1. Early Cancer Diagnosis in Primary Care: The evolving evidence Thomas Round GP XX Place Tower Hamlets Academic Clinical Fellow KCL thomasround@nhs.netthomasround@nhs.net / thomas.round@kcl.ac.ukthomas.round@kcl.ac.uk

2. Presented by 2 Or “Spotting the needle in the haystack” Thomas Round

3. Presented by

4. The UK Cancer Context More than 331,000 people were diagnosed with cancer in 2011 in the UK (CRUK 2014) Overall cancer incidence rates in the UK have increased by more than a third since the mid-1970s By 2030 the incidence is expected to rise by 45% (Mistry 2011). By 2020 almost 1 in 2 will get cancer in their lifetime (Macmillan 2013). Cancer causes more than one in four of all deaths (159,000) in the UK Half of people diagnosed with cancer now survive for at least 10 years Cancer survival rates in the UK have doubled in the last 40 years (CRUK 2014)

5. Presented by

6. The UK Cancer Context UK cancer survival rates are lower than many European countries (De Angelis 2013). 5,000-10,000 deaths per annum (within 5 years of diagnosis) might be avoided if survival rates matched the best in Europe (Abdel-Rahman 2009). Parts of the UK have achieved outcomes comparable to the best in Europe (Round 2013). Within the UK, and even London itself, there is a difference in survival rates (CRUK 2011). Late diagnosis is a major contributing factor to poor cancer survival rates in the UK (DoH 2007) It is estimated that about half of the difference in survival is due to ‘late diagnosis’ (Neal 2014)

7. Presented by Colorectal Cancer 1yr RS Lung Cancer 1yr RS Breast Cancer 1yr RSOvarian Cancer 1yr RS ICBP: 1 year relative survival Coleman et al, Lancet 2011

8. Presented by

9. The Tower Hamlets Context 9 Thomas Round Emergency route diagnosis Cancer survival rates Cancer diagnosis and survival rates in Tower Hamlets and Kensington and Chelsea.

10. Presented by The primary care cancer context The diagnosis of cancer in general practice is not straightforward (Hamilton 2004). A GP is likely to see 8 - 9 new cancer cases per year, and possibly 1000s with symptoms potentially of cancer (Richards 2009) Even for the commonest of cancers (eg lung, colorectal, breast) an individual GP is likely to see on average about one new cases per annum. For rarer cancers a GP will see a new case of ovarian cancer once every 5 years and a new case of testicular cancer every 20 years. Patient, doctor and system related factors can all contribute to delayed cancer diagnosis (Hansen 2008). Concerns about cancer diagnostic delay led to urgent suspected cancer referral routes, such as 2 week wait (2ww) in England (DoH 2000). For all urgent suspected cancer referrals (2ww) from GPs 10% will have cancer (PPV).

11. Presented by

12. 12 The Symptom Iceberg (McAteer 2010) Thomas Round

13. Presented by Cancer Policy Initiatives Urgent referral pathways for suspected cancer (2000) NICE guidelines for urgent referral (2005). (Being re-visited due 2015) Cancer Reform Strategy (2007) Identifies early diagnosis as key to improving outcomes National Awareness and Early Diagnosis Initiative (NAEDI) Improving Outcomes: A Strategy for Cancer (Jan 2011) Sets out Government’s ambition to save an additional 5000 lives p.a.

14. Presented by NAEDI (Richards 2009)

15. Presented by Delays in cancer diagnosis (Olesen 2009)

16. Presented by Cancer Diagnosis Pathway and Delays (Walter 2012) 16

17. Presented by Does delay make a difference to outcome? Intuitive answer is ‘yes’ Remarkably difficult to confirm Differences in definitions, measurement of delay, outcome measures Failure to account for differences in aggressiveness Lead time bias Delays of 3-6m for breast cancer result in 7% lower 5-year survival than delays of <3m (Richards Lancet 1999) Diagnostic delays in cancer do matter, but it is hard to quantify their impact on survival or mortality. (Neal BJC 2009)

18. Presented by NAEDI (Richards 2009)

19. Presented by Patient awareness of cancer symptoms (Robb 2009) Using standardised cancer awareness measures (CAMs) Awareness lower in BME groups

20. Presented by International Cancer Benchmarking Partnership (ICBP) (Forbes 2013) Symptom awareness in the UK did not differ from other countries.

21. Presented by International Cancer Benchmarking Partnership (ICBP) (Forbes 2013) The UK had the highest perceived barriers to symptomatic presentation

22. Presented by Cancer awareness campaigns

23. Presented by Increasing public awareness: impact on lung cancer National awareness campaign for symptoms of lung cancer; 6 weeks in 2012 Public awareness of symptoms increased from 41% to 50% Urgent referrals for suspected lung cancer increased by 30% May-June 2011May-June 2012 Cases76398335 Early stage (1 or 2)23.4%26.9% Late stage (3B or 4)62.5%59.6% Surgical resection13.7%16.0% CRUK analysis of LUCADA data 2013

24. Presented by NAEDI (Richards 2009)

25. Presented by Cancer Diagnosis Pathway and Delays (Walter 2012) 25

26. Presented by Lung Cancer: Reported avoidable delays (Rubin/RCGP 2013)

27. Presented by GP consultations prior to referral Comparison of crude (unadjusted) proportion of patients with three or more general practitioner consultations before hospital referral between the NHS Cancer Patient Survey 2010 and the National Audit of Cancer Diagnosis in Primary Care Lyratzopoulos Lancet Oncology 2012 National primary care audit 2009CPES 2010

28. Presented by Box plot for primary care interval by category of number of pre-referral consultations (1, 2, 3, 4 and ‘5+’) for patients with any of 18 cancers (n=13 035). Lyratzopoulos BJC 2013 Promptness of cancer diagnosis Amongst 13 035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman’s r=0.70).

29. Presented by Change in diagnostic intervals 2001/02-2007/08 (Neal 2013) http://www.nature.com/bjc/journal/v110/n3/full/bjc2013791a.html

30. Presented by NAEDI (Richards 2009)

31. Presented by Routes to Diagnosis All cancers in England 2007

32. Presented by Routes to Diagnosis: Comparing different studies NCIN 2012. All cancers in England 2007

33. Presented by Routes to Diagnosis: Survival

34. Presented by The waiting time paradox Torring BJC 2011

35. Presented by 2ww Referrals- variation between practices

36. Presented by Correlation between Conversion rate and Detection Rate (with lines plotting the median detection rate within deciles of conversion rate and the median conversion rate within deciles of detection rate) 2ww referrals: conversion and detection rates (Meechan 2012) Meechan BJGP 2012

37. Presented by NCIN Practice Cancer Profiles

38. Presented by Any potential solutions?

39. Presented by Any potential solutions? Re-establish relational continuity of care: Small GP teams – Relational continuity of care Continuity vs access? Longer consultations – These tend to enable the GP and patient to address the wider patient care agenda and contribute to improved outcomes Current primary care funding crisis makes this ever more difficult Information gathering, dissemination and continuity of information Recognition of the potential for bias/diagnostic error, and strategies to reduce this Information technology and coding (eg reason for encounter) Improved safety netting to patients, included documenting in the notes and ensure patient understanding Audit/feedback Including SEAs and review of cancer profiles

40. Presented by Risk Assessment Tools (Hamilton 2009)

41. Presented by Risk Assessment Tools (Hamilton 2009)

42. Presented by Risk Assessment Tools: Qcancer

43. Presented by Change in referral patterns with Risk Assessment Tools (Ablett-Spence et al. Report to NCAT 2012) Year to March 2010 (CI) (Pre) Year to July 2012 (CI) (Post)Change (CI) 2WW Referral rate (per 100,000) (England) 206.9 (205.8,208.0) 280.3 (279.1,281.6)73.4 (35.5%) RAT 190.5 (187.6,193.4) 283.9 (280.4,287.5) 93.4 (49.1% (46.1, 52.0)) No RAT 203.0 (201.7,204.2) 285.3 (283.8,286.8) 82.3 (40.5% (39.4, 41.7)) Conversion rate (%) (England) 8.6 (8.5,8.7)6.0 (5.9,6.1)-2.6 RAT 8,9 (8.5,9.4)6.1 (5.9,6.4)-2.8 (-3.3, -2.3) No RAT 8.7 (8.5,8.9)6.0 (5.9,6.1)-2.7 (-2.9, -2.5) Detection rate (%) (England) 37.2 (36.7,37.7)40.1 (39.5,40.6)2.8 RAT 38.0 (36.6,39.5)41.9 (40.4,43.5)3.9 (1.7, 6.0) No RAT 37.7 (37.1,38.3)40.1 (39.5,40.7)2.4 (1.5, 3.2) Colorectal Cancer

44. Presented by Any practice intervention 44 Of the 8134 practices in England, 1160 were removed because of small list size (<1000) or significant change in list size between the two periods. 2129 practices (30% of the England total) participated in one or more of four specified NAEDI initiatives – use of Risk Assessment Tools, criterion based audit, significant event analysis, development of practice plans.

45. Presented by Conclusions Early cancer diagnosis is complex Patient, doctor and system factors can all contribute to delay There remains variation in process and outcomes – In the UK – Between comparable countries Use of investigations Gatekeeping and GP/specialist interface Available pathways for assessment Variation in practice and quality of care has improved, but there is more to do Relational continuity of care and information Further work on risk assesssment tools NICE 2ww guidelines (2005) often based on “red flag” symptoms: being revisited – due for publication 2015 Continuing CRUK NAEDI and other related research programmes

46. Early Cancer Diagnosis in Primary Care: The evolving evidence Thomas Round GP XX Place Tower Hamlets Academic Clinical Fellow KCL thomasround@nhs.netthomasround@nhs.net / thomas.round@kcl.ac.ukthomas.round@kcl.ac.uk