmental
characteristics)
MEDIATORS
(e.g. psychologicalfactors)
Social Contact
Hope, well
informed futility
Engagement
route
INDIVIDUAL
Personal characteristics
(e.g. age )
Programme Specifics
(inc type of engagement)
Expectations
Perceptions of
self/personal id
Social id
Spirituality
Knowledge acquisition (skills, employability, env knowledge)
ENVIRONMENTAL
MODERATORS
Type
Quietness
Features
Going into nature
Restoration / recuperation
Being away from stressors
Spirituality
Achievement / contribution Altruism, responsibility
Environmental imporvment/change
Getting out of bed
Change in personal/social id ( my place in the world )
Physical Activity
Enjoyment/pleasure
MECHANISM
MODERATORS
Typeof env change
Achievement
Tranquillity
Socialcohesion
Socialcapital
Enjoyment
Activity type/intensity
Fulfillment

62. MOTIVATIONS
PERSONAL
MEDIATORSFULFILMENT
SOCIAL
IDENTITY
PHYSICAL
ABILITY
EXPECTATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONS
OF SELF MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN
CONSERVATION ACTIVITIES AND HEALTH
FROM:
Husk K, Lovell R, Cooper C, Stahl-
Timmins W, Garside R. Participation in
environmental enhancement and conservation
activities for health and well-being in adults.
Cochrane Database of Systematic Reviews 2013.
P
H
YS
IC
A
L
A
C
TIVITY
S
E
LF
-C
O
N
F
ID
E
N
C
E
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G
IN
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N
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R
E
E
N
JO
YM
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N
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N
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P
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H
E
A
LTH
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LA
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D
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O
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S
SOCIAL FUNCTION
PHYSICAL HEALTH
P
O
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N
TIA
L
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H
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M
S
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MODERATORS
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C
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XT
(A
W
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D
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TYP
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Q
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TN
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ACTIVITY MODERATORS
E
XP
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N
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D
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A
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.)
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A
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+
Q
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A
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O
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LIF
E

64. MOTIVATIONS
PERSONAL
MEDIATORSFULFILMENT
SOCIAL
IDENTITY
PHYSICAL
ABILITY
EXPECTATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONS
OF SELF MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN
CONSERVATION ACTIVITIES AND HEALTH
FROM:
Husk K, Lovell R, Cooper C, Stahl-
Timmins W, Garside R. Participation in
environmental enhancement and conservation
activities for health and well-being in adults.
Cochrane Database of Systematic Reviews 2013.
P
H
YS
IC
A
L
A
C
TIVITY
S
E
LF
-C
O
N
F
ID
E
N
C
E
G
O
IN
G
IN
TO
N
ATU
R
E
E
N
JO
YM
E
N
T/P
LE
A
S
U
R
E
R
E
S
TO
R
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N
/
R
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C
U
P
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R
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N
B
E
IN
G
A
W
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F
R
O
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S
TR
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SS
O
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S
S
O
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IA
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C
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TA
C
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K
N
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Q
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/
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ID
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S
P
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A
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MENTAL HEALTH
H
E
A
LTH
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LA
TE
D
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O
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S
SOCIAL FUNCTION
PHYSICAL HEALTH
P
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N
TIA
L
M
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C
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S
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MECHANISM
MODERATORS
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TYP
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/
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N
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C
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XT
(A
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TYP
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ACTIVITY MODERATORS
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O
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65. PERSONAL
MEDIATORS
FULFILMENT
EXPECTATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONS
OF SELF
MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN
CONSERVATION ACTIVITIES AND HEALTH
FROM:
Husk K, Lovell R, Cooper C, Stahl-
Timmins W, Garside R. Participation in
environmental enhancement and conservation
activities for health and well-being in adults.
Cochrane Database of Systematic Reviews 2013.
SOCIAL
IDENTITY
PHYSICAL
ABILITY
P
H
YS
IC
A
L
A
C
TIVITY
S
E
LF
-C
O
N
F
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67. POTENTIAL MECHANISMS OF CHANGE / PROCESS
OUTCOMES
SPIRITUALITYCHANGE IN PERSONAL / SOCIAL IDENTITY
SOCIAL CONTACT
BEING
AWAY FROM STRESSORS
RESTORATION / RECUPERATION
AC
HIEVEMENT / CONTRIBUTION
KNOWLEDGE ACQUISITION
SELF-CONFIDENCE
ENJOYMENT/PLEASUREGOING INTO NATURE
PHYSICAL ACTIVITY
WELLBEING AND THE ENVIRONMENT:POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
ENVIRONMENTAL MODERATORS
ACTIVITY MODERATORS
MECHANISM MODERATORS
PERSONAL MEDIATORS
CHANGE IN
SOCIAL / GROUP
COHESION
TYPE OF
ENVIRONMENTAL
CHANGE
ENJOYMENT
ACHIEVEMENT(S)
DEVELOPMENT
OF SOCIAL
CAPITAL
ACTIVITY TYPE /
INTENSITY
TYPE
DEGREE OF
ENVIRONMENTAL
CHANGE
QUIETNESS
FEATURES
CONTEXT
(AWAY / NEAR)
TYPE OF
ENGAGEMENT
OTHER
PARTICIPANTS
TYPE OF PROGRAMME
(AIMS, OBJECTIVES, ETC.)
ENGAGEMENT
ROUTE(S)
EXPECTATIONS
FULFILMENT
MOTIVATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONS
OF SELF
SOCIAL
IDENTITY
PHYSICAL
ABILITY
EXPECTATIONS
MENTAL
HEALTH
SOCIAL
FUNCTION
PHYSICAL
HEALTH
QUALITY
OF LIFE
OTHER
ACTIVITIES

68. Dr Will Stahl-Timmins
blog.willstahl.com
www.bmj.com/infographics
Twitter: @will_s_t
www.bmj.com/infographics

85. Stahl-Timmins, W.; Redshaw,
C.; White, M.P.; Fleming, L.;
Depledge, M.H. 2013.
The Pharma Transport Town:
Understanding the Routes to
Sustainable Pharmaceutical
Use. Science, 339(6119) pp
514-515.

87. VETERINARY USE
PHARMACEUTICAL
COMPANIES,
MANUFACTURERS
& DISTRIBUTERS
PHARMACY
SPILLS
PROMOTION
HEALTH
PROFESSIONALS
MEDICAL
LITERATURE
EDUCATION
PEOPLEAT HOME
DEMAND
USE
PRESCRIPTIONS
BODY
NON-USE SINK
TOILET
FISH
MEAT
CROPS
HOUSEHOLD
WASTE
DISPOSAL
RETURN TO
PHARMACY
WASTE WATER TREATMENT
METABOLISM
BIOSOLIDS
SPREAD ON LAND
RUN-OFF
LANDFILL
LEACHATE
LEACHATE
WATER
ABSTRACTION
& TREATMENT
SURFACE WATER
EXFILTRATION EXFILTRATION
LEACHATE
EXTRACTION
RETURNED ITEMS
INCINERATED
MANUFACTURING
WASTE
LEAKS
LEACHATE
INCINERATION
FARMANIMALSRUN-OFF
IRRIGATION
GROUND WATER
LEAKS
FATE 2 – INCINERATION
INFLUENCE
PHARMACEUTICAL TRANSPORT
INTO ENVIRONMENT
High temperature incineration (above 1200°C) is
viewed as the safest disposal route for unwanted
pharmaceuticals (particularly those with high
halogen content).
Unfortunately, high temperature incineration is
expensive and in some situations only medium
temperature incinerators (above 850°C) are
available.
AIR POLLUTION
PROMOTIONAL INFLUENCES
The pharmaceutical industry spends billions of dollars annually promoting
its products9
. This plays an important role in raising medical professionals’
awareness and potentially improving clinical outcomes. However, the pathways
of promotional influences are not always recognised. Direct-to-consumer
advertising and promotional gifts to physicians, neither of which should
influence clinical decision making, have been shown to influence prescription
rates and thus, indirectly, the amount of chemicals entering the environment.10
REFERENCE LITERATURE
There are many different sources that health professionals use for
reference when prescribing, including national formularies, pub-
lished guidance, mobile phone apps, and others. However, the
published scientific evidence on which such resources are based
are sometimes funded by the pharmaceutical industry.11
Those
who receive such funding are more likely to report favorable re-
sults in the academic press than independent researchers.12,13
TRAINING AND EDUCATION
Education can be an important way of encouraging responsible
and effective prescibing practice. Health professionals’ attitudes
towards the pharmaceutical industry and their products are formed
during training.14
Restricting contact with pharmaceutical industry
representatives during this time can attenuate positive attitudes
towards the industry15
and may subsequently reduce promotional
influence on prescription rates.16
NON-USE
Many individuals do not take all, or even any, of their prescribed medication. Reasons include
forgetting, reluctance, thinking them no longer necessary, side-effects and being ‘out of date’.17,18
Forgetting can be tackled using simple psychological techniques.19
In the UK it is estimated that
63% of unused medication is disposed of via household waste, 12% via the sink or toilet and only
22% are returned to pharmacies for safe disposal.20
Similarly low rates of safe disposal are
reported in the US.21
KEY
BIOAVAILABILITY?
We have an understanding of pharmaceutical transport around our environment, from our homes
to waterways, aquatic organisms, fields and therefore potentially crops and/or animals. However,
we lack knowledge about whether these compounds could be transferred to the consumer and if
they have the same effect as taking medication.
This graphic illustrates the complex movement of pharmaceuticals around our social and
physical environments, cycling endlessly.
Legislative pyramids24
provide a hierarchy of management strategies for waste reduction
(reducing in sustainability down the pyramid). This concept could be used to limit environmental
contamination by pharmaceuticals.
ROUTES TO SUSTAINABILITY
FATE 4 – DOWNSTREAM
Once pharmaceuticals have entered the environment they can
continue to be transported via our waterways to other towns and
eventually the sea. Some pharmaceuticals have even been found
as far away as the arctic!
FATE 1 – METABOLISM
When drugs are consumed, a proportion of the drug interacts
or binds with a receptor in the body, which causes a biological
response. The body transforms the remaining compound into
a more water soluble form, allowing it to be excreted.
Pharmaceuticals can be excreted as parent compounds (the drug
consumed) or metabolites, in urine or faeces. In some cases an
excreted metabolite can be as bioactive as the parent compound,
such as Norfluoxetine, the metabolite of Fluoxetine HCl (Prozac®).
DRINKING WATER
Water treatment processes vary across the world; with water for processing sourced
from groundwater, surface water or from waste water treatment plants. As
pharmaceuticals are present in all these compartments, the presence of drugs
in our drinking water is of little surprise.22,23
FATE 3 – LOSSES
BIODEGRADATION
SORPTION
Degradation is the term used
to describe the breakdown of a chemical into
smaller component compounds or elements.
Usually only partial degradation occurs (where
specific chemical sub-structures are lost).
Total degradation of a pharmaceutical
to its elements, also termed complete
mineralisation, is uncommon.
or biotic degradation, involves metabolism
of pharmaceuticals by a biological organism,
such as bacteria - and does occur in almost
all parts of this transport system. However
many pharmaceuticals are stable com-
pounds, that are resistant to biodegradation
and therefore persist in the environment.
is the process by which compounds become
associated with another substance via
absorption (permeation of a substance
by another) or adsorption (surface assimila-
tion of one substance upon another). This is
a process often seen in high organic content
materials such as soil and sewage sludge.
ROUTES BACK TO PEOPLE
BACKGROUND
There are growing concerns about the ubiquitous presence of pharmaceuticals in
the environment1
, especially when coupled with knowledge of the dramatic impacts
individual drugs and mixtures can have upon biota2,3
- such as antibiotic resistance4,5
and endocrine disruption6
.
As future pharmaceutical usage is predicted to rise, due to a number of reasons
including the aging demographic, availability of generics and global epidemics,
such as obesity and bird-flu7
, it is essential that we begin to take steps towards
limiting environmental contamination.
This information graphic poster shows the complex system of pharmaceutical
transport around the areas in which we live (adapted from Petrović et al.8
). It also
shows influence routes, suggesting possible points of intervention to begin to
address the problems associated with environmental pharmaceutical pollution.
The quantities of waste that can be incinerated are limited by the amount
of air pollution that is considered safe - and depends on other sources
of air pollution in the area.
REFERENCES
1 Kallenborn, R. et al. in Pharmaceuticals in the Environment: Sources, Fate, Effects and Risks (ed K. Kummerer) 61–74 (Springer, 2008)
2 Gilbert, N. Drug waste harms fish. Nature 476, 265 (2011).
3 Taggart, M. A. et al. Diclofenac residues in carcasses of domestic ungulates available to vultures in India. Environ. Int. 33, 759-765
(2007).
4 MALIK, A. & AHMAD, M. 1994. Incidence of drug and metal resistance in E. coli strains from sewage water and soil. Chem Environ Res,
3,
3-11. And RADTKE, T., M. & GIST, G., L. 1989. Wastewater sludge disposal - antibiotic resistant bacteria may pose health hazard.
journal
of Environmental Health, 52, 102-105
5 Plano et al. BMC Microbiology 2011, 11:5 http://www.biomedcentral.com/1471-2180/11/5
6 PORTER, W. P., JAEGER, J. W. & CARLSON, I. H. 1999. Endocrine, immune, and behavioral effects of aldicarb (carbamate), atrazine
(triazine)
and nitrate (fertilizer) mixtures at groundwater concentrations. Toxicology and Industrial Health, 15, 133-150.
7 Depledge, M. 2011. Pharmaceuticals: Reduce drug waste in the environment. Nature 478:7367, 36.
8 Petrovic, M., Gonzales, S., Barcelo, D. 2003. Analysis and removal of emerging contaminants in wastewater and drinking water. Trends
in Analytical Chemistry, v 22, n 10, p685-696
9 Mintzes, B. (2002). Direct to consumer advertising is medicalising normal human experience. BMJ. 2002 April 13; 324(7342): 908–911.
10 Moynihan R & Henry D (2006) The fight against disease mongering: Generating knowledge for action. PLoS Med 3(4): e191.
11 Wazana A. Physicians and the pharmaceutical industry, is a gift ever just a gift? JAMA 2000;283:373-80.
12 Bodenheimer, T. et al. (2000). Uneasy Alliance — Clinical Investigators and the Pharmaceutical Industry. N Engl J Med; 342:1539-1544.
13 Stelfox, H.T., Chua, G., O’Rourke, K. & Detsky, A.S. (1998). Conflict of Interest in the Debate over Calcium-channel antagonists. N Engl J
Med 1998; 338:101-1061
14 Friedberg M, et al (1999). Evaluation of conflict of interest in economic analyses of new drugs used in oncology. JAMA; 282:1453-7.
15 Monaghan, M.S. et al. (2003): Student Understanding of the Relationship Between the Health Professions and the Pharmaceutical
Industry. Teach & Learning in Medicine, 15:1, 14-20
16 McCormick BB, et al. (2001). Effect of restricting contact between pharmaceutical company representatives and internal medicine
residents on posttraining attitudes and behavior. JAMA;286:1994–9
17 Benson, J. & Britten, N (2002). Patients' decisions about whether or not to take antihypertensive drugs: qualitative study. BMJ,
2002;325:873.1
18 Cooper et al. (2007). Why people do not take their psychotropic drugs as prescribed: results of the 2000 National Psychiatric Morbidity
Survey. Acta Psychiatrica Scandinavica, 16(1), 47–53.
19 Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes.
Advances in Experimental Social Psychology, 38, 69-119.
20 Bound, J.P. & Voulvoulis, N. (2005). Household disposal of pharmaceuticals as a pathway for aquatic contamination in the United
Kingdom. Environmental Health Perspectives, 113, 1705-1711.
21 Glassmeyer, S.T., Hinchey, E.K., Boehme, S.E. et al (2009). Disposal practices for unwanted residential medications in the United
States. Environmental International, 35, 566-572.
22 World Health Organisation. Pharmaceuticals in drinking water. (2011).
23 Official Journal of the European Union. DIRECTIVE 2008/98/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 19 Novem-
ber 2008 on waste and repealing certain Directives 22.11.2008. L 312/3
24 Mark J. Benotti et al.Pharmaceuticals and Endocrine Disrupting Compounds in U.S. Drinking Water Environ. Sci. Technol., 2009, 43 (3),
pp 597–603
25 Kümmerer, K, and Hempel, M (Eds) 2010 Green and Sustainable Pharmacy Springer, pp 313.
26 Brother’s Brother Foundation, http://www.brothersbrother.org/medical.htm [accessed 28 sep 2012].
27 Gospel Medical Mission International, http://gospelmedical.org/ [accessed 28 sep 2012].
28 Owen, R, and Jobling, S, 2012 Environmental science: The hidden costs of flexible fertility. Nature, 485 (7399) 441-441.
29 Kim, I, and Tanaka, H, 2010 Use of Ozone-Based Processes for the Removal of Pharmaceuticals Detected in a Wastewater Treatment
Plant. Water Environment Research, 82 (4) 294-301.
PHOTODEGRADATION
is a form of abiotic degradation, which can be
important for the breakdown of pharmaceuti-
cals, particularly in surface waters and during
some waste water treatment processes.
Absorption of radiant energy (photons), such
as those in sunlight, by a compound results in
photochemical transformation of the compound
into smaller fragments.
BIOACCUMULATION
of pharmaceuticals can occur in organisms
in the environment. Where a drug has a higher
affinity for the chemical properties of particular
tissues (e.g. fat) than it does the surrounding
environment, it can become concentrated
in an organism.
REDUCE
REUSE
RECYCLE
RECLAIM
REMOVE
Widespread acceptance of
medical donation programmes26,27
would result in greater reuse of
drugs and could be facilitated by
use of smaller packaging.
The challenge of finding ways in which
drugs could be recycled (processing
of unwanted drugs, recovery of ‘usable’
compounds and subsequent product manu-
facture) lies with the chemical industry.
Reclamation of pharmaceuticals (most likely
at the waste water treatment works), followed
by purification and reuse of drugs expensive
to produce, could in theory be implemented
alongside removal programmes.
Removal programmes could incorporate capture and
destroy approaches (e.g. granular activated carbon28
),
chemical transformation processes (e.g. ozone processing29
), or could seek
to maximise natural degradation processes by optimisation of treatment
e.g. identifying, isolating and seeding with drug-degrading bacterial strains.
Upstream interventions
should be the highest
priority. Green pharmacy,
which seeks to develop
specific targeted drugs
and/or more effective
delivery mechanisms, has
the potential to reduce the
dosages required.25
Also,
education of consumers and
prescribers could result in more
appropriate disposal and reduce
unnecessary prescribing.
THE PHARMA TRANSPORT TOWN:
Dr Will Stahl-Timmins | Dr Mathew White | Prof Michael Depledge | Prof Lora Fleming | Dr Clare Redshaw
UNDERSTANDING THE ROUTES TO SUSTAINABLE PHARMACEUTICAL USE Funded by:
EUROPEAN UNION
Investing in Your Future
European Regional
Development Fund 2007-13
WINNER
PEOPLE’S CHOICE
POSTERS & GRAPHICS
INTERNATIONAL SCIENCE
AND ENGINEERING
VISUALIZATION
CHALLENGE 2012
AS PUBLISHED
IN
1 FEBRUARY 2013
VOL 339, ISSUE 6119
PAGE 515
SCIENCE: