Upper Gastrointestinal Cancer Dr Rosemary Phillips Lead for Upper GI Cancer Princess Alexandra Hospital NHS Trust Harlow

Aims Epidemiology Presentation – Cancer Type Presentation – Symptoms Discussion Points Conclusion

Epidemiology

Age-Standardised One-, Five- and Ten-Year Net Survival, Selected Cancers, Adults (Aged 15-99), England and Wales, 2010-2011 Breast is for female only. Laryngeal is for male only. Five- and ten-year survival for 2010-2011 is predicted using an excess hazard statistical model. Survival for bowel cancer is a weighted average derived from data for colon (C18) and rectum cancer (C19-C20, C21.8) Source: cruk.org/cancerstats You are welcome to reuse this Cancer Research UK statistics content for your own work. Credit us as authors by referencing Cancer Research UK as the primary source. Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].

Time to presentation for Upper GI cancer

PAH –CWT Upper GI Referrals

PAH – cancers via CWT or other route?

Alarm Symptoms Dysphagia Weight loss (unintentional) Anaemia (IDA) Vomiting – persistent Bleeding Abdominal mass Obstructive jaundice (especially painless) But when upper GI cancers present with alarm symptoms……..it is usually too late

Common Upper GI symptoms Dyspepsia Heartburn Upper abdominal pain Wind Nausea But non-alarm upper GI symptoms are very common………..so who do you refer?

NICE – lowered symptom cut off 'risk threshold‘: “whereby if the risk of symptoms being caused by cancer is above a certain level then action (investigation or referral) is warranted” The positive predictive value (PPV) was used to determine the threshold: Was 5% Now 3% - hence some new ‘alarm’ symptoms included

PRESENTATION – Cancer Type

OESOPHAGEAL CANCER

New NICE Oesophageal Cancer Referral Criteria 1.2.1 Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2weeks) to assess for oesophageal cancer in people: with dysphagia or aged 55 and over with weight loss and any of the following: upper abdominal pain reflux dyspepsia [new 2015] 1.2.2 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with hematemesis [new 2015]

New NICE Oesophageal Cancer Referral Criteria cont 1.2.3 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or raised platelet count with any of the following: nausea vomiting weight loss reflux dyspepsia upper abdominal pain, or nausea or vomiting with any of the following: upper abdominal pain.[new 2015]

Dysphagia cases 55yr female, overweight 70 yr man Weight loss 1 stone Couple of episodes of mild feeling of dysphagia with bread/meat 70 yr man Weight loss 1 stone Having to chop food small/ mince to get down Occasional vomiting

STOMACH CANCER

New NICE Stomach Cancer Referral Criteria 1.2.6 Consider a suspected cancer pathway referral (for an appointment within 2weeks) for people with an upper abdominal mass consistent with stomach cancer.[new 2015]   1.2.7 Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2weeks) to assess for stomach cancer in people: with dysphagia or aged 55 and over with weight loss and any of the following: upper abdominal pain reflux dyspepsia.[new 2015] 1.2.8 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with hematemesis.[new 2015]

New NICE Stomach Cancer Referral Criteria cont 1.2.9 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or raised platelet count with any of the following: nausea vomiting weight loss reflux dyspepsia upper abdominal pain, or nausea or vomiting with any of the following: upper abdominal pain.[new 2015]

Dyspepsia cases 55 yr old man 60 yr old man Recent NSAIDs for sports injury, then dyspepsia 60 yr old man Heavy smoker Dyspepsia for 6 months unresponsive to o/c ranitidine Lost 4kg in weight

Nausea and vomiting cases 55 yr old female 2 month of nausea in the mornings Relieved by eating breakfast No alarm symptoms 50 yr old woman Vomiting daily after most meals Reduced appetite and ½ stone weight loss

Iron Deficiency Anaemia Important to remember: There can be co-existant upper and lower GI pathologies PLEASE check ferritin before commencing iron NICE now says ‘low haemoglobin’……..does not have to be IDA for upper GI cancers

IDA cases 45yr female, IDA 55 yr old man not vegetarian Heavy periods no GI symptoms 55 yr old man not vegetarian Tired Hb 9.0 IDA or non-IDA picture

PANCREATIC CANCER

New NICE Pancreatic Cancer Referral Criteria 1.2.4 Refer people using a suspected cancer pathway referral(for an appointment within 2weeks) for pancreatic cancer if they are aged 40 and over and have jaundice.[new 2015]   1.2.5 Consider an urgent direct access CT scan (to be performed within 2weeks), 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]

Jaundice cases 50 yr old obese female 45 yr old man Recurrent RUQ pain with eating Presents with acute jaundice and RUQ pain 45 yr old man Gradual onset jaundice Loss of appetite Back discomfort

Abdominal pain cases 50 yr male 60yr old man Dyspepsia since holiday with alcohol Nausea Improving with ranitidine 60yr old man Vague upper abdominal pain Loss of appetite Half a stone weight loss Diabetes diagnosed 6 months ago

LIVER CANCER

New NICE Liver Cancer Referral Criteria 1.2.11 Consider an urgent direct access ultrasound scan (to be performed within 2weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver.[new 2015]

GALLBLADDER CANCER

New NICE Gallbladder Cancer Referral Criteria 1.2.10 Consider an urgent direct access ultrasound scan (to be performed within 2weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder.[new 2015]

PRESENTATION – Symptom

NICE: Recommendations organised by symptom and findings of primary care investigations

DISCUSSION POINTS

What if ‘CWT DTT’ is negative NICE “1.15.1 Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this” Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be: planned within a time frame agreed with the person or patient-initiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist or worsen.[new 2015] Patient Wants shortest possible time to diagnosis whether cancer or not

What if ‘CWT DTT’ is negative GP wants…….. Specialist wants………

Impact on services GP consultations GP tests Endoscopy Radiology ……..??

Any questions ????

Conclusion

Upper GI cancers - high incidence and poor outcome Alarm symptoms often mean its too late ……However upper GI symptoms are very common and most won’t have cancer

When to refer… If cancer really suspected then CWT/FT/2WW (use new NICE criteria) If concern just as urgent …….patients still don’t have to wait long <6 weeks All of us are happy to discuss on the phone……..we have a gastro consultant of the week (GOW)

REFERENCES http://publications.cancerresearchuk.org/downlo ads/Product/CS_REPORT_TOP10INCMORT.pdf Achieving World-class Cancer Outcomes A Strategy For England 2015-2020 http://www.cancerresearchuk.org/health- professional/cancer-statistics/survival/common- cancers-compared#heading-Zero Suspected cancer: recognition and referral. NICE guideline Published: 22 June 2015 nice.org.uk/guidance/ng12