1. Early Diagnosis and Prognostic Indicator
Dr Richard Roope RCGP & CRUK Clinical Lead for Cancer
CRUK Senior Clinical Advisor
November 10th 2015
GP Refresher Week

2. Early Diagnosis and Prognostic Indicator
Dr Richard Roope RCGP & CRUK Clinical Lead for Cancer Cancer Research UK Senior Clinical Advisor

3. Cancer – why all the interest?

4. Cancer – why all the interest?
Loss of life years <75 1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents 2
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents 3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal 4
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal

5. Cancer – why all the interest?
Loss of life years <75 1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents 2
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents 3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal 4
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal
Which do you think is the correct column?
(high to low)

6. Cancer – why all the interest?
Loss of life years <75 1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents 2
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents 3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal 4
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal

7. Cancer – why all the interest?

8. Cancer – why all the interest?

9. Cancer – why all the interest?
1 in 2 people will be diagnosed with one or more cancers in their lifetime

10. Cancer – why all the interest?
Lifetime risk of cancer

11. Cancer – why all the interest?
1 in 2 people will be diagnosed with on or more cancers in their lifetime
10 year survival has improved to reach 50%

12. Cancer – why all the interest?
1 in 2 people will be diagnosed with on or more cancers in their lifetime
10 year survival has improved to reach 50%
– last accessed

13. Cancer – why all the interest?
1 in 2 people will be diagnosed with on or more cancers in their lifetime
10 year survival has improved to reach 50%, but…
Cancer survival in the UK still lags behind comparable health economies

14. Cancer – why all the interest?
Hasn’t cancer had its turn?

15. Cancer – why all the interest?
Hasn’t cancer had its turn?
Cancer receives what proportion of NHS spend?
2.4%
5.4%
8.4%
11.4%
14.4%

16. Cancer – why all the interest?
Hasn’t cancer had its turn?
Total NHS spend in 2012/3: £125,700,000

17. Cancer – why all the interest?
Hasn’t cancer had its turn?
Total NHS spend in 2012/3: £125,700,000
Total NHS spend in 2012/3: £2008 per head

18. Cancer – why all the interest?
Hasn’t cancer had its turn?
Total NHS spend in 2012/3: £125,700,000
Total NHS spend in 2012/3: £2008 per head
Total NHS spend on cancer care: £109 per head

19. Cancer – why all the interest?
Hasn’t cancer had its turn?
Total NHS spend in 2012/3: £125,700,000
Total NHS spend in 2012/3: £2008 per head
Total NHS spend on cancer care: £109 per head
Just 5.4% of NHS spend

20. Cancer – why is early diagnosis important?

21. Cancer – why is early diagnosis important?
Breast Cancer – 5 year relative survival
(last accessed )

22. Cancer – why is early diagnosis important?

23. Cancer – why is early diagnosis important?
Lung Cancer - 5 year relative survival
(last accessed )

24. Cancer – why is early diagnosis important?

25. Cancer – why is early diagnosis important?
Prostate Cancer - 5 year relative survival
(last accessed )

26. Cancer – why is early diagnosis important?

27. Cancer – why is early diagnosis important?
Bowel Cancer - 5 year relative survival
(last accessed )

28. Cancer – why is early diagnosis important?

29. Cancer – Current situation
All Cancers
(last accessed )

30. Cancer – Current situation
All Cancers
Stage Shift

31. Cancer – Earlier stage of diagnosis
Increase in numbers diagnosed at stage 1 & 2
(last accessed )

32. Cancer – Earlier stage of diagnosis
Minimum increased 5 year survival with 10% increase in stages 1 & 2
Breast
3.8%
Prostate
2.4%
Colorectal
4.0%
Lung
2.0%
Bladder
1.3%
Kidney
Ovary
Endometrium
3.7%
NHL
0.2%
Melanoma
2.3%
(last accessed )

33. Cancer – where were we?

34. Cancer – where have we come from?
January Improving Outcomes: A Strategy for Cancer

35. Cancer – where were we?
Avoidable deaths pa if survival in England matched the best in Europe
Breast ~2000 Myeloma 250
Colorectal ~1700 Endometrial 250
Lung ~1300 Leukaemia 240
Oesophagogastric Brain 225
Kidney ~ Melanoma 190
Ovary ~ Cervix 180
NHL/HD Oral/Larynx 170
Bladder Pancreas 75

36. Cancer – what did we do?

37. Cancer – what did we do?

38. Cancer – what did we do? Research stream Primary Care Engagement
Input to Cancer Network and SCNs
RCGP Education Events
etc

39. Cancer – How did we do?

40. Cancer – How did we do?
How did we do it?

41. Cancer – How did we do?

42. Cancer – How did we do?

43. Cancer – How did we do? Variation Dorset CCG:

44. Cancer – How did we do?
Smoothed maps of the one-year survival index (%) for all cancers combined by CCG: England, 1996 and 2011, patients ages years
1996
Ambition
Dorset
England
2011

45. Cancer – How did we do? PHE Press release 16.9.15:
“Cancers are being diagnosed earlier in England”
(last accessed )

46. Cancer – How did we do?
However compared to Europe?

47. Cancer – How did we do? However compared to Europe?

48. Cancer – How did we do?
However compared to Europe?

49. Cancer – why are we different in UK?

50. Cancer – why are we different in UK?
Why do we lag behind other Health Systems?

51. Cancer – why are we different in UK?
International Cancer Benchmarking Partnership

52. Cancer – why are we different in UK?
International Cancer Benchmarking Partnership
As gatekeepers – the gate needs to be wider
Outcomes closely linked to “readiness to act”
Patients fear wasting GP time
Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? British Journal of Cancer (2013) 108, 292–300. doi: /bjc

53. Cancer – Where from here?

54. Cancer – Where from here?

55. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives
Transform patient experience and quality of life
Invest now to save later
(last accessed )

56. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:

57. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Over 40% of cancers are preventable
Under 75 mortality rate for cancer considered preventable (last accessed )

58. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention

59. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Ambition:

60. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Ambition:
Fall in age-standardised incidence
Adult smoking rates to fall to 13% (currently 18.8%)

61. Cancer – Where from here?
Smoking Prevalence

62. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Drive a national ambition to achieve earlier diagnosis, and with it stage shift

63. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Drive a national ambition to achieve earlier diagnosis, and with it stage shift
Ambition:
Increase 5ys and 10ys – with 57% surviving 10+ years
Increase 1ys to 75% with reduction of variation

64. Cancer – Where from here?
Smoothed maps of the one-year survival index (%) for all cancers combined by CCG: England, 1996 and 2011, patients ages years
1996
Ambition
Dorset
England
2011

65. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Drive a national ambition to achieve earlier diagnosis, and with it stage shift
“If the taskforce recommendations are implemented 30,000 cancer deaths a year could be saved by 2020, of these 11,000 will be through early diagnosis”

66. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives:
Spearhead a radical upgrade in prevention
Drive a national ambition to achieve earlier diagnosis, and with it stage shift
“If the taskforce recommendations are implemented 30,000 cancer deaths a year could be saved by 2020, of these 11,000 will be through early diagnosis”

67. Cancer Strategy – Recommendations
Early Diagnosis
Implement NICE Guidance (NG12)
Invest in diagnostic capacity
Direct access to diagnostic capacity
Enhance screening uptake
28 days to diagnosis (to replace 2WW)
Education – Undergraduate, postgraduate, CPD

68. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives
Transform patient experience and quality of life

69. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives
Transform patient experience and quality of life
Patient experience to be given as high a priority as clinical effectiveness and safety
Transform approach to support those living with and beyond cancer
Continuous improvement in patient experience, with reduction in variation
Continuous improvement in long-term quality of life

70. Cancer – Where from here?
Cancer Strategy has three core aims:
Save thousands more lives
Transform patient experience and quality of life
Invest now to save later

71. Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
Follow-up
Late effects
Rehabilitation
Health promotion
End of life
Basic palliation
Specialised
Social
Bereavement

72. Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
Follow-up
Late effects
Rehabilitation
Health promotion
End of life
Basic palliation
Specialised
Social
Bereavement
Primary Care has a part to play throughout the cancer pathway, and is well placed to do so…

73. Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
Follow-up
Late effects
Rehabilitation
Health promotion
End of life
Basic palliation
Specialised
Social
Bereavement
Primary Care has a part to play throughout the cancer pathway, and is well placed to do so…
if adequately resourced…

74. Cancer Strategy – now what?
The Lancet Oncology:
“The expanding role of Primary Care in Cancer Control”
“For a long time, the role of primary care in cancer was largely seen a peripheral, but as prevention, diagnosis, survivorship, and end-of-life care assume greater importance in cancer policy, the defining characteristics of primary care become more important”
The Lancet Oncology, Vol. 16, No. 12

75. Cancer Strategy – now what?
The Lancet Oncology:
“The expanding role of Primary Care in Cancer Control”
“The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. ”
The Lancet Oncology, Vol. 16, No. 12

76. NICE Guidance Suspected cancer: recognition and referral
NICE guidelines [NG12] – June 2015

77. NICE Guidance
Aim
The aim of the guidelines is to improve cancer diagnosis:
The timeliness
The quality
The consistency

78. NICE Guidance Implementation
“While guidelines assist the practice of healthcare professionals, they do not replace their knowledge and skills.”

79. NICE Guidance Implementation
“For all clinical scenarios it is assumed that the health professional will have a discussion with the patient about the risks and benefits of intervention, enabling the patient to exercise a fully informed decision.”

80. NICE Guidance Implementation
The guideline focuses on those areas of clinical practice:
That are known to be controversial or uncertain
Where there is identifiable practice variation
Where there is lack of high quality evidence
Where NICE guidelines are likely to have the most impact.

81. NICE Guidance Implementation It is assumed that:
an appropriate history and physical examination are undertaken
urinalysis is undertaken where appropriate
simple blood tests (Fbc, biochemistry and inflammatory markers) are done

82. NICE Guidance What is new?
This is the first guidance that uses primary care evidence, which is available for the first time
Adds symptom pathways for the first time
Uses the same referral thresholds for all cancers

83. NICE Guidance What is new?
This is the first guidance that uses primary care evidence, which is available for the first time
Adds symptom pathways for the first time
Uses the same referral thresholds for all cancers (PPV 3%)

84. NICE Guidance What is new? (General)
Many – being symptom centred and using 3% PPV, the ages vary (range 30-60)
Some criteria have been dropped (no evidence to support them)
Timeline specifics have gone – replaced with “recurrent” or “persistent”.

85. NICE Guidance
What is new? (Specifics)
Relevance of ↑ Platelet count

86. NICE Guidance What is new? (Specifics) Relevance of ↑ Platelet count
Up to 10% of patients with a raised platelet count will have cancer:
Seen in cancers of:
Lung
Upper GI
Endometrial
Ovarian
Breast

87. NICE Guidance What is new? (Specifics - examples)
2ww lung - Haemoptysis only in 40+
Mesothelioma now covered
Lower GI – high risk groups (eg ulcerative colitis) not mentioned.
2ww breast: unexplained axillary lump
Haematuria and ↑platelets →gynae ultrasound
Dermatoscopy suggestive of melanoma → 2ww dermatology

88. NICE Guidance What is new? (Specifics - examples)
Persistent bone pain, unexplained fracture: do Fbc + ESR
60+ with hypercalcaemia/↓wbc: electrophoresis and BJP within 48h
Palpable abdominal mass <16 (used to be under 1y)

89. NICE Guidance
Implementation will take a while

90. NICE Guidance Electronic Clinical Decision Support tools
2 week referral forms will change
Commissioners and Trusts: engage with new pathways
Guidance from RCGP to follow

91. NICE Guidance Summary: Why? To address our lowly cancer outcomes rank
How? To lower threshold/readiness to refer with consistency
When? Gradual roll out over next few months

92. NICE Guidance
Summary:
Results?

93. NICE Guidance Summary: Results?
Better medicine – earlier diagnosis (not just of cancer)
Fewer consultations
Better outcomes
Less complaints
Less £££

94. NICE Guidance
Summary:
Results?
Earlier Diagnosis

95. Early diagnosis
We have done amazingly, rising to the challenge of 2011

96. Early diagnosis
We have done amazingly, rising to the challenge of 2011
We can do even better, individually

97. Early diagnosis
We have done amazingly, rising to the challenge of 2011
We can do even better, individually
As a wider health community we could do so much more
…if resourced properly:
We need to spend money now…
to save money (and misery) later

98. Early diagnosis

99. Early diagnosis
Thank you

100. Early diagnosis
Any questions?