Early diagnosis of cancer in primary care: how can we improve and would it matter?

The challenges of early diagnosis of cancer in primary careJon EmeryProfessor of General PracticeUniversity of Western AustraliaDirector of PC4

Early cancer diagnosisI went to see my oncologist in hospital earlier this week and we talked about this and that, and the importance of catching cancer early, which I found a bit annoying as they had not caught my cancer early, but it turned out he was just filling in time and wanted to talk to me about something different.

Onctalk.comCochrane review of Hemoccult screening on colorectal cancer mortality

Symptomatic cancer and early diagnosisRichards et al Lancet 1999Delays from symptoms to diagnosis of 3-6 months associated with 7% worse 5-year survival from breast cancerEffects not due to lead time biasLonger delays associated with more advanced disease

Colorectal cancer diagnostic interval and mortalityTorring et al BJC 2010Waiting list paradoxDiagnostic intervals >5 weeks associated with worsening mortality if alarm symptoms. Similar U-shaped association for lung, melanoma and prostate cancer.

Variations in cancer survivalInternational variations in cancer survivalAustralia, Canada and Sweden better than UK and DenmarkDifferences greatest for 1- year survival

Variations in cancer survivalRural cancer outcomes in Australia worseApproximately 20% worse 5- year survival for common cancersDifferences in treatments received (eg radical prostatectomy Baade 2011)Later stage at presentation (eg colorectal cancer Baade 2011)

Can some of the variations in cancer survival be improved by earlier diagnosis?

Potential approachesImprove uptake of proven screening testsSystematic application of evidence around symptoms as predictors of cancerCommunity symptom awarenessGeneral populationTargeted high risk groupsGeneral practice level interventionsTumour markersDiagnostic aids

Models of diagnostic delay

Walter, Scott, Webster, Emery. JHSRP 2011Models of diagnostic delayFirst symptomFirst contact with the GPReferral to hospitalInitiation of investigation of cancer-related symptomsFirst visit at the hospitalReferral to treatmentTreatment initiationSystem delayDoctor delayPatient delayDelay in primary careDelay in secondary care

F Olesen BJC 2009 12Diagnosing cancer in general practice: how well do symptoms predict cancer?Shapley et al BJGP 201025 studies includedRectal bleeding; change in bowel habit; iron deficiency anaemia; haematuria; malignant DRE; haemoptysis; dysphagia; breast lump; post-menopausal bleeding.

Diagnosing cancer in general practice: how well do symptoms predict cancer?

Hamilton BJC 2005Improving Rural Cancer Outcomes Project

Patients with lung, prostate, breast, colorectal cancer in Goldfields and Great Southern66 patientsInterview patientsSymptom appraisal and help-seekingCalendar landmarking and diagram to aid recallMedical notes auditMixed methods matrix analysis

PerthOur Improving Rural Cancer Outcomes Project is split into two research phases, the Development Phase and the Intervention Phase.We are just wrapping up the first phase of our, where we have recruited 66 patients with lung, prostate, breast and colorectal cancers from the Goldfields and Great Southern regions. so 7 lung, 14 prostate, 24 breast and 21 colorectal patients

In patient interviews we have determined their symptom appraisal process, their experience with the health service, and how their treatment decisions came a about.

We have also conducted medical record audits of their hospital and GP records to determine timing of diagnosis and treatment pathways.

So it is essentially about finding out exactly where and why the problems are occuring so that we can do something about it.15Improving rural cancer outcomes (IRCO) projectSymptom appraisal (days)GP interval (days)MeanMedianIQR [25th, 75th]MeanMedianIQR [25th, 75th]Breast2700, 131331, 40Colorectal13090, 491848748, 139Lung3690, 1036120, 9Prostate3091512, 28334210, 263Significant overall differences between tumour groups for symptom appraisal and GP diagnostic intervals*

* After log transformationSymptom appraisal and patient beliefs Comparison of symptoms against personal models of diseaseAlternative explanations for symptomsCommon misconceptions about cancer symptoms

I mean its like you know a horse ,colic in a horse... it comes on pretty damn quick and ... you know you think well, you know I began to think maybe Ive got a twisted bowel or something.

17Symptom appraisal and patient beliefs Comparison of symptoms against personal models of diseaseAlternative explanations for symptomsCommon misconceptions about cancer symptoms

And when youre walking around in slushy mud and all that your gumboots stick to them and youve got to ... if you keep doing it long enough your hips get that sore you know?

18Symptom appraisal and patient beliefs Comparison of symptoms against personal models of diseaseAlternative explanations for symptomsCommon misconceptions about cancer symptoms

The trouble is with cancer, I think you know it creeps in on you and ... and like theres a bit of blood there but no pain and you think well if thered been some pain there youd have definitely said oh shit theres something wrong here.

19Symptom appraisal & help-seeking in rural AustraliaThe rural Australian character

And the country men are worse than the women, by a long shot. Theyre, you know, bush blokes. You know, Im not going to the doctor. Ill be right, mate.

20Symptom appraisal & help-seeking in rural AustraliaFear in relation to rural machismo

Being a real hero bloke, you know, you dont go to the doctor about that. Im not going there going where they wanna go, nup.

21Symptom appraisal & help-seeking in rural AustraliaStoic response to symptoms

Well, I had a bit of diarrhoea And it just didn't want to seem to go away really Id had it for about three months before I went and seen the doctor I just put up with it thought oh it'll go away soon. then I just got sick of it. Yeah, because I had to - I finished up wearing um [incontinence] pads and things you know.

22Improving rural cancer outcomes projectAccess and Specialist diagnostic interval (days)Total diagnostic interval (days)MeanMedianIQR [25th, 75th]MeanMedianIQR [25th, 75th]Breast226338, 100801510,29Colorectal55200125, 4213473016,60Lung234122, 2031231411,30Prostate99190147, 3463576853,83Overall significant differences between tumour groups in*: access to specialistsspecialist intervalstotal diagnostic interval * After log transformationThe IRCO TrialCommunity level: Community campaign to reduce symptom appraisal and help-seeking intervalsPractice level: to reduce diagnostic interval2 x 2 factorial RandomisedControlled TrialOutcome: total diagnostic interval

And Ill just finish here but the work done in the development phase is informing our intervention phase which consists of a 2 year community intervention campaign starting later this year, targeting symptom awareness and early help-seeking, using a social marketing approach. And this will be run in the Goldfields, Great Southern and Wheatbelt regions.

There is also a Provider level intervention component which will occur in GPs randomised into intervention and control groups in each trial area, and this includes development of GP education resources about positive predictive values of symptom clusters and promoting access to fast track routes to new service models aimed at providing streamlined access to investigations and treatment planning.

So we are in discussions with the department of health for improving access to diagnostic investigations for bowel and prostate cancers specifically for rural patients, which will be implemented in the next few months.

So this is all happening on a strong evidence base that delays do matter particularly shown in the case of breast cancer which is very much a model for us, however noone has investigated delays in the way we are in this study.

And we dont know if the interventions we put in place will make a difference, so we will be evaluating them using a Randomised Control Trial design, and based on our findings will be making recommendations to the policy makers.

So it is certainly a very exciting project to be a part of and were hoping that this is a start to rather than just stating there is a problem, actually getting in there and testing out ways to do something about it.24Approaches to reducing symptom appraisal and help-seeking intervals

Improving rural cancer outcomes project

Tumour markers in general practice?In symptomatic diagnosisUseful: fetoprotein, Bence Jones protein, HCG, PSAUncertain value: Ca125, Ca-19-9, Of no value: CEA, Ca15-3, thyroglobulinLittle research in primary care populations

Sturgeon et al BMJ 2009AFP: testic and germ cell and HCC with USSHCG: germ cell/testic; trophoblastic neoplasia

28The BEST Studies

Immunohistochemistry of trefoil factor 3 (TFF3)BMJ 2010. doi:10.1136/bmj.c4372Sensitivity 90.0%; specificity 93.5% for clinically relevant Barretts oesophagus in primary care populationDiagnostic aidsDermoscopy and sequential digital monitoring (Menzies, Emery et al BJD 2009)Doubled sensitivity for diagnosis of melanoma to 97%63.5% reduction in excision of benign lesionsImportance of monitoring strategy

Diagnostic aidsThe Molemate TrialSiascopy vs 7-point checklist (Best Practice)

Major featuresMinor featuresChange in sizeLargest diameter 7mm+Irregular shapeInflammationIrregular colourOozingChange in sensation

The gatekeeper role and early cancer diagnosisRelative 1-year survivalMedianp-valueGatekeeperYes67.80.004No73.4

Primary care 1st point of callYes66.30.001No73.4Vedsted et al BJGP 2011What is the right balance of gatekeeping for possible cancer?

Emeraldinsight.com

?? Metro only?Acknowledgements IRCO teamDArcy Holman, Vicky Gray, Emma Croager, Terry Slevin, Christobel Saunders, Fiona Walter and othersMolemate TeamFiona Walter, Helen Morris, Toby Prevost, Ann-Louise Kinmonth, Per Hall and othersDiscovery TeamWillie Hamilton, Fiona Walter, Greg Rubin, Richard Neal and othersConsensus working group on early diagnosis of cancerDavid Weller, Greg Rubin, Richard Neal, Fiona Walter, Suzanne Scott, Willie Hamilton, Frede Olesen, Peter Vedsted and others