1. Direct access diagnostics and cancer update
13th Oct 2017

2. Reminder on NICE referral guidelines for suspected cancer
New direct access pathways for diagnostics to support these
Safety-netting template for urgent diagnostic tests
Results of audit of fast-track referrals to Homerton for lung, upper GI and lower GI

3. NICE NG12 2015 Lower thresholds for investigation and referral
Move towards GPs taking ownership of investigation for cancer
Overall across London referrals are rising

6. NG 12 Macmillan summary – put this on your desktop. https://www

7. Main changes
Use of FBC
Raised platelets are part of the referral criteria for lung, oesophageal, gastric and endometrial cancers
Raised WBC is a trigger for investigation for bladder cancer in patients over 60 with non-visible haematuria

8. Urological cancers and haematuria

9. CT chest pathway

11. NICE guidance on Urgent referral
Patients should be referred to a member of the MDT whilst awaiting a CXR in the presence of:
Persistent haemoptysis in smokers/ex-smokers older than 40 years
signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
Stridor
Emergency referral should be considered for patients with superior vena cava obstruction or stridor.

12. Case 1
42 year old lady with chronic cough; frequent “runny nose” but no known allergies. CXR, spirometry – normal.
What would you do next?
Refer for an ENT examination + fibreoptic laryngoscopy
Trial of nasal steroid
PEF diary and inhalers
X-ray (or CT) of sinuses
CT chest

13. Case 2 66 year old man 40 pack years of smoking
Diagnosed COPD: “blue bloater”
Presented with increased dyspnoea
GP noted an abnormality

15. Case 3 49 year old lady Mild cough for 5 weeks Smoker
No previous attendances to surgery in last 2 years
Sent for CXR – “normal appearance”
What would you do?

16. Case 4 38 year old Pakistani lady Cough and haemoptysis for 4 weeks
CXR “bulky left hilum”
Further history obtained in clinic
Never smoked
Recent trip to Pakistan
2 WW referral

17. Case 5 2WW referral: 42 y F; cough for 4 weeks
Started with flu-like illness
Initially green sputum, now settled
Dry cough persists
6 pack-year history
Examination unremarkable

18. What next??

20. “Red Flags” Cough without preceeding infection
Haemoptysis without infection
Mild persistent “smoker’s” cough
Weight loss in a smoker
Anaemia without GI symptoms
Increasing dyspnoea or tiredness in a smoker
Thrombocytosis

21. Information required on referral
DM, Allergies, Asthma, other specific problems
Current medication – lists often not attached with faxed referral, patients do not bring or remember meds
Has the patient been told why they have been referred?
U&E in last 6 months if normal
CXR (external imaging problems)

22. Lung referral tips from the audit

23. Radiation
mSv equivalent dose, takes into account type of radiation and affect on individual tissues
10mSv increased lifetime risk cancer 1 in 2000
Overall lifetime risk invasive cancer 1 in 3 women, 1in 2 men.
Background radiation 2.5 mSv/year
Cornwall radon dose 6.9m Sv/yr
Domestic Pilots 2.2 mSv/yr
7 Hr flight 0.2 m Sv
CXR 0.02
AXR 0.4

24. Grays are absorbed dose 0.1 Gy = 100 m Sv for x-rays

26. CT Doses (mSv) Chest 4.5 Abdomen 5.7 Pelvis 4.4 Abdo and Pelvis 4.4
KUB 1.5
IVU 5.2
Head 1.4
Sinus 0.28
WBCT additional lifetime risk of cancer of 1 in 184 or 99.45% chance of no effect.
X-ray risk.

27. Lower GI

28. Lower GI Abdominal pain has been added as an important symptom
Change in bowel habit no longer specifies to looser or more frequent stool
No cut-off for iron deficiency anaemia (although Hb<120 in men and <110 in women was in the draft guidance)
Please note, in the national guidance, use of FOBT is recommended in certain circumstances – this is not in the London guidance – we are waiting for the FIT test to be available – watch this space!

29. Lower GI audit tips

30. Lower GI audit tips

31. Direct access flexi-sig and colonoscopy
Do remember that we still have access to DAFS and DACS
Flexi sig appropriate for patients with persistent rectal bleeding but no other features of concern
Colonoscopy for low risk but not no risk patients

32. Upper GI This is where direct access comes in!
Change to GPs organising tests rather than proceeding with a fast track referral

33. Oesophageal/gastric

34. New urgent direct access OGD
Available at Homerton
Please make sure that you have the correct forms in use in your practices

35. Upper GI algorithm

36. Upper GI audit results

38. Pancreatic cancer

39. CT CAP pathway

40. Fast track referrals good practice
Safety-netting of all referrals
Practices already do this very well
Safety-netting of all referrals for urgent investigations
New template available

41. New safety-netting template

45. Fast-track referrals - Patient information
Preparing your patients is crucial when you initiate a fast-track referral
The hospital team cannot hold a referral if the patient is going to be away, so you and the patient need to decide how to proceed
The Homerton aim to offer an appointment within a week of referral, so it is acceptable to hold onto a referral until the patient returns from a trip if they are unwilling to cancel and understand the risk of a delay in diagnosis

46. Ensure that your patient understands that they may be offered a test before their appointment
Ensure that you have up to date bloods, especially UE is they may need a CT
Explain that patients referred to the lower GI service will be contacted by a nurse to discuss a test before their appointment – please ensure they are happy to proceed
Please explain to patients you refer to dermatology that there is now a one-stop clinic service, so their appointment may involve a biopsy the same day

47. New handy patient cards with Homerton cancer office number available to give to patients on referral
New patient leaflet explaining the fast-track referral process available
Be explicit that the patient is being referred on a suspected cancer pathway– patients prefer to be investigated and explaining a cancer pathway DECREASES anxiety rather than provoking it (BJGP 2014)

48. Additional cancer updates
FIT testing for the bowel screening programme
Update on results of the GP contract for bowel screening
Bowelscope

49. FIT test for bowel screening
Coming in next year
Means only need to send one sample
Should be more acceptable and increase uptake

50. Bowel screening GP contract

51. Bowelscope
New screening test for bowel cancer being rolled out nationally
One-off flexible sigmoidoscopy at age 55
No catch-up planned
Started in Hackney this year

52. Bowelscope Rationale Early identification of cancers
Identification of adenomas – removed and surveillance then arranged
2/3 of colorectal cancers are in the sigmoid colon and rectum
NNS to prevent a diagnosis of colorectal cancer is 191
NNS to prevent a death is 489

53. Uptake is likely to be poor
Do please encourage your patients to take up the opportunity

54. Thank you – any questions?