Hereford and Worcester Sub Regional Trainers’ Workshop

Hereford and Worcester Sub Regional Trainers’ Workshop
The Holiday Inn, Kidderminster Road Bromsgrove, B61 9AB 9th November 2017 Dr Richard Roope RCGP and Cancer Research UK Cancer Clinical Champion Senior Clinical Advisor Cancer Research UK

Trainers’ Workshop Earlier Diagnosis of Cancer

Earlier Diagnosis of Cancer
Trainers’ Workshop Earlier Diagnosis of Cancer Cancer: why all the interest? Why is it important? How have we done? How could we do even better?

Trainers’ Workshop Cancer: why all the interest?

Cancer: why all the interest?
Trainers’ Workshop Cancer: why all the interest? Causes of death <75 1 Circulatory Disease Cancer Liver Respiratory Other 2 Cancer Other Circulatory Disease Liver Respiratory 3 Circulatory Disease Cancer Respiratory Liver Other 4 Cancer Circulatory Disease Other Respiratory Liver

Trainers’ Workshop Cancer: why all the interest? Causes of death <75 1 Circulatory Disease Cancer Liver Respiratory Other 2 Cancer Other Circulatory Disease Liver Respiratory 3 Circulatory Disease Cancer Respiratory Liver Other 4 Cancer Circulatory Disease Other Respiratory Liver Which do you think is the correct column? (high to low)

Trainers’ Workshop Cancer: why all the interest? Causes of death <75 1 Circulatory Disease Cancer Liver Respiratory Other 2 Cancer Other Circulatory Disease Liver Respiratory 3 Circulatory Disease Cancer Respiratory Liver Other 4 Cancer Circulatory Disease Other Respiratory Liver

Trainers’ Workshop Cancer: why all the interest? (last accessed )

Trainers’ Workshop Cancer: why all the interest? 37% (last accessed )

Trainers’ Workshop Cancer: why all the interest? (last accessed )

Trainers’ Workshop Cancer – why is it important? The Future:

Trainers’ Workshop Cancer – why is it important?

Trainers’ Workshop The perfect storm:

Trainers’ Workshop The Scale of the Challenge:
The perfect storm…

The perfect storm… Aging population

Trainers’ Workshop Aging Population

Trainers’ Workshop Aging Population - Centenarians
2013 2062 X Male 2,242 50,000 22.3 Female 12,328 80,000 6.5 TOTAL 14,750 130,000 8.8 last accessed last accessed

The perfect storm… Aging population Lifestyles less healthy: Smoking Diet Alcohol Exercise Sun exposure

The perfect storm… Aging population Lifestyles less healthy: Smoking Diet Alcohol Exercise Sun exposure Increasing survival

Trainers’ Workshop The perfect storm:
Numbers of cancers 2013 2030 % increase UK 352,000 424,789 20.7% Global 14.1 million 23.6 million 67.4%

By the end of 2016, there were 1,000 people in the UK being diagnosed with cancer every day Mistry, M., et al., Cancer incidence in the United Kingdom: projections to the year Br J Cancer, : p

Trainers’ Workshop Cancer: why all the interest? 1 in 2 people will be diagnosed with one or more cancers in their lifetime

Lifetime risk of cancer:
Trainers’ Workshop Lifetime risk of cancer:

Trainers’ Workshop Cancer: why all the interest? 1 in 2 people will be diagnosed with one or more cancers in their lifetime 10 year survival has improved to reach 50%

Trainers’ Workshop Cancer: why all the interest? 1 in 2 people will be diagnosed with one or more cancers in their lifetime 10 year survival has improved to reach 50% – last accessed

Trainers’ Workshop Cancer: why all the interest? 1 in 2 people will be diagnosed with one 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

Trainers’ Workshop Hasn’t cancer had its turn?

Hasn’t cancer had its turn?
Trainers’ Workshop Hasn’t cancer had its turn? Cancer receives what proportion of NHS spend? 2.4% 5.4% 8.4% 11.4% 14.4% Discuss with your neighbour….

Trainers’ Workshop Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000,000

Trainers’ Workshop Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000,000 Total NHS spend in 2012/3: £2008 per head

Trainers’ Workshop Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000,000 Total NHS spend in 2012/3: £2008 per head Total NHS spend cancer care: £109 per head

Trainers’ Workshop Hasn’t cancer had its turn? Total NHS spend in 2012/3: £125,700,000,000 Total NHS spend in 2012/3: £2008 per head Total NHS spend cancer care: £109 per head Just 5.4% of NHS spend last accessed

Trainers’ Workshop Hasn’t cancer had its turn? Cancer receives what proportion of NHS spend? 2.4% 5.4% 8.4% 11.4% 14.4%

Trainers’ Workshop Why is early diagnosis important?

Why is early diagnosis important?
Trainers’ Workshop Why is early diagnosis important? (last accessed )

Trainers’ Workshop Why is early diagnosis important? All Cancers (last accessed )

Trainers’ Workshop Why is early diagnosis important? All Cancers Stage Shift (last accessed )

Trainers’ Workshop Minimum increased 5 year survival with 10% increase in stages 1 & 2 Colorectal 4.00% Ovary Breast 3.80% Endometrium 3.70% Prostate 2.40% Melanoma 2.30% Lung 2.00% Kidney Bladder 1.30% NHL 0.20% (last accessed )

Trainers’ Workshop Why is early diagnosis important? Cost

Trainers’ Workshop Why is early diagnosis important? ↓72.8% ↓62.7% ↓64.9% ↓38.9%

Trainers’ Workshop How have we done?

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

Trainers’ Workshop How have we done? Avoidable deaths pa if survival in England matched the best in Europe Breast ~ Myeloma 250 Colorectal ~ Endometrial 250 Lung ~ Leukaemia 240 Oesophagogastric Brain Kidney ~ Melanoma 190 Ovary ~ Cervix NHL/HD Oral/Larynx 170 Bladder Pancreas

Trainers’ Workshop Research stream Primary Care Engagement
How have we done? Research stream Primary Care Engagement Input to Cancer Network and SCNs RCGP Education Events etc

Trainers’ Workshop How have we done?

(last accessed )

Trainers’ Workshop Emergency Presentations of Cancer

(last accessed )

Trainers’ Workshop How have we done? ↑66.0% ↓1.2% ↑77.8%
(last accessed )

Trainers’ Workshop Variation: NHS Herefordshire CCG, South Worcestershire CCG NHS Redditch and Bromsgrove CCG (last accessed )

Trainers’ Workshop Englandion NHS Newcastle and North East
NHS South Worcestershire NHS Redditch and Bromsgrove (last accessed )

Trainers’ Workshop PHE Press release 16.9.15:
“Cancers are being diagnosed earlier in England” (last accessed )

Trainers’ Workshop However compared to Europe?

Trainers’ Workshop However compared to Europe?

Trainers’ Workshop Why do we lag behind other Health Systems?

Trainers’ Workshop Why do we lag behind other Health Systems?
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 (last accessed )

Trainers’ Workshop Gate openers…

Trainers’ Workshop

Trainers’ Workshop Cancer Strategy 2015-2020 has three core aims:
Save thousands more lives Transform patient experience and quality of life Invest now to save later (last accessed )

1. Save more lives Early Diagnosis

1. Save more lives Early Diagnosis Enhance screening uptake Implement NICE Guidance (NG12) Invest in diagnostic capacity Direct access to diagnostic capacity 28 days to diagnosis (to replace 2WW) Education – Undergraduate, postgraduate, CPD

Save thousands more lives Transform patient experience and quality of life

Save thousands more lives Transform patient experience and quality of life Early diagnosis determines experience throughout whole cancer pathway Mendonca SC, Abel GA, Saunders CL, Wardle J, Lyratzopoulos G. Pre-referral general practitioner consultations and subsequent experience of cancer care: evidence from the English Cancer Patient Experience Survey. European Journal of Cancer Care

Save thousands more lives Transform patient experience and quality of life Invest now to save later

Save thousands more lives Transform patient experience and quality of life Invest now to save later Investing in early diagnosis will save money…

Trainers’ Workshop

Trainers’ Workshop Prevention Tobacco Food Immunisations Exercise
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

Trainers’ Workshop Value in investing in early diagnosis:

Trainers’ Workshop Value in investing in early diagnosis:
Why? To address our lowly cancer outcomes rank How? To lower threshold/readiness to refer with consistency: Right patient, right place, right time When? Now

Trainers’ Workshop How? Bowel Cancer – survival improving:
Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop Importance of bowel screening

Trainers’ Workshop Importance of bowel screening
(accessed )

Screening presentations – hugely better outcomes Should be area of priority

Role of GP Endorsement

Role of GP Endorsement – increases uptake by 8%1 Br J Cancer. 2017 Jun 6;116(12): doi: /bjc Epub 2017 May 18.

Role of GP Endorsement – increases uptake by 8%1 Rolled out by some Screening Hubs

Trainers’ Workshop NG12 - Suspected cancer: recognition and referral

Trainers’ Workshop NG12 - Suspected cancer: recognition and referral
Recommendation 16: We recommend the following to take forward the new NICE guidelines: • NICE should work with organisations such as Cancer Research UK, the Royal College of GPs and Macmillan Cancer Support to disseminate and communicate the new referral guidelines to GP practices as quickly as possible.

Trainers’ Workshop NICE Guidance (NG12) Aim
The aim of the guidelines is to improve cancer diagnosis: The timeliness The quality The consistency Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12) Implementation
“While guidelines assist the practice of healthcare professionals, they do not replace their knowledge and skills.” Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

“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.” Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

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. Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

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 Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12) 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 Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12) 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 minimum referral thresholds for all cancers (PPV 3%) Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12) 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”. Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12) What is new? (Specifics)
Relevance of ↑ Platelet count Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Relevance of ↑ Platelet count Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first Br J Gen Pract 2017; 67 (659): e405-e413.

Relevance of ↑ Platelet count 7.8% of patients (11.6% of males, 6.2% of females) will have a 1 year cancer incidence: Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first Br J Gen Pract 2017; 67 (659): e405-e413.

Relevance of ↑ Platelet count 7.8% of patients (11.6% of males, 6.2% of females) will have a 1 year cancer incidence: If a second blood test shows platelet count to be the same or higher: 18.1% of males and 10.1% of females will have a 1 year cancer incidence Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first Br J Gen Pract 2017; 67 (659): e405-e413.

Relevance of ↑ Platelet count Seen in cancers of: Lung Lower GI Prostate Breast OG Ovarian Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first Br J Gen Pract 2017; 67 (659): e405-e413.

Trainers’ Workshop NICE Guidance (NG12)
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 Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop NICE Guidance (NG12)
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) Start with some background. Cancer strategy for England in July 2015, developed by an Independent Cancer Taskforce (on which RCGP was represented), presents a vision for cancer control in the next five years. These are strategies that lay out a vision and plan for the future: a framework to guide our thinking. But what do these strategies mean in practice? And more specifically what does this mean for primary care? Let’s consider the scale of the challenge first

Trainers’ Workshop Safety netting.

Trainers’ Workshop Safety netting. More in afternoon workshop

Trainers’ Workshop Value in investing in early diagnosis: Results?

Trainers’ Workshop Value in investing in early diagnosis: Results?
Better medicine – earlier diagnosis (not just of cancer) Fewer consultations Better outcomes Less complaints/litigation Less £££

Trainers’ Workshop Key to cancer

Trainers’ Workshop Key to cancer Education

Trainers’ Workshop Key to cancer Education – public
Education – patients Education – profession

Education – patients Education – profession Education – policy makers

Education – patients Education – profession Education – policy makers Education – politicians

Earlier Diagnosis of Cancer
Trainers’ Workshop Earlier Diagnosis of Cancer Cancer: why all the interest? Why is it important? How have we done? How could we do even better?

Trainers’ Workshop Insanity:

Trainers’ Workshop Insanity:
doing the same thing over and over again and expecting different results

Trainers’ Workshop Insanity:
doing the same thing over and over again and expecting different results Albert Einstein

Trainers’ Workshop The ones who are crazy enough to think they can change the world, are the ones who do.

Trainers’ Workshop The ones who are crazy enough to think they can change the world, are the ones who do. Steve Jobs

Trainers’ Workshop Our common goal?

Trainers’ Workshop One person can make a difference,
and everyone should try.

Trainers’ Workshop One person can make a difference,
and everyone should try. John F Kennedy

Trainers’ Workshop Thank you

Trainers’ Workshop Any questions?

Hereford and Worcester Sub Regional Trainers’ Workshop

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