Direct access diagnostics and cancer update 13th Oct 2017

Reminder on NICE referral guidelines for suspected cancer New direct access pathways for diagnostics to support these Safety-netting template for urgent diagnostic tests Results of audit of fast-track referrals to Homerton for lung, upper GI and lower GI

NICE NG12 2015 Lower thresholds for investigation and referral Move towards GPs taking ownership of investigation for cancer Overall across London referrals are rising

NG 12 Macmillan summary – put this on your desktop. https://www

Main changes Use of FBC Raised platelets are part of the referral criteria for lung, oesophageal, gastric and endometrial cancers Raised WBC is a trigger for investigation for bladder cancer in patients over 60 with non-visible haematuria

Urological cancers and haematuria

CT chest pathway

NICE guidance on Urgent referral Patients should be referred to a member of the MDT whilst awaiting a CXR in the presence of: Persistent haemoptysis in smokers/ex-smokers older than 40 years signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure) Stridor Emergency referral should be considered for patients with superior vena cava obstruction or stridor.

Case 1 42 year old lady with chronic cough; frequent “runny nose” but no known allergies. CXR, spirometry – normal. What would you do next? Refer for an ENT examination + fibreoptic laryngoscopy Trial of nasal steroid PEF diary and inhalers X-ray (or CT) of sinuses CT chest

Case 2 66 year old man 40 pack years of smoking Diagnosed COPD: “blue bloater” Presented with increased dyspnoea GP noted an abnormality

Case 3 49 year old lady Mild cough for 5 weeks Smoker No previous attendances to surgery in last 2 years Sent for CXR – “normal appearance” What would you do?

Case 4 38 year old Pakistani lady Cough and haemoptysis for 4 weeks CXR “bulky left hilum” Further history obtained in clinic Never smoked Recent trip to Pakistan 2 WW referral

Case 5 2WW referral: 42 y F; cough for 4 weeks Started with flu-like illness Initially green sputum, now settled Dry cough persists 6 pack-year history Examination unremarkable

What next??

“Red Flags” Cough without preceeding infection Haemoptysis without infection Mild persistent “smoker’s” cough Weight loss in a smoker Anaemia without GI symptoms Increasing dyspnoea or tiredness in a smoker Thrombocytosis

Information required on referral DM, Allergies, Asthma, other specific problems Current medication – lists often not attached with faxed referral, patients do not bring or remember meds Has the patient been told why they have been referred? U&E in last 6 months if normal CXR (external imaging problems)

Lung referral tips from the audit

Radiation mSv equivalent dose, takes into account type of radiation and affect on individual tissues 10mSv increased lifetime risk cancer 1 in 2000 Overall lifetime risk invasive cancer 1 in 3 women, 1in 2 men. Background radiation 2.5 mSv/year Cornwall radon dose 6.9m Sv/yr Domestic Pilots 2.2 mSv/yr 7 Hr flight 0.2 m Sv CXR 0.02 AXR 0.4

Grays are absorbed dose 0.1 Gy = 100 m Sv for x-rays

CT Doses (mSv) Chest 4.5 Abdomen 5.7 Pelvis 4.4 Abdo and Pelvis 4.4 KUB 1.5 IVU 5.2 Head 1.4 Sinus 0.28 WBCT additional lifetime risk of cancer of 1 in 184 or 99.45% chance of no effect. X-ray risk. http://xrayrisk.com

Lower GI

Lower GI Abdominal pain has been added as an important symptom Change in bowel habit no longer specifies to looser or more frequent stool No cut-off for iron deficiency anaemia (although Hb<120 in men and <110 in women was in the draft guidance) Please note, in the national guidance, use of FOBT is recommended in certain circumstances – this is not in the London guidance – we are waiting for the FIT test to be available – watch this space!

Lower GI audit tips

Lower GI audit tips

Direct access flexi-sig and colonoscopy Do remember that we still have access to DAFS and DACS Flexi sig appropriate for patients with persistent rectal bleeding but no other features of concern Colonoscopy for low risk but not no risk patients

Upper GI This is where direct access comes in! Change to GPs organising tests rather than proceeding with a fast track referral

Oesophageal/gastric

New urgent direct access OGD Available at Homerton Please make sure that you have the correct forms in use in your practices

Upper GI algorithm

Upper GI audit results

Pancreatic cancer

CT CAP pathway

Fast track referrals good practice Safety-netting of all referrals Practices already do this very well Safety-netting of all referrals for urgent investigations New template available

New safety-netting template

Fast-track referrals - Patient information Preparing your patients is crucial when you initiate a fast-track referral The hospital team cannot hold a referral if the patient is going to be away, so you and the patient need to decide how to proceed The Homerton aim to offer an appointment within a week of referral, so it is acceptable to hold onto a referral until the patient returns from a trip if they are unwilling to cancel and understand the risk of a delay in diagnosis

Ensure that your patient understands that they may be offered a test before their appointment Ensure that you have up to date bloods, especially UE is they may need a CT Explain that patients referred to the lower GI service will be contacted by a nurse to discuss a test before their appointment – please ensure they are happy to proceed Please explain to patients you refer to dermatology that there is now a one-stop clinic service, so their appointment may involve a biopsy the same day

New handy patient cards with Homerton cancer office number available to give to patients on referral New patient leaflet explaining the fast-track referral process available Be explicit that the patient is being referred on a suspected cancer pathway– patients prefer to be investigated and explaining a cancer pathway DECREASES anxiety rather than provoking it (BJGP 2014)

Additional cancer updates FIT testing for the bowel screening programme Update on results of the GP contract for bowel screening Bowelscope

FIT test for bowel screening Coming in next year Means only need to send one sample Should be more acceptable and increase uptake

Bowel screening GP contract

Bowelscope New screening test for bowel cancer being rolled out nationally One-off flexible sigmoidoscopy at age 55 No catch-up planned Started in Hackney this year

Bowelscope Rationale Early identification of cancers Identification of adenomas – removed and surveillance then arranged 2/3 of colorectal cancers are in the sigmoid colon and rectum NNS to prevent a diagnosis of colorectal cancer is 191 NNS to prevent a death is 489

Uptake is likely to be poor Do please encourage your patients to take up the opportunity

Thank you – any questions?