1. IMPLEMENTATION OF NG 12 - RECOGNITION AND REFERRAL OF SUSPECTED CANCER
LEYLAND

2. HAEMATURIA r A 60 year old lady
09/11/2018
HAEMATURIA r
A 60 year old lady
3rd attendance in 2 months with dysuria and frequency (Nitrofurantoin 3/7 then Trimethoprim 7/7)
1st attendance surgery – urinalysis: trace blood 2nd attendance OOH – no record of urinalysis
Symptoms come and go
No menopausal bleeding but increased vaginal discharge
Normal exam No significant PMHx
Urinalysis today – Trace Protein Leucs+ Blood+
What would you do next?

3. VAGUE SYMPTOMS A 67 year old woman 3rd appointment in 6 weeks.
09/11/2018
VAGUE SYMPTOMS
A 67 year old woman
3rd appointment in 6 weeks.
She is feeling tired, with reduced appetite and says her daughter thinks she has lost weight.
You have this 6th sense that she may have cancer.
What can you do now?

5. G.P. scientist and artist
HISTORY
EXAMINATION
INVESTIGATIONS
COMMUNICATION WITH PATIENT
REFERRAL

6. NG12 – IMPROVING EARLY DIAGNOSIS
Symptom thresholds lowered - from 5% to 3%
For children and young adults – even lower thresholds
Guidance organised by signs and symptoms
GPs recommended to refer patients directly for tests
“Very urgent” referrals now recommended for some symptoms
Specific recommendations on safety netting

7. What does a >3% risk look like?
Your new car has been recalled as there is a dangerous fault that could leave the car uncontrollable.
There is a one in thirty chance that your car is affected
Would you ignore the warning?

8. 09/11/2018

9. New from 2015 New onset diabetes >60 associated with weight loss.
09/11/2018
New from 2015
New onset diabetes >60 associated with weight loss.
High glucose levels – endometrial.
Thrombocytosis.
GP Access to diagnostics.
CT abdomen MRI brain Upper GI endoscopy.
Consider an urgent direct access CT scan 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]
Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 and over with:unexplained symptoms of vaginal discharge who:
are presenting with these symptoms for the first time or
have thrombocytosis or
report haematuria, or
visible haematuria and:
low haemoglobin levels or
thrombocytosis or
high blood glucose levels. [new 2015

10. 09/11/2018
Direct GP Access has been advised – CT scan for pancreatic cancer for instance

11. INDICATION FOR URGENT CT SCAN
AGE 60 + WEIGHT LOSS and any of the following
DIARRHOEA
BACK PAIN
ABDOMINAL PAIN
NAUSEA
VOMITING
CONSTIPATATION
NEW ONSET DIABETES

12. 09/11/2018
Access to urgent CT
MBHT – No – but can access through Advice and Guidance
LTH – No
ELTH – Yes
Blackpool - No
Demonstrates inequity across the Alliance – what do you do when NG12 advised a 2 week CT scan? Most GP’s have access to urgent USS – but we know this is not the best way of diagnosing pancreatic cancers. Similarly, CXR’s only have a pick up rate of around 75% for lung cancer – if a GP has access to CT thorax then this can be arranged if there is a high degree of suspicion but a CXR is reported as OK.

13. ENDOSCOPY UPPER GI (2 WEEKS) 55 with weight loss and
Upper Abdominal Pain or
Reflux or
Dyspepsia

14. Access to upper GI endoscopy
09/11/2018
Access to upper GI endoscopy
MBHT – yes via a 2WW referral upper GI
LTH – yes if meet 2WW criteria
ELTH - yes
Blackpool - no
Where are we now across Lancashire and South Cumbria

15. HAEMATURIA r A 60 year old lady
09/11/2018
HAEMATURIA r
A 60 year old lady
3rd attendance in 2 months with dysuria and frequency (Nitrofurantoin 3/7 then Trimethoprim 7/7)
1st attendance surgery – urinalysis: trace blood 2nd attendance OOH – no record of urinalysis
Symptoms come and go
No menopausal bleeding but increased vaginal discharge
Normal exam No significant PMHx
Urinalysis today – Trace Protein Leucs+ Blood+
What would you do next?
Arrange FBC and U+E’s –( Hb 11.2 WCC 7.4 Platelets 490)
Send MSU –( reported as normal)
Safety net – arrange follow up – book the appointment yourself if your practice system allows
Given results what next
Raised Platelets – Lung endometrial upper GI
Direct Access Pelvic USS – non urgent – 55+ with unexplained vaginal discharge and any of the following THROMBOCYTOSIS OR HAEMATURIA
Diagnosis – Endometrial Cancer

16. G.P. scientist and artist
HISTORY
EXAMINATION
INVESTIGATIONS
COMMUNICATION WITH PATIENT
REFERRAL

17. Thrombocytosis and Cancer
09/11/2018
Thrombocytosis and Cancer
2017 BJGP Prospective Study
50,000 Adults >40y
Compared 1 year incidence cancer with plts >400
Matched controls with normal plt counts
11% men dx with cancer in the next 12 months
6% women
Higher platelet count – higher risk
2 raised counts in 6 months 18% men 10% women with cancer dx
Lung colorectal most common (1/3 no other symptoms)
Lung, Endometrial, Gastric, Oesophageal – and colorectal
Thrombocytosis recognised as an indicator for Cancer in NG12 guidance and now supported further by this prospective study
Red whale use the term LEGO to which they have now added LEGO-C.
Endometrial Cancer
Consider direct access ultrasound in women:• Aged 55 and over presenting with unexplained symptoms of vaginal discharge who:
– Are presenting with these symptoms for the first time OR Have thrombocytosis OR Report haematuria.
Consider direct access ultrasound in women:• Aged 55 and over presenting with visible haematuria and any of the following:
– Low haemoglobin
– Thrombocytosis
– High blood glucose level

18. Practicalities raised platelets
Primary Haematological
Essential thrombocytosis
Myeloproliferative disorders (JAK2 test 60%)
Secondary or Reactive
Chronic inflammation/post operative
Infection/Acute bleeding and blood loss/Exercise
Heart Attack/Burns/Iron deficiency anaemia
CANCER

19. Awareness Raised platelets should trigger suspicion of cancer.
Review patients and check for other symptoms.
Remember 1/3rd - no symptoms.
So consider CXR and FIT (if available).
Safety net the patient.

20. FIT Diagnostic Guidance DG 30 July 2017 ?suspected colorectal cancer
09/11/2018
FIT
Diagnostic Guidance DG 30
July 2017
?suspected colorectal cancer
In absence of rectal bleeding
Unexplained symptoms
Not 2WW criteria
Low risk 0.1% to 3% probability
DG30 guidance replaced the NG12 guidance regarding the use of FOB in the early diagnosis of cancer.
The original NG12 guidance stated - In the absence of rectal bleeding, offer testing for occult blood in faeces to patients:
• Aged 50 or over with unexplained Abdominal pain or weight loss
• Aged under 60 with either -changes in bowel habit or iron deficiency anaemia
• Aged 60 and over with Anaemia even in the absence of iron deficiency

21. Access To FIT MBHT – No - but FOB still available LTH – Yes ELTH – No
09/11/2018
Access To FIT
MBHT – No - but FOB still available
LTH – Yes
ELTH – No
Blackpool – No
CANCER ALLIANCE FIT PROGRAMME – Roll out 2018?
LTH and Preston Chorley and Ribble CCG’s with the support of CRUK facilitators and Macmillan GPs have already rolled out access to FIT for GP’s in their region. This innovative work has formed the backbone of the Cancer Alliance Fit programme and there is an ambition to roll out FIT to all CCG’s in 2018 with the support of the Cancer Alliance who have successfully bid for transformation funding to support this programme of work.

22. Safety Netting and pitfalls
CXR for symptomatic – 23% negative.
USS can miss over 10% pancreatic cancers.
Microscopic Haematuria – low PPV for cancer.
Vague Symptoms – over to Neil.

23. Thankyou
Dr Chrissie Hunt
CRUK Strategic Lead GP

24. VAGUE SYMPTOMS 11/7/18
Neil Smith

25. CHALLENGES OF G.P. & CANCER
Gatekeeper V Increased referrals = better survival
Rare presentation V Presents with common symptoms
Easy to miss V Catastrophic consequences
Shift demand V Lack resources
Evidence of what is best V No service
Consultants too specialised V G.P. expected to be experts
Specific pathways V Very narrow, inflexible

27. Challenge yourself and others Try new ideas Think big
Our strategy defines what we do. Our beliefs guide the way we do things. We believe that to beat cancer sooner, you need to…
Challenge yourself and others
Try new ideas
Think big
Focus on what matters
Always look to learn
Provide solutions
Involve the right people
Trust others to do their job
Do what’s best to beat cancer

28. VAGUE SYMPTOMS A 67 year old woman 3rd appointment in 6 weeks.
She is feeling tired, with reduced appetite and says her daughter thinks she has lost weight.
You have this 6th sense that she may have cancer.
What can you do now?

29. G.P. scientist and artist
HISTORY
EXAMINATION
INVESTIGATIONS
COMMUNICATION WITH PATIENT
REFERRAL

30. VAGUE SYMPTOMS
Some cancer diagnoses are easier than others (haemoptysis, dysphagia, haematuria)
Most cancers present with undifferentiated symptoms
Most people with vague symptoms do not have cancer
Myeloma usually presents late as emergency after multiple appointment
Pancreatic cancer no obvious early symptoms and signs and often have false reassurance from normal test
Lung cancer commonest early symptom is fatigue

31. Weight loss Appetite loss Fatigue
NG12 – investigations and referral for none specific features of cancer
Weight loss
Appetite loss
Fatigue
DVT
Diabetes
Fever
Infections
Night sweats
Pallor
Pruritis

33. URGENT SCANS USS URGENTLY AT SAME TIME AS 2WW REFERRAL
(both within 24 hours of seeing the patient- ideally at the same time)
Gynaecology Ovarian- CA125 >30
Gynaecology PMB- women aged 55 and over with postmenopausal bleeding
Jaundice/Upper abdominal mass
Testicular- non painful enlargement or change in shape or texture of the testes

34. Type message and send……

35. Multi-diagnostic centres for cancer One stop shop
High G.P. suspicion but no pathway
CRUK- ACE project of pilots
Useful for G.P.s and patients
Not overwhelming if well organised
Nice guidelines (weight loss, appetite loss, fatigue)

36. OUTCOMES of vague symptom pilots
Conversion rates 3-48% (depends on referral criteria)
Picked up other diseases (GI, lung, rheumatology, cardiac)
Types cancer- wide range as variable systems
Often late stage/ metastatic (prompt but not early diagnosis)

38. Proposed Multi-diagnostic Centre/ vague symptom clinic*
09/11/2018
Proposed Multi-diagnostic Centre/ vague symptom clinic*
Minimum baseline tests: (but you can do more!)
Urinalysis, Chest X-ray,
FBC, U&E, eGFR, ESR, CRP, LFT, TFT, Calcium,
PSA or Ca 125

39. G.P. clinical review- THINK
09/11/2018
G.P. clinical review- THINK
Can these symptoms be “explained”
Dentition, depression, degree of weight loss >5%
GI, rheumatologic, cardiovascular

40. New vague symptoms referral form
09/11/2018
New vague symptoms referral form

42. Pennine Lancashire Clinical Transformation Board Consensus

43. What about other test? Not essential but consider based on patient
CT -Chest abdomen pelvis may be available to G.P.s- you could have options
USS- abdomen/pelvis, soft tissue
FIT- faecal immuno-chemical test

44. POTENTIAL BLOOD TEST Plasma electrophoresis & Benz Jones protein
Tumour markers- no proven value in primary care (other than PSA and Ca125)
Virology- HIV, hepatitis, mononucleosis
Fe, folate, B12, Glucose, HBA1c, PTH, INR
Coeliac screen
Auto-antibodies, autoimmune panel

45. CANCER ALLIANCE PLAN Project manager- Courtney Spinks
Standardised G.P. investigations and referrals
Standardised process and data set
Flexible hospital delivery
Evaluation and sustainability

46. MESSAGE TO G.P.S Diagnosing some cancers is difficult
Some patients don’t fit the system
Developing new multi-diagnostic centres for vague or none specific symptoms
G.P.s are artists!
Important to work up patients, test & review
Paint a picture & fill your canvas