IMPLEMENTATION OF NG 12 - RECOGNITION AND REFERRAL OF SUSPECTED CANCER LEYLAND 11.7.18

HAEMATURIA r A 60 year old lady 09/11/2018 HAEMATURIA r A 60 year old lady 3rd attendance in 2 months with dysuria and frequency (Nitrofurantoin 3/7 then Trimethoprim 7/7) 1st attendance surgery – urinalysis: trace blood 2nd attendance OOH – no record of urinalysis Symptoms come and go No menopausal bleeding but increased vaginal discharge Normal exam No significant PMHx Urinalysis today – Trace Protein Leucs+ Blood+ What would you do next?

VAGUE SYMPTOMS A 67 year old woman 3rd appointment in 6 weeks. 09/11/2018 VAGUE SYMPTOMS A 67 year old woman 3rd appointment in 6 weeks. She is feeling tired, with reduced appetite and says her daughter thinks she has lost weight. You have this 6th sense that she may have cancer. What can you do now?

G.P. scientist and artist HISTORY EXAMINATION INVESTIGATIONS COMMUNICATION WITH PATIENT REFERRAL

NG12 – IMPROVING EARLY DIAGNOSIS Symptom thresholds lowered - from 5% to 3% For children and young adults – even lower thresholds Guidance organised by signs and symptoms GPs recommended to refer patients directly for tests “Very urgent” referrals now recommended for some symptoms Specific recommendations on safety netting

What does a >3% risk look like? Your new car has been recalled as there is a dangerous fault that could leave the car uncontrollable. There is a one in thirty chance that your car is affected Would you ignore the warning?

09/11/2018

New from 2015 New onset diabetes >60 associated with weight loss. 09/11/2018 New from 2015 New onset diabetes >60 associated with weight loss. High glucose levels – endometrial. Thrombocytosis. GP Access to diagnostics. CT abdomen MRI brain Upper GI endoscopy. Consider an urgent direct access CT scan or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following: diarrhoea back pain abdominal pain nausea vomiting constipation new‑onset diabetes. [new 2015] Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 and over with:unexplained symptoms of vaginal discharge who: are presenting with these symptoms for the first time or have thrombocytosis or report haematuria, or visible haematuria and: low haemoglobin levels or thrombocytosis or high blood glucose levels. [new 2015

09/11/2018 Direct GP Access has been advised – CT scan for pancreatic cancer for instance

INDICATION FOR URGENT CT SCAN AGE 60 + WEIGHT LOSS and any of the following DIARRHOEA BACK PAIN ABDOMINAL PAIN NAUSEA VOMITING CONSTIPATATION NEW ONSET DIABETES

09/11/2018 Access to urgent CT MBHT – No – but can access through Advice and Guidance LTH – No ELTH – Yes Blackpool - No Demonstrates inequity across the Alliance – what do you do when NG12 advised a 2 week CT scan? Most GP’s have access to urgent USS – but we know this is not the best way of diagnosing pancreatic cancers. Similarly, CXR’s only have a pick up rate of around 75% for lung cancer – if a GP has access to CT thorax then this can be arranged if there is a high degree of suspicion but a CXR is reported as OK.

ENDOSCOPY UPPER GI (2 WEEKS) 55 with weight loss and Upper Abdominal Pain or Reflux or Dyspepsia

Access to upper GI endoscopy 09/11/2018 Access to upper GI endoscopy MBHT – yes via a 2WW referral upper GI LTH – yes if meet 2WW criteria ELTH - yes Blackpool - no Where are we now across Lancashire and South Cumbria

HAEMATURIA r A 60 year old lady 09/11/2018 HAEMATURIA r A 60 year old lady 3rd attendance in 2 months with dysuria and frequency (Nitrofurantoin 3/7 then Trimethoprim 7/7) 1st attendance surgery – urinalysis: trace blood 2nd attendance OOH – no record of urinalysis Symptoms come and go No menopausal bleeding but increased vaginal discharge Normal exam No significant PMHx Urinalysis today – Trace Protein Leucs+ Blood+ What would you do next? Arrange FBC and U+E’s –( Hb 11.2 WCC 7.4 Platelets 490) Send MSU –( reported as normal) Safety net – arrange follow up – book the appointment yourself if your practice system allows Given results what next Raised Platelets – Lung endometrial upper GI Direct Access Pelvic USS – non urgent – 55+ with unexplained vaginal discharge and any of the following THROMBOCYTOSIS OR HAEMATURIA Diagnosis – Endometrial Cancer

G.P. scientist and artist HISTORY EXAMINATION INVESTIGATIONS COMMUNICATION WITH PATIENT REFERRAL

Thrombocytosis and Cancer 09/11/2018 Thrombocytosis and Cancer 2017 BJGP Prospective Study 50,000 Adults >40y Compared 1 year incidence cancer with plts >400 Matched controls with normal plt counts 11% men dx with cancer in the next 12 months 6% women Higher platelet count – higher risk 2 raised counts in 6 months 18% men 10% women with cancer dx Lung colorectal most common (1/3 no other symptoms) Lung, Endometrial, Gastric, Oesophageal – and colorectal Thrombocytosis recognised as an indicator for Cancer in NG12 guidance and now supported further by this prospective study Red whale use the term LEGO to which they have now added LEGO-C. Endometrial Cancer Consider direct access ultrasound in women:• Aged 55 and over presenting with unexplained symptoms of vaginal discharge who: – Are presenting with these symptoms for the first time OR Have thrombocytosis OR Report haematuria. Consider direct access ultrasound in women:• Aged 55 and over presenting with visible haematuria and any of the following: – Low haemoglobin – Thrombocytosis – High blood glucose level

Practicalities raised platelets Primary Haematological Essential thrombocytosis Myeloproliferative disorders (JAK2 test 60%) Secondary or Reactive Chronic inflammation/post operative Infection/Acute bleeding and blood loss/Exercise Heart Attack/Burns/Iron deficiency anaemia CANCER

Awareness Raised platelets should trigger suspicion of cancer. Review patients and check for other symptoms. Remember 1/3rd - no symptoms. So consider CXR and FIT (if available). Safety net the patient.

FIT Diagnostic Guidance DG 30 July 2017 ?suspected colorectal cancer 09/11/2018 FIT Diagnostic Guidance DG 30 July 2017 ?suspected colorectal cancer In absence of rectal bleeding Unexplained symptoms Not 2WW criteria Low risk 0.1% to 3% probability DG30 guidance replaced the NG12 guidance regarding the use of FOB in the early diagnosis of cancer. The original NG12 guidance stated - In the absence of rectal bleeding, offer testing for occult blood in faeces to patients: • Aged 50 or over with unexplained Abdominal pain or weight loss • Aged under 60 with either -changes in bowel habit or iron deficiency anaemia • Aged 60 and over with Anaemia even in the absence of iron deficiency

Access To FIT MBHT – No - but FOB still available LTH – Yes ELTH – No 09/11/2018 Access To FIT MBHT – No - but FOB still available LTH – Yes ELTH – No Blackpool – No CANCER ALLIANCE FIT PROGRAMME – Roll out 2018? LTH and Preston Chorley and Ribble CCG’s with the support of CRUK facilitators and Macmillan GPs have already rolled out access to FIT for GP’s in their region. This innovative work has formed the backbone of the Cancer Alliance Fit programme and there is an ambition to roll out FIT to all CCG’s in 2018 with the support of the Cancer Alliance who have successfully bid for transformation funding to support this programme of work.

Safety Netting and pitfalls CXR for symptomatic – 23% negative. USS can miss over 10% pancreatic cancers. Microscopic Haematuria – low PPV for cancer. Vague Symptoms – over to Neil.

Thankyou Dr Chrissie Hunt CRUK Strategic Lead GP

VAGUE SYMPTOMS 11/7/18 Neil Smith

CHALLENGES OF G.P. & CANCER Gatekeeper V Increased referrals = better survival Rare presentation V Presents with common symptoms Easy to miss V Catastrophic consequences Shift demand V Lack resources Evidence of what is best V No service Consultants too specialised V G.P. expected to be experts Specific pathways V Very narrow, inflexible

Challenge yourself and others Try new ideas Think big Our strategy defines what we do. Our beliefs guide the way we do things. We believe that to beat cancer sooner, you need to… Challenge yourself and others Try new ideas Think big Focus on what matters Always look to learn Provide solutions Involve the right people Trust others to do their job Do what’s best to beat cancer

VAGUE SYMPTOMS A 67 year old woman 3rd appointment in 6 weeks. She is feeling tired, with reduced appetite and says her daughter thinks she has lost weight. You have this 6th sense that she may have cancer. What can you do now?

G.P. scientist and artist HISTORY EXAMINATION INVESTIGATIONS COMMUNICATION WITH PATIENT REFERRAL

VAGUE SYMPTOMS Some cancer diagnoses are easier than others (haemoptysis, dysphagia, haematuria) Most cancers present with undifferentiated symptoms Most people with vague symptoms do not have cancer Myeloma usually presents late as emergency after multiple appointment Pancreatic cancer no obvious early symptoms and signs and often have false reassurance from normal test Lung cancer commonest early symptom is fatigue

Weight loss Appetite loss Fatigue NG12 – investigations and referral for none specific features of cancer Weight loss Appetite loss Fatigue DVT Diabetes Fever Infections Night sweats Pallor Pruritis

URGENT SCANS USS URGENTLY AT SAME TIME AS 2WW REFERRAL (both within 24 hours of seeing the patient- ideally at the same time) Gynaecology Ovarian- CA125 >30 Gynaecology PMB- women aged 55 and over with postmenopausal bleeding Jaundice/Upper abdominal mass Testicular- non painful enlargement or change in shape or texture of the testes  

Type message and send……

Multi-diagnostic centres for cancer One stop shop High G.P. suspicion but no pathway CRUK- ACE project of pilots Useful for G.P.s and patients Not overwhelming if well organised Nice guidelines (weight loss, appetite loss, fatigue)

OUTCOMES of vague symptom pilots Conversion rates 3-48% (depends on referral criteria) Picked up other diseases (GI, lung, rheumatology, cardiac) Types cancer- wide range as variable systems Often late stage/ metastatic (prompt but not early diagnosis)

Proposed Multi-diagnostic Centre/ vague symptom clinic* 09/11/2018 Proposed Multi-diagnostic Centre/ vague symptom clinic* Minimum baseline tests: (but you can do more!) Urinalysis, Chest X-ray, FBC, U&E, eGFR, ESR, CRP, LFT, TFT, Calcium, PSA or Ca 125

G.P. clinical review- THINK 09/11/2018 G.P. clinical review- THINK Can these symptoms be “explained” Dentition, depression, degree of weight loss >5% GI, rheumatologic, cardiovascular

New vague symptoms referral form 09/11/2018 New vague symptoms referral form

Pennine Lancashire Clinical Transformation Board Consensus

What about other test? Not essential but consider based on patient CT -Chest abdomen pelvis may be available to G.P.s- you could have options USS- abdomen/pelvis, soft tissue FIT- faecal immuno-chemical test

POTENTIAL BLOOD TEST Plasma electrophoresis & Benz Jones protein Tumour markers- no proven value in primary care (other than PSA and Ca125) Virology- HIV, hepatitis, mononucleosis Fe, folate, B12, Glucose, HBA1c, PTH, INR Coeliac screen Auto-antibodies, autoimmune panel

CANCER ALLIANCE PLAN Project manager- Courtney Spinks Standardised G.P. investigations and referrals Standardised process and data set Flexible hospital delivery Evaluation and sustainability

MESSAGE TO G.P.S Diagnosing some cancers is difficult Some patients don’t fit the system Developing new multi-diagnostic centres for vague or none specific symptoms G.P.s are artists! Important to work up patients, test & review Paint a picture & fill your canvas