Cancer diagnosis in primary careGuidelines and vague symptoms

Dr Peter Holloway

Primary Care Lead, EoE Cancer Alliance

CRUK GP

By 2028, the proportion of cancers diagnosed at stages 1 and 2 will rise from around half now to three-quarters of cancer patients

o Symptom awareness

o Lower the threshold for GP referral

o Accelerate access to diagnosis and treatment

o Screening –maximise opportunity, personalised and risk stratified, family testing

❖ Modernise the Bowel Cancer Screenng Programme: FIT

❖ Review of screening and diagnostic capacity

❖ Extend lung health checks

NHS LONG TERM PLANAND CANCER 1

❖ GPs to use latest evidence based guidance from NICE. PCNs to improve early diagnosis by 2023/4

❖ Faster diagnosis standard (FDS) by 2020 : diagnosis or cancer excluded by 28days

❖ Overhaul of diagnosis: capital investment, RDCs and non-specific symtoms

❖ Innovation and technology

❖ Living with and beyond cancer

NHS LONG TERM PLANAND CANCER 2

❖ 8-10 new cancers per year (excl non-melanoma skin cancer)

❖ > 100 2 ww referrals per year

❖ Approx 0.5% of consultations will generate a 2WW referral

❖ Primary care is no longer just GPs

❖ Tension with “gatekeeper “role

CANCER AND THE AVERAGE GP

“Hoarseness of the voice for more than three weeks is

carcinoma of the larynx until proven otherwise”

Peter Ellis, Consultant ENT Surgeon, Addenbrooke’s , 1980

❖ 1999: Two week wait system introduced

❖ 2005: NICE guidance CG27

❖ 2011: NICE guidance CG121

❖ 2015: NICE NG12

❖ 2017: FIT in primary care

NICE GUIDANCE (NG12): SUSPECTED CANCER: RECOGNITION AND REFERRAL

The recommendations in this guideline represent the view of NICE, arrived at after careful

consideration of the evidence available. When exercising their judgement, professionals and

practitioners are expected to take this guideline fully into account, alongside the individual

needs, preferences and values of their patients or the people using their service. It is not

mandatory to apply the recommendations, and the guideline does not override the

responsibility to make decisions appropriate to the circumstances of the individual, in

consultation with them and their families and carers or guardian.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of

implementing NICE recommendations wherever possible.

❖ Site of suspected cancer

❖ The symptom

❖ Findings of primary care investigations

NG12

Symptoms in children and young peopleInformation and support for people with suspected cancer and their families and/or carersActive monitoring in primary care of people who have presented with symptoms(safety netting)Best practice in the diagnostic process

❖ Children and young people : specialised guidance but discuss with /c paediatrician

❖ Information and support for people with suspected cancer and their families and/or carers

❖ Safety netting: “Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this. ” False negatives. Review

❖ The diagnostic process

NG12

The diagnostic process

❖ Take part in continuing education, peer review and other activities to improve and maintain clinical consulting, reasoning and diagnostic skills, in order to identify at an early stage people who may have cancer, and to communicate the possibility of cancer to the person. [2005]

❖ Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical. [2005]

❖ Put in place local arrangements to ensure that letters about non-urgent referrals are assessed by the specialist, so that the person can be seen more urgently if necessary. [2005]

❖ Put in place local arrangements to ensure that there is a maximum waiting period for non-urgent referrals, in accordance with national targets and local arrangements. [2005]

❖ Ensure local arrangements are in place to identify people who miss their appointments so that they can be followed up. [2005]

❖ Include all appropriate information in referral correspondence, including whether the referral is urgent or non-urgent. [2005]

❖ Use local referral proformas if these are in use. [2005]

❖ Once the decision to refer has been made, make sure that the referral is made within 1 working day

NG 12: THE DIAGNOSTIC PROCESS

Attitudinal change: Perhaps the greatest challenge will be making these changes work with the grain of the current NHS gatekeeping

model. This will require: giving the public faster and easier access to primary care and/or diagnostic services and encouraging them to

present earlier when they have symptoms; encouraging GPs to lower their thresholds for investigating and referring patients; ensuring that commissioners do not block referrals and that hospital clinicians and

managers welcome, rather than discourage, referrals

Professor Sir Mike Richards Former National Cancer Director, 1999–2013

UNFINISHED BUSINESS: NOV 2018

❖ CRUK facilitators & CRUK Strategic GP

❖ EoE CA/ STP / CCG GP leads. Macmillan GPs

❖ NICE website: /www.nice.org.uk/guidance/ng12;GatewayC: Improving early detection of cancer through e-learning for primary care

o IT : CRUK desk easel/infographic

o Q risk

o Macmillan CDS tool

o C the signs

o PHE fingertips

NG12: HELP WITH IMPLEMENTATION

FINGERTIPS OVERVIEW

PHE CONVERSION RATES

PHE DETECTION RATES

data.healthdatainsight.org.uk

ROUTES TO DIAGNOSIS

HEADLINE DATA 1

HEADLINE DATA 2

CADIAS: GP CONTACT

❖ Most patients had been seen by a GP about their symptoms.

❖ Number of GP visits similar to the national average. Most number of visits was 19, this occurred on 1 occasion.

❖ Seeing more than one GP occurs on almost every occasion. Most number of GPs was 7, this occurred on 4 occasions.

❖ Most patients were sent to A&E by a GP, followed by self referral and from other health care professionals.

❖ There are very few patient concerns regarding access to a GPs.

❖ Vague symptoms: can be only or main presenting symptom

❖ Deep organ cancers often present atypically and do not fit NICE guidelines

❖ Patients may use different terminology and/or underestimate the significance or severity of their symptoms

❖ Fragmented care can lead to diagnostic delay

❖ Normal investigation does not preclude pathology at another site

❖ Safety netting

❖ Failsafe administrative processes

❖ THINK CANCER!

CADIAS : GP LEARNING

EAST OF ENGLAND MDC AIMS & OBJECTIVES

The overall aim us to develop the shortest and safest route to cancer diagnosis particularly with non-specific, vague symptoms.

The key objectives are to:

❖ Set up three MDC Pilot projects with 12 month service delivery across the east of England.

❖ Provide a rapid route to diagnostic tests for patients with non-specific, vague symptoms which are of concern to their GP and do not meet 2 week wait referral criteria.

❖ Define Diagnosis within 28 days of referral

❖ Diagnose more cancers at an earlier stage

❖ Reduce time to treatment from symptom presentation

❖ Diagnose less cancer as an emergency presentation

❖ Improve diagnostic pathways for GPs

❖ Improve Patient experience

MDC PATHWAY

MIDAS EVALUATION 1

❖ Weekly outpatient clinic by GPwsi : 40 GP practices in I&ESCCG

❖ Referral criteria: unexplained weight loss, >40y, no other urgent pathway suitable, GP “gut” feeling

❖ 14 months : 110 patients referred, 98 seen

❖ Presenting complaints: almost all UWL , 1/3 > 3 symptoms

❖ Diagnostics: 1/3 not referred further (patient choice, watch and wait, emergency admission, death)

❖ 49 -> CT, 8->further USS, 7-> endoscopy

❖ One third of patients had abnormal diagnostics

MIDAS EVALUATION 2

❖ Conversion rate : 6.1% overall, >9% those referred for diagnostics

❖ Cancers diagnosed: lung, liver, renal, ovarian and pancreatic (BUT all stage 3 or 4)

❖ Non-cancer diagnosis: 30% (!). Other GI, cardiac, PMR etc

❖ Other 60% : severe or recurrent infection, psychological, unknown

❖ Pathway performance from GP referral : first appointment (4-65 days); diagnostic testing ( 6-129)

❖ Patient experience: 10 out of 10!

❖ Economic evaluation : ??

• The East of England Vague Symptoms Multidisciplinary Diagnostic Centre Project

was a three site pilot and worked with the second wave of the Accelerate,

Coordinate, Evaluate (ACE) national programme in United Kingdom.

• The service was provided at: Mid Essex NHS Trust (Broomfield Hospital,

Chelmsford), Ipswich Hospital NHS Trust (Ipswich Hospital, Ipswich) and East &

North Hertfordshire NHS Trust (Lister Hospital, Stevenage).

INTRODUCTION

METHOD• To provide a rapid route to diagnostic investigations for patients who present to primary

care with non-specific, but concerning symptoms and who do not meet the two week

wait (2WW) referral criteria for cancer in the East of England region.

AIM

• Sixteen types of cancer were diagnosed and the most common was non-

Hodgkin’s lymphoma (15%).

• Non-cancer diagnosis included gastroenterology (48%), respiratory (18%),

genitourinary (5%) and a range of other endocrine, reproductive and

neurological - related pathologies.

• In total, 322 referrals were received across the three sites with more females (58%)

than males referred.

• An average of ten referrals were received per month at Mid Essex, six at East & North

Hertfordshire and seven at Ipswich over the one year pilot.

• Mean age of service users was 69years (range: 23 – 97years)

• Main presenting complaint was unexplained weight loss across the sites with 26% of

the patients at Mid Essex, 22% at East & North Hertfordshire and 30% at Ipswich,

presenting with three or more vague symptoms.

CONCLUSION

MAIN FINDINGS

Table 1: Service uptake and clinical outcomes Figure 2: Pathway performance

Reference1 NHS England. Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020. A report of the Independent Cancer Taskforce. 2015. http://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf. Accessed March 18, 2018.

Arit Udoh1, Jufen Zhang1, Karen Hayden1, Malcolm Lawson2, Elizabeth Towers2, Thida Win3, Peter Holloway4, Tonia Dawson5, Sam Brown5

• This service was evaluated using data obtained from each of the three participating

sites. Patient experience survey, aligned with the National Cancer Patient

Experience Survey (NCPES) of the United Kingdom, was also conducted.

Patient experience survey

1Anglia Ruskin University, 2Mid Essex NHS Trust, 3East & North Hertfordshire NHS Trust, 4Ipswich Hospital NHS Trust, 5East of England Cancer Alliance

• The Mid Essex and East & North Hertfordshire sites achieved first clinic

appointment within 14days for all the patients in the cancer cohort.

• Time to diagnostic investigations and diagnosis was within four weeks for all the

cancer patients seen at Mid Essex and for the majority seen at the East & North

Hertfordshire and Ipswich sites.

• Patients who present to primary care with non-specific (vague) but concerning

symptoms are more likely to be referred on multiple pathways before appropriate

diagnostic cancer investigations are carried out1.

• This results in a delay in cancer diagnosis and timely access to treatment with a

negative impact on patients’ quality of life1.

*Time to diagnosis was not available for the Ipswich site, first clinic appointment also corresponded to scheduled diagnostic

investigations for the Mid Essex site.

• Median rating for patient satisfaction with service was 8, 9 and 10 out of 10 at the Mid

Essex, East & North Hertfordshire and Ipswich sites, respectively.

Table 2: Respondents’ rating of service

Respondents’ Rating

Trust

Mid Essex (n=35)

East & North Hertfordshire

(n=38)

Ipswich (n=20)

Appropriate info. was provided by GP prior to referral, n(%)

26 (74) 21 (55) 10 (50)

Visited GP three or more times with symptoms prior to referral, n(%)

17 (49) 12 (32) 6 (30)

Diagnostic findings was communicated promptly, n(%)

31 (89) 30 (79) 15 (75)

Info. & support received on pathway was good or very good, n(%)

32 (91) 34 (89) 20 (100)

Figure 1: Cancer diagnosis in pathway

Item Composite Trust

Mid Essex East & North Hertfordshire

Ipswich

Referrals, n 322 129 83 110

Referrals seen in pathway, n (%) 285 (89) 110 (85) 77 (93) 98 (89)

Inappropriate referrals, n (%) 22 (7) 4 (3.1) 6 (7) 12(11)

Cancer Diagnosis, n (%) 26 (9.1) 10 (9.1) 10 (13) 6 (6.1)

Non-Cancer Diagnosis, n (%) 92 (32) 27 (25) 35 (45) 30 (31)

AN EVALUATION OF THE EAST OF ENGLAND VAGUE SYMPTOMS MULTIDISCIPLINARY

DIAGNOSTIC CENTRE PILOT PROJECT

Acknowledgements: All participating patients and GPs.

RDC PRINCIPLES

❖ Improve pathway efficiency.

❖ Improve patient experience.

❖ Improve faster and early diagnosis.

❖ Improve unwarranted variation.

❖ Establish a pathway for serious but non-specific symptoms/ vague symptoms.

❖ Not be subject to a 2ww pathway.

❖ Have specific data collation

WHAT AN RDC IS AND ISN'T❖ What an RDC is:

o An offer of a co-ordinated rapid series of tests for patients with serious but non-specific symptoms/ vague symptoms.

o A single point of contact for the patient.

o Holistic diagnosis approach.

o RDC is likely to be the new term used nationally for MDC/vague symptoms pathway.

❖ What RDCs are not:

o A new physical centre.

o A one stop shop.

TitleWhy ACE? Supporting an innovation cycle

Rollout

Other Sources e.g.

EDAG

ACE Innovation Seed-bed (e.g.W1)

• Created ‘bottom-up’

• Varied portfolio of local, small scale innovations

≈Local systems traction; social movement;

≈Ideas that grow for the future ACE Pathfinder

(e.g.W2)• Recruited to a brief

• Cohort of projects trialling one idea

≈Greater scale /coverage

≈Pathfinder for national implementation

Examples of ideas being taken forwards:• Proactive lung approaches• STT with triage, colorectal pathway• Pathways for vague symptoms

• Showcase reports

• Shortlist of innovations

Funnel of ideas for pathfinder

approach

Current scope:• Multidisciplinary

diagnostic centres (MDCs) pilots

• Evaluative reports• Implementation

resources

The objective is to evaluate a range of service innovations so as to accelerate the pace of learning and change (in early diagnosis)

• Facilitates relationships across: primary & secondary care, NHS E, PHE and academics

• Offers independent support for assessing & evaluating innovations

• Is delivered in collaboration with the NHS, CRUK, and Macmillan Cancer Support