1. Upper Gastrointestinal Cancer
Dr Rosemary Phillips
Lead for Upper GI Cancer
Princess Alexandra Hospital NHS Trust
Harlow

2. Aims Epidemiology Presentation – Cancer Type Presentation – Symptoms
Discussion Points
Conclusion

3. Epidemiology

6. Age-Standardised One-, Five- and Ten-Year Net Survival, Selected Cancers, Adults (Aged 15-99), England and Wales,
Breast is for female only. Laryngeal is for male only.
Five- and ten-year survival for is predicted using an excess hazard statistical model.
Survival for bowel cancer is a weighted average derived from data for colon (C18) and rectum cancer (C19-C20, C21.8)
Source: cruk.org/cancerstats
You are welcome to reuse this Cancer Research UK statistics content for your own work. Credit us as authors by referencing Cancer Research UK as the primary source.
Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].

7. Time to presentation for Upper GI cancer

8. PAH –CWT Upper GI Referrals

9. PAH – cancers via CWT or other route?

10. Alarm Symptoms
Dysphagia
Weight loss (unintentional)
Anaemia (IDA)
Vomiting – persistent
Bleeding
Abdominal mass
Obstructive jaundice (especially painless)
But when upper GI cancers present with alarm symptoms……..it is usually too late

11. Common Upper GI symptoms
Dyspepsia
Heartburn
Upper abdominal pain
Wind
Nausea
But non-alarm upper GI symptoms are very common………..so who do you refer?

13. NICE – lowered symptom cut off
'risk threshold‘:
“whereby if the risk of symptoms being caused by cancer is above a certain level then action (investigation or referral) is warranted”
The positive predictive value (PPV) was used to determine the threshold:
Was 5%
Now 3% - hence some new ‘alarm’ symptoms included

14. PRESENTATION – Cancer Type

15. OESOPHAGEAL CANCER

16. New NICE Oesophageal Cancer Referral Criteria
1.2.1 Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2weeks) to assess for oesophageal cancer in people:
with dysphagia or
aged 55 and over with weight loss and any of the following:
upper abdominal pain
reflux
dyspepsia [new 2015]
1.2.2 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with hematemesis [new 2015]

17. New NICE Oesophageal Cancer Referral Criteria cont
1.2.3 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following:
nausea
vomiting
weight loss
reflux
dyspepsia
upper abdominal pain, or
nausea or vomiting with any of the following:
upper abdominal pain.[new 2015]

18. Dysphagia cases 55yr female, overweight 70 yr man Weight loss 1 stone
Couple of episodes of mild feeling of dysphagia with bread/meat
70 yr man
Weight loss 1 stone
Having to chop food small/ mince to get down
Occasional vomiting

20. STOMACH CANCER

21. New NICE Stomach Cancer Referral Criteria
1.2.6 Consider a suspected cancer pathway referral (for an appointment within 2weeks) for people with an upper abdominal mass consistent with stomach cancer.[new 2015]
1.2.7 Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2weeks) to assess for stomach cancer in people:
with dysphagia or
aged 55 and over with weight loss and any of the following:
upper abdominal pain
reflux
dyspepsia.[new 2015]
1.2.8 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with hematemesis.[new 2015]

22. New NICE Stomach Cancer Referral Criteria cont
1.2.9 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following:
nausea
vomiting
weight loss
reflux
dyspepsia
upper abdominal pain, or
nausea or vomiting with any of the following:
upper abdominal pain.[new 2015]

23. Dyspepsia cases 55 yr old man 60 yr old man
Recent NSAIDs for sports injury, then dyspepsia
60 yr old man
Heavy smoker
Dyspepsia for 6 months unresponsive to o/c ranitidine
Lost 4kg in weight

25. Nausea and vomiting cases
55 yr old female
2 month of nausea in the mornings
Relieved by eating breakfast
No alarm symptoms
50 yr old woman
Vomiting daily after most meals
Reduced appetite and ½ stone weight loss

27. Iron Deficiency Anaemia
Important to remember:
There can be co-existant upper and lower GI pathologies
PLEASE check ferritin before commencing iron
NICE now says ‘low haemoglobin’……..does not have to be IDA for upper GI cancers

28. IDA cases 45yr female, IDA 55 yr old man not vegetarian Heavy periods
no GI symptoms
55 yr old man not vegetarian
Tired
Hb 9.0 IDA or non-IDA picture

30. PANCREATIC CANCER

31. New NICE Pancreatic Cancer Referral Criteria
1.2.4 Refer people using a suspected cancer pathway referral(for an appointment within 2weeks) for pancreatic cancer if they are aged 40 and over and have jaundice.[new 2015]
1.2.5 Consider an urgent direct access CT scan (to be performed within 2weeks), 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]

32. Jaundice cases 50 yr old obese female 45 yr old man
Recurrent RUQ pain with eating
Presents with acute jaundice and RUQ pain
45 yr old man
Gradual onset jaundice
Loss of appetite
Back discomfort

34. Abdominal pain cases 50 yr male 60yr old man
Dyspepsia since holiday with alcohol
Nausea
Improving with ranitidine
60yr old man
Vague upper abdominal pain
Loss of appetite
Half a stone weight loss
Diabetes diagnosed 6 months ago

36. LIVER CANCER

37. New NICE Liver Cancer Referral Criteria
Consider an urgent direct access ultrasound scan (to be performed within 2weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver.[new 2015]

38. GALLBLADDER CANCER

39. New NICE Gallbladder Cancer Referral Criteria
Consider an urgent direct access ultrasound scan (to be performed within 2weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder.[new 2015]

40. PRESENTATION – Symptom

41. NICE: Recommendations organised by symptom and findings of primary care investigations

42. DISCUSSION POINTS

43. What if ‘CWT DTT’ is negative
NICE
“ Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this”
Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be:
planned within a time frame agreed with the person or
patient-initiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist or worsen.[new 2015]
Patient
Wants shortest possible time to diagnosis whether cancer or not

44. What if ‘CWT DTT’ is negative
GP wants……..
Specialist wants………

45. Impact on services GP consultations GP tests Endoscopy Radiology
……..??

47. Any questions ????

48. Conclusion

49. Upper GI cancers - high incidence and poor outcome
Alarm symptoms often mean its too late
……However upper GI symptoms are very common and most won’t have cancer

50. When to refer…
If cancer really suspected then CWT/FT/2WW (use new NICE criteria)
If concern just as urgent …….patients still don’t have to wait long <6 weeks
All of us are happy to discuss on the phone……..we have a gastro consultant of the week (GOW)

51. REFERENCES
ads/Product/CS_REPORT_TOP10INCMORT.pdf
Achieving World-class Cancer Outcomes A Strategy For England
professional/cancer-statistics/survival/common- cancers-compared#heading-Zero
Suspected cancer: recognition and referral. NICE guideline Published: 22 June nice.org.uk/guidance/ng12