1. Upper GI 2WW referrals & open access endoscopy Dr Amanda J Hughes

2. Upper GI 2WW referral forms & open access endoscopy Background Upper GI cancer Challenge Case scenarios New 2WW & open access forms Questions

3. Background 1) Increased demand for GI services

5. Increasing referrals but ↓yield 1/4/12 – 31/3/13 Approx 550 referred FT – 46/month 41 cancers ……….represents 25% of total upper GI cancers diagnosed 7.5% yield 1/4/13 – 30/11/14 Approx 1100 referred as FT – 55/month 66 cancers …………represents approximately 30% of total upper GI cancers diagnosed 6% yield 1/1/15- 31/3/15 = 366 referred FT i.e. 122 / month

6. Current open access forms not fit for purpose – “Group A” encompasses 2 WW symptoms – Out of line with NICE guidance Wolverhampton changed their referral process – Clinical Assessment service Straight to test Clinic review Advice to GP………………anecdotally patients referred WMH

7. Consequence: Unable to see all the patients referred / perform endoscopy required within timely basis

8. Oesophago gastric cancers 6% all cancers UK - oesophagus 13 th & stomach 15 th most common cancer 2/3 men 92% occur ≥ 55yrs

9. Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s British Journal Cancer (2013) 108, 25-31

10. Pancreatic Cancer 11 th most common cancer in UK Rare 50% in patients over 75yrs Risk factors: – Smoking ( 1:3) – Diabetes – Chronic pancreatitis – Obesity – Sedentary lifestyle – Genetic ( 1:10) > 50 % jaundice at 1 st presentation

11. Challenge Timely diagnosis & management of cancer patients Avoid overloading system with unnecessary referrals

12. Cases 74 yr female – 3 months dysphagia Food lodges distal oesophagus & regurgitates phlegm – 1 stone weight loss What do you want to do with her ?

13. Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s British Journal Cancer (2013) 108, 25-31

14. Endoscopy Diagnosis – SCC oesophagus

15. 71 yr female – “ New onset dyspepsia” – Previously seen with dyspepsia by Dr Cox, symptoms difficult to control & required Nexium. – Changed to Lansoprazole in community – dyspepsia returned What’s your management plan ?

16. Actual Management – Referred as fast track. - was that appropriate ? – Key symptom reflux – Consultant re-instituted Nexium

17. Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s British Journal Cancer (2013) 108, 25-31

18. 72yr male, smoker – 3/52 history of wt loss, nausea & vomiting – New onset iron deficiency – started on Fe – CXR – COAD How would you manage him ?

19. Actual management Referred to respiratory team as 2WW Respiratory consultant made clinical diagnosis of gastric outflow obstruction

20. Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s British Journal Cancer (2013) 108, 25-31

21. Investigations OGDCT

22. 45yr old female – Persistent dyspepsia – BMI 44 – Referred as fast track – is that truly appropriate ?

23. Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s British Journal Cancer (2013) 108, 25-31

24. 70 yr old – Jaundice – Diabetes diagnosed 1 yr ago – Weight loss – Most common causes in this age group ?

26. 73 yr old male RUQ pain Wt loss USS – multiple liver mets Who do you refer to ?

27. 73 yr old male RUQ pain Wt loss USS – multiple liver mets Who do you refer to ? Depends on history…. Patient known previous colorectal Ca Actually referred via upper GI pathway Most common primary sites for liver mets Colon Stomach Pancreas Breast Lung

28. New forms………. New NICE guidance May 2015 referral for suspected cancer.

30. Fast Track Criteria

32. Open Access Criteria

33. Summary Upper GI cancer – Common – Symptoms including PPV’s for oesophago gastric cancer Challenge – Selecting appropriate patients for onward referral Case scenarios Reviewed new 2WW & open access forms

34. Thank You Any Questions ??