Barts Health Trust 2WW Colorectal Workshop Dr Angela Wong, Clinical Director Cancer Consultant Gastroenterologist September 2015

CONTENTS 1. 2Overall Context   1. Cancer Plan 2000 2.Cancer Reform Strategy 2007 3. Improving Outcomes 2. Background 1. introduction 2. Routes to Diagnosis and Survival 3. Bartshealth 2WW 4. NICE guidance 5. Cases 6. STT 7. 2020 8. Conclusion 9. Questions?

1 1 Overall Context

Also 62 upgrade 31 DTT

Background Colorectal 1 2 Background Colorectal

Introduction 4 Colorectal 40,000 new colorectal cancers are diagnosed each year in the UK, up to a quarter of these following screening. A full time GP is likely to diagnose approximately 1 person with colorectal cancer every year. Five year survival is approximately 60%, though this figure includes cancers detected by screening as well as those identified after symptoms have occurred. Symptoms Most common being diarrhoea, constipation (sometimes referred to as ‘change of bowel habit’) rectal bleeding, loss of weight, and abdominal pain. Colorectal cancer may present with anaemia, particularly iron deficiency anaemia.

Routes for diagnosis for diagnosis 27% 2WW scheme (red flag signs) 48% GP/other OP/ routes of referral 25% AE presentation (late with poorer outcomes)

Colorectal Cancer Routes to diagnosis 5 Colorectal Cancer Routes to diagnosis Colorectal 5% 27% 25% 9% 5% 25% 0% 4%

Colorectal Cancer 1YS

1 3 Bartshealth trends

Bartshealth 2WW referral trends 2010-15

Conversion BH colorectal 2WW to cancer

Whipps Cross 2WW referral trends

Conversion 2WW colorectal referrals to cancer

NICE referral guidance 1 4 NICE referral guidance

NICE guidance June 2015 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if:  they are aged 40 and over with unexplained weight loss and abdominal pain or  they are aged 50 and over with unexplained rectal bleeding or  they are aged 60 and over with: iron–deficiency anaemia or changes in their bowel habit, or  tests show occult blood in their faeces [new 2015]

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in people with a rectal or abdominal mass. [new 2015] Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings: ٠abdominal pain ٠change in bowel habit ٠weight loss ٠iron-deficiency anaemia. [new 2015]

FOB Offer testing for occult blood in faeces to assess for colorectal cancer in adults without rectal bleeding who: are aged 50 and over with unexplained: ٠ abdominal pain or ٠weight loss, or ٠ are aged under 60 with ٠changes in their bowel habit or ٠iron-deficiency anaemia or ٠are aged 60 and over and have anaemia even in the absence of iron deficiency. [new 2015]

1 5 Cases

Case 1 22 year old Loose stool Rectal bleeding on and off for 1 year

Case 2 60 male Overt rectal bleeding GP x1, AE x 2 told haemorrhoids Admitted symptomatic anaemia

Case 3 65 yo male Carer Admitted weakness Found to have abnormal LFTs

1 6 STT

Traditional Pathway GP referral Consultant triage Out-patients 8 weeks Lower GI investigation Out-patients 6 weeks 3 months

STT model GP referral Nurse telephone assessment 3 days Lower GI investigation ? Out-patient review 2-4 weeks

1 7 What next 2020?

2020 NHS patients in England should get results for cancer tests within four weeks of being referred by a GP by 2020 under new plans to improve treatment. NHS England's cancer taskforce is also replacing old radiotherapy machines and increasing specialist staff to ensure it delivers "world class" cancer care. The five-year plan will cost £400m a year but experts say earlier treatment will result in similar savings. They say the plan could help an extra 30,000 patients survive for 10 years.

1 8 Conclusion

Conclusion Refer according to guidelines Follow clinical intuition Complete form Explain referred on a cancer pathway Discuss with people with suspected cancer (and their carers as appropriate, taking account of the need for confidentiality) their preferences for being involved in decision-making about referral options and further investigations including their potential risks and benefits. [2015] Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them. [2015] Give the person information on the possible diagnosis (both benign and malignant) in accordance with their wishes for information (see also the NICE guideline on patient experience in adult NHS services). [2015] The information given to people with suspected cancer and Suspected cancer Patient information and support their families and/or carers should cover, among other issues:  where the person is being referred to  how long they will have to wait for the appointment  how to obtain further information about the type of cancer suspected or help before the specialist appointment  what to expect from the service the person will be attending  what type of tests may be carried out, and what will happen during diagnostic procedures  how long it will take to get a diagnosis or test results  whether they can take someone with them to the appointment  who to contact if they do not receive confirmation of an  other sources of support. [new 2015] Provide information that is appropriate for the person in terms of language, ability and culture, recognising the potential for different cultural meanings associated with the possibility of cancer. [new 2015] Have information available in a variety of formats on both local and national sources of information and support for people who are being referred with suspected cancer. For more information on information sharing, see section 1.5 in the NICE guideline on patient experience in adult NHS services. [new 2015] Reassure people in the safety netting group (see recommendation in chapter 5) who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low. [new 2015] Explain to people who are being offered

1 9 Questions?