Towards Earlier Cancer Diagnosis Hamish Whitaker GP Tutor Guildford

Context 25% deaths in developed world from cancer Most present to primary care with symptoms, even if a screening test exists Early symptoms shared with benign disease Average full time UK GP will have a new cancer diagnosed in one of their patients each month

Context UK cancer mortality record poor compared to other countries Current estimate lives lost annually due to late diagnosis Two week rule and easier access to investigations has made little difference

Why the delay? Patient delay – eg only 41% patients report rectal bleeding to GP Positive predictive value of colorectal cancer with bleeding is 0.1%- but 2-3% by the time presented to GP (and 5-7% by time get to 2ary care) Do UK GPs have too high a threshold for selecting patients for referral? Pressure from PCT and 2ary care not to refer, criticism of inappropriate use of guidelines

Breast cancer 75% breast cancers identified following presentation of symptoms Screening much less impact Little evidence to guide referral exists Breast pain and lumps commonest symptoms 8% women with breast lump reported to primary care are cancer- but depends on age (0.5% if < 25 yrs)

Breast cancer Breast pain cancer risk 0.9% overall Younger women higher risk of inflammatory breast cancer Present with swelling redness and warmth, may appear rapidly and therefore be mistaken for infection Poor prognosis

Lung cancer Prognosis generally poor – does early diagnosis make a difference? Usually spread by the time symptoms presented Only 20% UK patients eligible for surgical resection Screening little impact – current study on annual cytology and CT in COPD smokers, and spiral CT

Lung cancer Italian spiral CT trial- can detect nodules of 0.5cm (CXR smallest 3cm) High false positive rate Encouraging symptom awareness Study in Doncaster to encourage reporting cough and early CXR increased rate of cancers diagnosed in stage 1 or 2 from 11% to 19% after campaign

Lung cancer 25% lung cancers have normal CXR But CXR cheap and easy to obtain Estimate if CXR all smokers over 60 with cough would speed the time to diagnosis by 9 months in 25% of cancer cases Haemoptysis is relatively uncommon in lung cancer- only 40% report it Haemoptysis risk is % depending on age

Lung cancer Cough, dyspnoea, weight loss, fatigue, chest pain, loss of appetite commoner symptoms than haemoptysis But even more common in benign conditions- positive predictive value 1% UK delay in diagnosis 51 days; Sweden 26 days Low threshold for CXR good strategy

Colorectal cancer Current UK guidelines 6 weeks of bleeding or bleeding with diarrhoea for TWR Over 60 risk of cancer > 2% for any bleeding so are current guidelines correct? Iron deficient anaemia- men <11 women <10 – risk of cancer 7.7% and 13.3% respectively Abdominal pain, constipation and diarrhoea much lower predictive value (<1%) Problem is colonoscopy more expensive, some risk, uncomfortable

Colorectal cancer CT colonography misses 1 in 10 lesions larger than 1cm – which colonoscopy picks up Biomarkers may help in future- matrix metalloproteinase-9, free DNA in rectum possibilities for future Risk scores – CAPER and SELVA- but both lead to too many false positives and excessive interventional investigation

Colorectal cancer GPs often do get it right “change in bowel habit” means diarrhoea or constipation and reasonable chance of bowel cancer Has 4% predictive value for cancer in 80yr old, whereas constipation or diarrhoea has 0.7% and 1.2% Unclear what these soft features are that GP uses to label as change in bowel habit

Prostate cancer Debate re importance of early diagnosis Screening trials show little benefit to mortality Treating small cancers gives small mortality gain, but possible complications ; incontinence/ impotence Treatment of larger cancers or spread less controversial- and these usually cause symptoms

Prostate cancer Suggests definitely appropriate to search for cancer if LUTS But positive predictive value only 3% for cancer Impotence can be an early symptom of cancer – rare Remember PSA in back pain in men

Ovarian cancer Symptoms are common and early- and often missed Fatigue, bloating, abdominal pain, urinary frequency Combination of Ca125 and TV ultrasound probably best initial investigation

Other cancers Oesophageal cancer 5.7% risk in men with dysphagia Urinary tract cancer 7.4% risk in men with haematuria (women 3.4%) <2% lymphadenopathy presented in 1ary care malignant Brain tumour risk with headache 0.1%

Tumour markers Over 50% tumour markers requested in primary and secondary care inappropriate – and requests for PSA in women and CA125 in men not unusual! Key points 1/measuring more than one not helpful (except germ cell HCG and AFP) 2/ not helpful in non specific symptoms – often raised in benign disease also

Tumour markers Main uses in monitoring cancers- response to treatment or detecting recurrence Not helpful in screening asymptomatic individuals Except AFP for hepatocellular ca in cirrhosis from Hep B or C Ca125 for ovarian cancer (with TVUS) and PSA debatable

Tumour markers PSA - prostate ; also elevated in BPH, prostatitis, UTI, cycling! PR doesnt raise. Finasteride reduces PSA C125- ovary. Also raised in endometriosis, menstruation, colitis, laparoscopy, SLE. In conjunction with TVUS. Can be negative despite cancer – refer if suspicious

Tumour markers CEA colon cancer – only useful for monitoring CA153 breast cancer – monitoring CA19-9 pancreatic cancer – can aid diagnosis HCG and AFP germ cell tumours – can aid diagnosis and AFP in hepatocellular ca

Tumour markers Calcitonin ; medullary thyroid cancer- can aid diagnosis Thyroglobulin ; follicular /papillary thyroid cancer -can aid diagnosis Paraproteins eg Bence Jones – myeloma; useful in diagnosis Ref BMJ 2009 ; 339:b3527

Conclusions GPs may have too high a threshold for investigation Gatekeeper role may inhibit early diagnosis, and financial pressures may be increasing this Two week rule does not appear to have made a significant impact on speeding cancer diagnosis