Early Cancer Diagnosis in Primary Care:

The evolving evidenceThomas RoundGP XX Place Tower Hamlets

Academic Clinical Fellow KCLthomasround@nhs.net / thomas.round@kcl.ac.uk

Presented by 2

Or “Spotting the needle in the haystack”

Thomas Round

Presented by

Presented by

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)

Presented by

Presented by

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)

Presented by

1995-99 2000-02 2005-0750

55

60

65

70

75

80

AUS CAN NOR DEN UK

NOR

DEN

UK

AUSCAN

1995-99 2000-02 2005-0790

92

94

96

98

100

AUS CAN SWE NOR DEN UK

SWE

NOR

DEN

UK

AUS

CAN

1995-99 2000-02 2005-0765

70

75

80

85

90

AUS CAN SWE NOR DEN UKAUS

NOR

DEN

UK

CAN

SWE

1995-99 2000-02 2005-0720

25

30

35

40

45SWE

NOR

DEN

UK

AUS

CAN

Colorectal Cancer 1yr RS Lung Cancer 1yr RS

Breast Cancer 1yr RS Ovarian Cancer 1yr RS

ICBP: 1 year relative survival Coleman et al, Lancet 2011

Presented by

Presented by 9

The Tower Hamlets Context

Thomas Round

Emergency route diagnosis Cancer survival rates

Cancer diagnosis and survival rates in Tower Hamlets and Kensington and Chelsea.

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).

Presented by

Presented by 12

The Symptom Iceberg (McAteer 2010)

Thomas Round

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.

Presented by

NAEDI (Richards 2009)

Presented by

Delays in cancer diagnosis(Olesen 2009)

Presented by 16

Cancer Diagnosis Pathway and Delays(Walter 2012)

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)

Presented by

NAEDI (Richards 2009)

Presented by

Patient awareness of cancer symptoms (Robb 2009)

• Using standardised cancer awareness measures (CAMs)

• Awareness lower in BME groups

Presented by

International Cancer Benchmarking Partnership (ICBP) (Forbes 2013)

• Symptom awareness in the UK did not differ from other countries. 

Presented by

International Cancer Benchmarking Partnership (ICBP) (Forbes 2013)

• The UK had the highest perceived barriers to symptomatic presentation

Presented by

Cancer awareness campaigns

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 2011

May-June 2012

Cases 7639 8335Early stage (1 or 2) 23.4% 26.9%Late stage (3B or 4) 62.5% 59.6%Surgical resection 13.7% 16.0%CRUK analysis of LUCADA data 2013

Presented by

NAEDI (Richards 2009)

Presented by

Cancer Diagnosis Pathway and Delays(Walter 2012)

25

Presented by

Lung Cancer: Reported avoidable delays(Rubin/RCGP 2013)

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

010

2030

4050

% M

ultipl

e mye

loma

Panc

reat

ic O

vary

Sto

mac

h Lu

ng Ly

mph

oma

Ren

al C

olore

ctal

Leuk

aem

ia O

esop

hage

al Pr

osta

te B

ladde

r En

dom

etria

l M

elano

ma

Bre

ast

National primary care audit 2009

CPES 2010

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 diagnosisAmongst 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).

Presented by

Change in diagnostic intervals2001/02-2007/08 (Neal 2013)

http://www.nature.com/bjc/journal/v110/n3/full/bjc2013791a.html

Presented by

NAEDI (Richards 2009)

Presented by

Routes to DiagnosisAll cancers in England 2007

Presented by

Routes to Diagnosis: Comparing different studies

NCIN 2012. All cancers in England 2007

Presented by

Routes to Diagnosis: Survival

Presented by

The waiting time paradoxTorring BJC 2011

Presented by

2ww Referrals- variation between practices

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

Presented by

NCIN Practice Cancer Profiles

Presented by

Any potential solutions?

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

Presented by

Risk Assessment Tools (Hamilton 2009)

Presented by

Risk Assessment Tools (Hamilton 2009)

Presented by

Risk Assessment Tools: Qcancer

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

Presented by 44

Any practice interventionOf 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.

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

Early Cancer Diagnosis in Primary Care:

The evolving evidenceThomas RoundGP XX Place Tower Hamlets

Academic Clinical Fellow KCLthomasround@nhs.net / thomas.round@kcl.ac.uk