Fast Track Referrals – Paisley, Rosemary and Time Nick Sharer May 2015

Once upon a Time (cancer plan 2000 … … reformed strategy 2007) Patient first seen within 14 days of receipt of GP urgent suspected cancer referral Patient treated within 62 days of receipt of GP urgent suspected cancer referral All cancers to be treated within 31 days of decision to treat First seen 2WWR from GP 14 days 31 days 62 days DTT

NICE Criteria for triggering a referral for a suspected UGI cancer 1. Any age with new and unexplained dyspepsia (recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting) with any of:  dysphagia  progressive unintentional weight loss  persistent vomiting  epigastric mass  chronic gastrointestinal bleeding  suspicious barium meal result

NICE UGI 2.Patients > 55 with unexplained and persistent recent- onset dyspepsia alone  urgent endoscopy  Patients < 55 years, endoscopic not necessary in the absence of alarm symptoms.  Helicobacter pylori status does not affect the decision to refer for suspected cancer. 3.Unexplained weight loss or iron deficiency anaemia and a haemoglobin of 11 g/dl or below (male) or 10 g/dl (non- menstruating female) 4.Persistent vomiting and weight loss in the absence of dyspepsia

NICE UGI 5.Unexplained upper abdominal pain and weight loss, with or without back pain 6.Upper abdominal mass without dyspepsia 7.‘Obstructive’ jaundice (consider urgent ultrasound if available)

NICE 2015 ( Publication awaited but reduces threshold of perceived risk from 5 ---> 3%) - additional criteria for triggering a referral for a suspected UGI cancer Patients > 55 with upper abdominal pain and raised platelet count Patients > 60 with weight loss and new-onset diabetes

Peter - referral 2WWR: 68yr man with abdominal pain, dyspepsia and vomiting. Patients believes problems caused by cod in parsley sauce a month ago ………………….. Peter cancels 3 appointments in row (4 weeks gone) What are the options with respect to 2WW target? a) Make another appointment b) Refer the him back to the GP c) Discuss with the patient what they want to do and accept the breach if necessary

2 weeks wait: Starts on receipt of referral Clock stops on attendance at clinic or diagnostic test relevant to referral reason Patient cannot be rejected if not available in two weeks 2 DNAs in a row can return to GP if in local access policy (not us) If patient cancels they have engaged with NHS and should not be returned without agreement Only the GP can downgrade referrals Referrals cannot be refused25

Peter 2 - straight to test Triaged direct to gastroscopy (occurs in 5 th week) Reddened patch of mucosa in lower oesophagus, nil else. ‘Probably oesophagitis’, reassured. Histology sent, not fast tracked 3 weeks later unsuspected adenocarcinoma reported (8 th weeks)

Peter 3 - Decision To Treat (DTT) Diagnosis discussed with GP and decided she is best placed to break news But visiting family in Paisley, currently asymptomatic Patient returning fortnight later but GP on annual leave, thus: Appointment for consultant surgeon’s clinic on return Prior MDT review recommended repeat mapping gastroscopy and staging CT (both pre-booked) (10 th week) Gastroscopy confirms 1.5cm shallow ulcer above GOJ. CT delayed (awaiting renal function results and equipment failure) (11 th week)

Peter 4 - Decision To Treat (DTT) MDT reviews histology and favourable CT (neither primary or secondary seen; 12 th week) Complete staging with EUS and PET (14 th week) Local and Network MDT discussions T1 N0 M0 disease Patient counselled (15 th week) Anaesthetic review Listed for primary resection (16 th week) R0 resection performed 18 th week (126 days) Was this coincidental disease in the first place?

Did we meet the target? First meet Target within 14 days Gastroscopy 35 days Breach accepted as patient offered alternatives that were not accepted (patient choice) Treatment within 31 days of DTT When was decision to treat made? With confirmatory histology (84 days) After complete staging (98 days) When patient agreed to surgery (105 days) Period between listing (DTT) and surgery 16 days

Did we meet the target? 62 day referral to first treatment Operated on day 126 Patient choice delayed the initial OGD by 21 days (actual day 35 – 14 day standard) Paisley holiday delays 14 days Likely cured disease Did we succeed or fail?

NICE Criteria for triggering a referral for a suspected LGI cancer 1.> 40 years with rectal bleeding and a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more 2.> 50 years with unexplained rectal bleeding (2015 update) 3.> 60 with change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more 4.Any age with right lower abdominal mass consistent with involvement of the large bowel 5.Palpable rectal mass 6.Unexplained iron deficiency anaemia and a haemoglobin of 11 g/dl or below (male) or 10 g/dl (non-menstruating female)

Rosemary 1 - referral to first seen 70 year lady 2WWR – “Hb 10.1 g/dl last colonoscopy showed few adenoma” Reviewed in clinic (day 12) No idea why she was here (~ 40 patients a month cancel OPD) First she knew was when hospital called to offer appointment FBC had been taken routinely for statin monitoring Asymptomatic No indices or haematinics available on EPR 3 colonoscopies over past 5 years for multiple small adenoma No other personal or FH history

Rosemary 2 - referral to first seen Hb 10.2Ferritin 224Urea 7.3 MCV 84Iron 4 ( )Creat 89 WBC 8.4TIBC 48 ( )CRP 66 Platelets 254Sat 8%ESR 71 Discussion over subsequent management

Rosemary 3 - DTT IDA not proven Myeloma exclusion Colonoscopy not indicated Therapeutic trial of iron and review.

Rules for Time? Diagnostics:  If cancer is not ruled out clock continues, even if clinician wants to wait weeks/months to monitor progress; thus we will breach Treatments:  Diagnostic procedures may count as treatment if “undertaken as therapeutic in intent” Active Monitoring:  No pause for medical deferral, weather or second opinion  Should not be used for thinking time or to make up for capacity issues  Can only be used after a diagnosis has been reached

Annual referrals for suspected GI malignancy to PGH

Rate of confirmed cancers from 2WWR  Upper GI – 10.5%  Lower GI - 6.6%  Combined GI - 8.2%  IDA %

Take home messages 2WWR numbers continue to increase NICE is shortly to recommend a lowering of the threshold for referral (5% to 3%) In GI disease the combined upper and lower conversion rate runs at 8.2% Patients should be made aware that their presenting symptoms potentially represent cancer Adhere to referral guidance