1. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research William Hamilton, Professor of primary care diagnostics, Peninsula College of Medicine and Dentistry The Hamilton risk assessment tools – what are they and how can we use them?

2. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research The problem The UK has a relatively poor track record when compared with other European countries. In part this is due to late diagnosis, with an estimated 7,500+ lives lost annually Later diagnosis can be due to late presentation, non-recognition of cancer as a possibility by us GPs, or delays in secondary care (or a mixture of these).

3. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research The problem: colon This is one of the four commonest cancers, and possibly the one with most to benefit from improvements in diagnosis. Half of patients never have a NICE-qualifying symptom Only a quarter are diagnosed via 2-week rule clinics A quarter present as emergencies Earlier diagnosis may give a stage shift or prevent some of the emergencies

4. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research The problem: lung This is the commonest cause of cancer death in the UK. Mortality is high, as very few are diagnosed at an operable stage. There is an easy test – the chest X-ray - but no screening test. Almost all present to GPs with symptoms.

5. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research The problem: we GPs do a good job as gatekeepers We are justifiably proud of UK general practice The gatekeeper role has brought many benefits to patients, not least by ensuring the correct specialist is seen It has also brought disadvantages, arising from GPs’ desire to use resources appropriately. In cancer this means not investigating the low-risk symptom – and NICE tells us not to.

6. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research How do we select patients for cancer investigation? Some is from hands-on experience Some from ‘gut feeling’ Some from advice – like NICE Some from patient pressure Some from reading up research

7. School for Primary Care Research Increasing the evidence base for primary care practice The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research. School for Primary Care Research The research behind this programme We found all the cancers in an area in Devon, and generated five controls for each Identified all symptoms reported to GPs before diagnosis Identified which symptoms were relevant Estimated the ‘risk’ of cancer for each symptom in a patient attending their GP

8. Colorectal Constipation Diarrhoea Rectal bleeding Loss of Weight Abdominal pain Abdominal tenderness Abnormal rectal exam Haemoglobin 10-13g/dl Haemoglobin < 10 g/dl 0.40.92.41.21.1 1.50.972.3 PPV as a single symptom 0.81.12.43.01.51.72.61.22.6 Constipation 1.53.43.11.92.4112.22.9 Diarrhoea 6.84.73.14.58.53.63.2 Rectal bleeding 1.43.46.47.41.34.7 Loss of Weight 3.01.43.32.26.9 Abdominal pain 1.75.82.7>10 Abdominal tenderness

9. Anaemia in men

10. Anaemia in women

11. Lung Cancer Assessment Tool for Non –Smokers Male  Female  Cough Fatigue Dyspnoea Chest pain Loss of weight Loss of appetite Thrombocytosis Abnormal spirometry Haemoptysis 0.4 0.70.81.10.91.6 2.4PPV alone 0.6 0.8 1.81.62.01.22.0Cough 0.560.90.81.01.21.84.03.3Fatigue 0.91.22.0 2.34.9Dyspnoea 0.91.8 2.01.45.0Chest pain 1.22.36.11.59.2Loss of weight 1.70.92.7>10Loss of appetite 3.6>10Thrombocytosis >10Abn. spirometry 17Haemoptysis

12. The effect of smoking

13. B Lung Cancer Assessment Tool for Smokers Male  Female  Cough Fatigue Dyspnoea Chest pain Loss of weight Loss of appetite Thrombocytosis Abnormal spirometry Haemoptysis 0.90.81.21.32.11.84.24.04.5 PPV alone 1.31.01.40.92.32.86.53.63.9 Cough 1.21.41.32.02.32.4>106.1 Fatigue 1.52.23.15.52.4>106.9 Dyspnoea 1.44.47.6>10 4.1 Chest pain 1.75.0>10 Loss of weight 2.7 Loss of appetite 12Haemoptysis