Early Diagnosis and Prognostic Indicator Dr Richard Roope RCGP & CRUK Clinical Lead for Cancer CRUK Senior Clinical Advisor November 10th 2015 GP Refresher Week

Early Diagnosis and Prognostic Indicator Dr Richard Roope RCGP & CRUK Clinical Lead for Cancer Cancer Research UK Senior Clinical Advisor

Cancer – why all the interest?

Cancer – why all the interest? Loss of life years <75 1 Circulatory Disease Cancer Gastrointestinal Mental Health Accidents 2 Cancer Circulatory Disease Mental Health Gastrointestinal Accidents 3 Circulatory Disease Cancer Mental Health Accidents Gastrointestinal 4 Cancer Mental Health Circulatory Disease Accidents Gastrointestinal

Cancer – why all the interest? Loss of life years <75 1 Circulatory Disease Cancer Gastrointestinal Mental Health Accidents 2 Cancer Circulatory Disease Mental Health Gastrointestinal Accidents 3 Circulatory Disease Cancer Mental Health Accidents Gastrointestinal 4 Cancer Mental Health Circulatory Disease Accidents Gastrointestinal Which do you think is the correct column? (high to low)

Cancer – why all the interest? Loss of life years <75 1 Circulatory Disease Cancer Gastrointestinal Mental Health Accidents 2 Cancer Circulatory Disease Mental Health Gastrointestinal Accidents 3 Circulatory Disease Cancer Mental Health Accidents Gastrointestinal 4 Cancer Mental Health Circulatory Disease Accidents Gastrointestinal

Cancer – why all the interest?

Cancer – why all the interest?

Cancer – why all the interest? 1 in 2 people will be diagnosed with one or more cancers in their lifetime

Cancer – why all the interest? Lifetime risk of cancer http://www.cancerresearchuk.org/cancer-info/cancerstats/incidence/risk/

Cancer – why all the interest? 1 in 2 people will be diagnosed with on or more cancers in their lifetime 10 year survival has improved to reach 50%

Cancer – why all the interest? 1 in 2 people will be diagnosed with on or more cancers in their lifetime 10 year survival has improved to reach 50% www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined#heading-One – last accessed 10.10.15

Cancer – why all the interest? 1 in 2 people will be diagnosed with on or more cancers in their lifetime 10 year survival has improved to reach 50%, but… Cancer survival in the UK still lags behind comparable health economies

Cancer – why all the interest? Hasn’t cancer had its turn?

Cancer – why all the interest? Hasn’t cancer had its turn? Cancer receives what proportion of NHS spend? 2.4% 5.4% 8.4% 11.4% 14.4%

Cancer – why all the interest? Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000

Cancer – why all the interest? Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000 Total NHS spend in 2012/3: £2008 per head

Cancer – why all the interest? Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000 Total NHS spend in 2012/3: £2008 per head Total NHS spend on cancer care: £109 per head

Cancer – why all the interest? Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000 Total NHS spend in 2012/3: £2008 per head Total NHS spend on cancer care: £109 per head Just 5.4% of NHS spend http://www.nuffieldtrust.org.uk/nhs-numbers-0

Cancer – why is early diagnosis important?

Cancer – why is early diagnosis important? Breast Cancer – 5 year relative survival 2002-6 http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/survival#heading-Two (last accessed 25.10.15)

Cancer – why is early diagnosis important?

Cancer – why is early diagnosis important? Lung Cancer - 5 year relative survival 2003-6 http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/lung-cancer/survival#heading-Three (last accessed 25.10.15)

Cancer – why is early diagnosis important?

Cancer – why is early diagnosis important? Prostate Cancer - 5 year relative survival 2002-6 http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/survival#heading-Three (last accessed 25.10.15)

Cancer – why is early diagnosis important?

Cancer – why is early diagnosis important? Bowel Cancer - 5 year relative survival 2002-6 http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival#heading-Three (last accessed 25.10.15)

Cancer – why is early diagnosis important?

Cancer – Current situation All Cancers www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined#heading-Two (last accessed 25.10.15)

Cancer – Current situation All Cancers Stage Shift

Cancer – Earlier stage of diagnosis Increase in numbers diagnosed at stage 1 & 2 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/388160/fourth_annual_report.pdf (last accessed 25.10.15)

Cancer – Earlier stage of diagnosis Minimum increased 5 year survival with 10% increase in stages 1 & 2 Breast 3.8% Prostate 2.4% Colorectal 4.0% Lung 2.0% Bladder 1.3% Kidney Ovary Endometrium 3.7% NHL 0.2% Melanoma 2.3% https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/388160/fourth_annual_report.pdf (last accessed 25.10.15)

Cancer – where were we?

Cancer – where have we come from? January 2011 - Improving Outcomes: A Strategy for Cancer

Cancer – where were we? Avoidable deaths pa if survival in England matched the best in Europe Breast ~2000 Myeloma 250 Colorectal ~1700 Endometrial 250 Lung ~1300 Leukaemia 240 Oesophagogastric 950 Brain 225 Kidney ~ 700 Melanoma 190 Ovary ~ 500 Cervix 180 NHL/HD 370 Oral/Larynx 170 Bladder 290 Pancreas 75

Cancer – what did we do?

Cancer – what did we do?

Cancer – what did we do? Research stream Primary Care Engagement Input to Cancer Network and SCNs RCGP Education Events etc

Cancer – How did we do?

Cancer – How did we do? How did we do it?

Cancer – How did we do?

Cancer – How did we do?

Cancer – How did we do? Variation Dorset CCG: http://lci.cancertoolkit.co.uk/Survival

Cancer – How did we do? Smoothed maps of the one-year survival index (%) for all cancers combined by CCG: England, 1996 and 2011, patients ages 15-99 years 1996 Ambition Dorset England 2011

Cancer – How did we do? PHE Press release 16.9.15: “Cancers are being diagnosed earlier in England” https://www.gov.uk/government/news/cancers-are-being-diagnosed-earlier-in-england (last accessed 25.10.15)

Cancer – How did we do? However compared to Europe?

Cancer – How did we do? However compared to Europe? http://scienceblog.cancerresearchuk.org/2015/08/05/cancer-survival-in-england-is-improving-but-still-lagging-behind-similar-countries/

Cancer – How did we do? However compared to Europe?

Cancer – why are we different in UK?

Cancer – why are we different in UK? Why do we lag behind other Health Systems?

Cancer – why are we different in UK? International Cancer Benchmarking Partnership

Cancer – why are we different in UK? International Cancer Benchmarking Partnership As gatekeepers – the gate needs to be wider Outcomes closely linked to “readiness to act” Patients fear wasting GP time Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? British Journal of Cancer (2013) 108, 292–300. doi:10.1038/bjc.2012.542

Cancer – Where from here?

Cancer – Where from here?

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives Transform patient experience and quality of life Invest now to save later www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (last accessed 25.10.15)

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives:

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Over 40% of cancers are preventable Under 75 mortality rate for cancer considered preventable www.phoutcomes.info/public-health-outcomes-framework#page/8/gid/1000044/pat/6/par/E12000008/ati/101/are/E06000036/iid/40502/ (last accessed 25.10.15)

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Ambition:

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Ambition: Fall in age-standardised incidence Adult smoking rates to fall to 13% (currently 18.8%)

Cancer – Where from here? Smoking Prevalence

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Drive a national ambition to achieve earlier diagnosis, and with it stage shift

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Drive a national ambition to achieve earlier diagnosis, and with it stage shift Ambition: Increase 5ys and 10ys – with 57% surviving 10+ years Increase 1ys to 75% with reduction of variation

Cancer – Where from here? Smoothed maps of the one-year survival index (%) for all cancers combined by CCG: England, 1996 and 2011, patients ages 15-99 years 1996 Ambition Dorset England 2011

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Drive a national ambition to achieve earlier diagnosis, and with it stage shift “If the taskforce recommendations are implemented 30,000 cancer deaths a year could be saved by 2020, of these 11,000 will be through early diagnosis”

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives: Spearhead a radical upgrade in prevention Drive a national ambition to achieve earlier diagnosis, and with it stage shift “If the taskforce recommendations are implemented 30,000 cancer deaths a year could be saved by 2020, of these 11,000 will be through early diagnosis”

Cancer Strategy – Recommendations Early Diagnosis Implement NICE Guidance (NG12) Invest in diagnostic capacity Direct access to diagnostic capacity Enhance screening uptake 28 days to diagnosis (to replace 2WW) Education – Undergraduate, postgraduate, CPD

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives Transform patient experience and quality of life

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives Transform patient experience and quality of life Patient experience to be given as high a priority as clinical effectiveness and safety Transform approach to support those living with and beyond cancer Continuous improvement in patient experience, with reduction in variation Continuous improvement in long-term quality of life

Cancer – Where from here? Cancer Strategy 2015-2020 has three core aims: Save thousands more lives Transform patient experience and quality of life Invest now to save later

Cancer Strategy – now what? Prevention Tobacco Obesity Immunisations Activity Environment Early detection Awareness Health care seeking Screening Access Diagnosis Investigations Access Technology Decision support Treatment Surgery Chemotherapy Radiotherapy Comorbidity Psychology Survivorship Follow-up Late effects Rehabilitation Health promotion End of life Basic palliation Specialised Social Bereavement

Cancer Strategy – now what? Prevention Tobacco Obesity Immunisations Activity Environment Early detection Awareness Health care seeking Screening Access Diagnosis Investigations Access Technology Decision support Treatment Surgery Chemotherapy Radiotherapy Comorbidity Psychology Survivorship Follow-up Late effects Rehabilitation Health promotion End of life Basic palliation Specialised Social Bereavement Primary Care has a part to play throughout the cancer pathway, and is well placed to do so…

Cancer Strategy – now what? Prevention Tobacco Obesity Immunisations Activity Environment Early detection Awareness Health care seeking Screening Access Diagnosis Investigations Access Technology Decision support Treatment Surgery Chemotherapy Radiotherapy Comorbidity Psychology Survivorship Follow-up Late effects Rehabilitation Health promotion End of life Basic palliation Specialised Social Bereavement Primary Care has a part to play throughout the cancer pathway, and is well placed to do so… if adequately resourced…

Cancer Strategy – now what? The Lancet Oncology: “The expanding role of Primary Care in Cancer Control” “For a long time, the role of primary care in cancer was largely seen a peripheral, but as prevention, diagnosis, survivorship, and end-of-life care assume greater importance in cancer policy, the defining characteristics of primary care become more important” The Lancet Oncology, Vol. 16, No. 12

Cancer Strategy – now what? The Lancet Oncology: “The expanding role of Primary Care in Cancer Control” “The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. ” The Lancet Oncology, Vol. 16, No. 12

NICE Guidance Suspected cancer: recognition and referral NICE guidelines [NG12] – June 2015

NICE Guidance Aim The aim of the guidelines is to improve cancer diagnosis: The timeliness The quality The consistency

NICE Guidance Implementation “While guidelines assist the practice of healthcare professionals, they do not replace their knowledge and skills.”

NICE Guidance Implementation “For all clinical scenarios it is assumed that the health professional will have a discussion with the patient about the risks and benefits of intervention, enabling the patient to exercise a fully informed decision.”

NICE Guidance Implementation The guideline focuses on those areas of clinical practice: That are known to be controversial or uncertain Where there is identifiable practice variation Where there is lack of high quality evidence Where NICE guidelines are likely to have the most impact.

NICE Guidance Implementation It is assumed that: an appropriate history and physical examination are undertaken urinalysis is undertaken where appropriate simple blood tests (Fbc, biochemistry and inflammatory markers) are done

NICE Guidance What is new? This is the first guidance that uses primary care evidence, which is available for the first time Adds symptom pathways for the first time Uses the same referral thresholds for all cancers

NICE Guidance What is new? This is the first guidance that uses primary care evidence, which is available for the first time Adds symptom pathways for the first time Uses the same referral thresholds for all cancers (PPV 3%)

NICE Guidance What is new? (General) Many – being symptom centred and using 3% PPV, the ages vary (range 30-60) Some criteria have been dropped (no evidence to support them) Timeline specifics have gone – replaced with “recurrent” or “persistent”.

NICE Guidance What is new? (Specifics) Relevance of ↑ Platelet count

NICE Guidance What is new? (Specifics) Relevance of ↑ Platelet count Up to 10% of patients with a raised platelet count will have cancer: Seen in cancers of: Lung Upper GI Endometrial Ovarian Breast

NICE Guidance What is new? (Specifics - examples) 2ww lung - Haemoptysis only in 40+ Mesothelioma now covered Lower GI – high risk groups (eg ulcerative colitis) not mentioned. 2ww breast: unexplained axillary lump Haematuria and ↑platelets →gynae ultrasound Dermatoscopy suggestive of melanoma → 2ww dermatology

NICE Guidance What is new? (Specifics - examples) Persistent bone pain, unexplained fracture: do Fbc + ESR 60+ with hypercalcaemia/↓wbc: electrophoresis and BJP within 48h Palpable abdominal mass <16 (used to be under 1y)

NICE Guidance Implementation will take a while

NICE Guidance Electronic Clinical Decision Support tools 2 week referral forms will change Commissioners and Trusts: engage with new pathways Guidance from RCGP to follow

NICE Guidance Summary: Why? To address our lowly cancer outcomes rank How? To lower threshold/readiness to refer with consistency When? Gradual roll out over next few months

NICE Guidance Summary: Results?

NICE Guidance Summary: Results? Better medicine – earlier diagnosis (not just of cancer) Fewer consultations Better outcomes Less complaints Less £££

NICE Guidance Summary: Results? Earlier Diagnosis

Early diagnosis We have done amazingly, rising to the challenge of 2011

Early diagnosis We have done amazingly, rising to the challenge of 2011 We can do even better, individually

Early diagnosis We have done amazingly, rising to the challenge of 2011 We can do even better, individually As a wider health community we could do so much more …if resourced properly: We need to spend money now… to save money (and misery) later

Early diagnosis

Early diagnosis Thank you

Early diagnosis Any questions?