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Early Diagnosis and Prognostic Indicator
Dr Richard Roope
RCGP & CRUK Clinical Lead for Cancer
CRUK Senior Clinical Advisor
November 10th 2015
GP Refresher Week
Early Diagnosis and Prognostic Indicator
Dr Richard Roope
RCGP & CRUK Clinical Lead for Cancer
Cancer Research UK Senior Clinical Advisor
Cancer – why all the interest?
Cancer – why all the interest?
Loss of life years <75
1.
2.
3.
4.
5.
1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents
2
1.
2.
3.
4.
5.
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents
1.
2.
3.
4.
5.
3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal
4
1.
2.
3.
4.
5.
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal
Cancer – why all the interest?
Loss of life years <75
1.
2.
3.
4.
5.
1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents
2
1.
2.
3.
4.
5.
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents
1.
2.
3.
4.
5.
3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal
4
1.
2.
3.
4.
5.
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal
Which do you think is the correct column?
(high to low)
Cancer – why all the interest?
Loss of life years <75
1.
2.
3.
4.
5.
1
Circulatory Disease
Cancer
Gastrointestinal
Mental Health
Accidents
2
1.
2.
3.
4.
5.
Cancer
Circulatory Disease
Mental Health
Gastrointestinal
Accidents
1.
2.
3.
4.
5.
3
Circulatory Disease
Cancer
Mental Health
Accidents
Gastrointestinal
4
1.
2.
3.
4.
5.
Cancer
Mental Health
Circulatory Disease
Accidents
Gastrointestinal
Cancer – why all the interest?
Cancer – why all the interest?
Cancer – why all the interest?
•1 in 2 people will be diagnosed with one or more cancers in their lifetime
Cancer – why all the interest?
• Lifetime risk of cancer
http://www.cancerresearchuk.org/cancer-info/cancerstats/incidence/risk/
Cancer – why all the interest?
•1 in 2 people will be diagnosed with on or more cancers in their lifetime
•10 year survival has improved to reach 50%
Cancer – why all the interest?
•1 in 2 people will be diagnosed with on or more cancers in their lifetime
•10 year survival has improved to reach 50%
www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined#heading-One – last accessed 10.10.15
Cancer – why all the interest?
•1 in 2 people will be diagnosed with on or more cancers in their lifetime
•10 year survival has improved to reach 50%, but…
•Cancer survival in the UK still lags behind comparable health economies
Cancer – why all the interest?
•Hasn’t cancer had its turn?
Cancer – why all the interest?
•Hasn’t cancer had its turn?
Cancer receives what proportion of NHS spend?
1. 2.4%
2. 5.4%
3. 8.4%
4. 11.4%
5. 14.4%
Cancer – why all the interest?
•Hasn’t cancer had its turn?
•Total NHS spend in 2012/3:
£125,700,000
Cancer – why all the interest?
•Hasn’t cancer had its turn?
•Total NHS spend in 2012/3:
£125,700,000
•Total NHS spend in 2012/3:
£2008 per head
Cancer – why all the interest?
•Hasn’t cancer had its turn?
•Total NHS spend in 2012/3:
£125,700,000
•Total NHS spend in 2012/3:
£2008 per head
•Total NHS spend on cancer care:
£109 per head
Cancer – why all the interest?
•Hasn’t cancer had its turn?
•Total NHS spend in 2012/3:
£125,700,000
•Total NHS spend in 2012/3:
£2008 per head
•Total NHS spend on cancer care:
£109 per head
• Just 5.4% of NHS spend
http://www.nuffieldtrust.org.uk/nhs-numbers-0
Cancer – why is early diagnosis important?
Cancer – why is early diagnosis important?
Breast Cancer – 5 year relative survival 2002-6
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancertype/breast-cancer/survival#heading-Two (last accessed 25.10.15)
Cancer – why is early diagnosis important?
Cancer – why is early diagnosis important?
Lung Cancer - 5 year relative survival 2003-6
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-bycancer-type/lung-cancer/survival#heading-Three (last accessed 25.10.15)
Cancer – why is early diagnosis important?
Cancer – why is early diagnosis important?
Prostate Cancer - 5 year relative survival 2002-6
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-bycancer-type/prostate-cancer/survival#heading-Three (last accessed 25.10.15)
Cancer – why is early diagnosis important?
Cancer – why is early diagnosis important?
Bowel Cancer - 5 year relative survival 2002-6
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-bycancer-type/bowel-cancer/survival#heading-Three (last accessed 25.10.15)
Cancer – why is early diagnosis important?
Cancer – Current situation
All Cancers
www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancerscombined#heading-Two (last accessed 25.10.15)
Cancer – Current situation
All Cancers
Stage Shift
Cancer – Earlier stage of diagnosis
Increase in numbers diagnosed at stage 1 & 2
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
388160/fourth_annual_report.pdf (last accessed 25.10.15)
Cancer – Earlier stage of diagnosis
• Minimum increased 5 year survival with 10% increase in stages 1 & 2
Breast
Prostate
Colorectal
Lung
Bladder
Kidney
Ovary
Endometrium
NHL
Melanoma
3.8%
2.4%
4.0%
2.0%
1.3%
2.0%
4.0%
3.7%
0.2%
2.3%
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
388160/fourth_annual_report.pdf (last accessed 25.10.15)
Cancer – where were we?
Cancer – where have we come from?
January 2011 - Improving Outcomes: A Strategy for Cancer
Cancer – where were we?
• Avoidable deaths pa if survival in England matched
the best in Europe
•
•
•
•
•
•
•
•
Breast
~2000
Colorectal
~1700
Lung
~1300
Oesophagogastric 950
Kidney
~ 700
Ovary
~ 500
NHL/HD
370
Bladder
290
Myeloma
Endometrial
Leukaemia
Brain
Melanoma
Cervix
Oral/Larynx
Pancreas
250
250
240
225
190
180
170
75
Cancer – what did we do?
Cancer – what did we do?
Cancer – what did we do?
•
•
•
•
Research stream
Primary Care Engagement
Input to Cancer Network and SCNs
RCGP Education Events
– etc
Cancer – How did we do?
Cancer – How did we do?
• How did we do it?
Cancer – How did we do?
Cancer – How did we do?
Cancer – How did we do?
Variation
Dorset CCG:
Cancer 1 year survival
72
70
68
66
64
England
62
Dorset
60
58
56
54
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
http://lci.cancertoolkit.co.uk/Survival
Cancer – How did we do?
Smoothed maps of the one-year survival index (%) for all cancers
combined by CCG: England, 1996 and 2011, patients ages 15-99 years
1996
Ambition
Dorset
England
2011
Cancer – How did we do?
PHE Press release 16.9.15:
“Cancers are being diagnosed earlier in England”
https://www.gov.uk/government/news/cancers-are-being-diagnosed-earlier-in-england
(last accessed 25.10.15)
Cancer – How did we do?
However compared to Europe?
Cancer – How did we do?
However compared to Europe?
http://scienceblog.cancerresearchuk.org/2015/0
8/05/cancer-survival-in-england-is-improvingbut-still-lagging-behind-similar-countries/
Cancer – How did we do?
However compared to Europe?
Cancer – why are we different in UK?
Cancer – why are we different in UK?
• Why do we lag behind other Health Systems?
Cancer – why are we different in UK?
• International Cancer Benchmarking Partnership
Cancer – why are we different in UK?
• International Cancer Benchmarking Partnership
• As gatekeepers – the gate needs to be wider
• Outcomes closely linked to “readiness to act”
• Patients fear wasting GP time
Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and
the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer
survival? British Journal of Cancer (2013) 108, 292–300. doi:10.1038/bjc.2012.542
Cancer – Where from here?
Cancer – Where from here?
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives
2. Transform patient experience and quality of life
3. Invest now to save later
www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (last accessed 25.10.15)
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
• Over 40% of cancers are preventable
Under 75 mortality rate for cancer considered preventable
www.phoutcomes.info/public-health-outcomesframework#page/8/gid/1000044/pat/6/par/E12000008/ati/101/are/E0600003
6/iid/40502/ (last accessed 25.10.15)
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
Ambition:
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
Ambition:
• Fall in age-standardised incidence
• Adult smoking rates to fall to 13% (currently 18.8%)
Cancer – Where from here?
Smoking Prevalence
40%
% cigarette smokers (3 month moving average)
35%
30%
25%
All
20%
A-C1
C2-E
15%
10%
5%
0%
Jan 16 Jan 17 Jan 18 Jan 19 Jan 20
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
• Drive a national ambition to achieve earlier diagnosis,
and with it stage shift
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
• Drive a national ambition to achieve earlier diagnosis,
and with it stage shift
Ambition:
• Increase 5ys and 10ys – with 57% surviving 10+ years
• Increase 1ys to 75% with reduction of variation
Cancer – Where from here?
Smoothed maps of the one-year survival index (%) for all cancers
combined by CCG: England, 1996 and 2011, patients ages 15-99 years
1996
Ambition
Dorset
England
2011
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
• Drive a national ambition to achieve earlier diagnosis,
and with it stage shift
• “If the taskforce recommendations are implemented
30,000 cancer deaths a year could be saved by
2020, of these 11,000 will be through early diagnosis”
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives:
• Spearhead a radical upgrade in prevention
• Drive a national ambition to achieve earlier diagnosis,
and with it stage shift
• “If the taskforce recommendations are implemented
30,000 cancer deaths a year could be saved by
2020, of these 11,000 will be through early diagnosis”
Cancer Strategy – Recommendations
• Early Diagnosis
• Implement NICE Guidance (NG12)
• Invest in diagnostic capacity
• Direct access to diagnostic capacity
• Enhance screening uptake
• 28 days to diagnosis (to replace 2WW)
• Education – Undergraduate, postgraduate, CPD
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives
2. Transform patient experience and quality of life
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives
2. Transform patient experience and quality of life
• Patient experience to be given as high a
priority as clinical effectiveness and safety
• Transform approach to support those living
with and beyond cancer
• Continuous improvement in patient
experience, with reduction in variation
• Continuous improvement in long-term
quality of life
Cancer – Where from here?
• Cancer Strategy 2015-2020 has three core aims:
1. Save thousands more lives
2. Transform patient experience and quality of life
3. Invest now to save later
Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
End of life
Follow-up
Basic palliation
Late effects
Specialised
Rehabilitation
Social
Health promotion Bereavement
Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
End of life
Follow-up
Basic palliation
Late effects
Specialised
Rehabilitation
Social
Health promotion Bereavement
Primary Care has a part to play
throughout the cancer pathway, and is
well placed to do so…
Cancer Strategy – now what?
Prevention
Tobacco
Obesity
Immunisations
Activity
Environment
Early detection
Awareness
Health care seeking
Screening
Access
Diagnosis
Investigations
Access
Technology
Decision support
Treatment
Surgery
Chemotherapy
Radiotherapy
Comorbidity
Psychology
Survivorship
End of life
Follow-up
Basic palliation
Late effects
Specialised
Rehabilitation
Social
Health promotion Bereavement
Primary Care has a part to play
throughout the cancer pathway, and is
well placed to do so…
if adequately resourced…
Cancer Strategy – now what?
The Lancet Oncology:
“The expanding role of Primary Care in Cancer Control”
“For a long time, the role of primary care in cancer was
largely seen a peripheral, but as prevention, diagnosis,
survivorship, and end-of-life care assume greater
importance in cancer policy, the defining characteristics of
primary care become more important”
The Lancet Oncology, Vol. 16, No. 12
Cancer Strategy – now what?
The Lancet Oncology:
“The expanding role of Primary Care in Cancer Control”
“The strengths of primary care—its continuous, coordinated,
and comprehensive care for individuals and families—are
particularly evident in prevention and diagnosis, in shared
follow-up and survivorship care, and in end-of-life care. ”
The Lancet Oncology, Vol. 16, No. 12
NICE Guidance
Suspected cancer: recognition and referral
NICE guidelines [NG12] – June 2015
NICE Guidance
Aim
The aim of the guidelines is to improve cancer diagnosis:
• The timeliness
• The quality
• The consistency
NICE Guidance
Implementation
“While guidelines assist the practice of
healthcare professionals, they do not
replace their knowledge and skills.”
NICE Guidance
Implementation
“For all clinical scenarios it is assumed that the
health professional will have a discussion with the
patient about the risks and benefits of intervention,
enabling the patient to exercise a fully informed
decision.”
NICE Guidance
Implementation
The guideline focuses on those areas of clinical practice:
•
•
•
•
That are known to be controversial or uncertain
Where there is identifiable practice variation
Where there is lack of high quality evidence
Where NICE guidelines are likely to have the most
impact.
NICE Guidance
Implementation
It is assumed that:
• an appropriate history and physical examination are
undertaken
• urinalysis is undertaken where appropriate
• simple blood tests (Fbc, biochemistry and inflammatory
markers) are done
NICE Guidance
What is new?
• This is the first guidance that uses primary care
evidence, which is available for the first time
• Adds symptom pathways for the first time
• Uses the same referral thresholds for all cancers
NICE Guidance
What is new?
• This is the first guidance that uses primary care
evidence, which is available for the first time
• Adds symptom pathways for the first time
• Uses the same referral thresholds for all cancers
(PPV 3%)
NICE Guidance
What is new? (General)
• Many – being symptom centred and using 3% PPV,
the ages vary (range 30-60)
• Some criteria have been dropped (no evidence to
support them)
• Timeline specifics have gone – replaced with
“recurrent” or “persistent”.
NICE Guidance
What is new? (Specifics)
• Relevance of ↑ Platelet count
NICE Guidance
What is new? (Specifics)
• Relevance of ↑ Platelet count
Up to 10% of patients with a raised platelet count will have cancer:
Seen in cancers of:
 Lung
 Upper GI
 Endometrial
 Ovarian
 Breast
NICE Guidance
What is new? (Specifics - examples)
• 2ww lung - Haemoptysis only in 40+
• Mesothelioma now covered
• Lower GI – high risk groups (eg ulcerative colitis) not
mentioned.
• 2ww breast: unexplained axillary lump
• Haematuria and ↑platelets →gynae ultrasound
• Dermatoscopy suggestive of melanoma → 2ww
dermatology
NICE Guidance
What is new? (Specifics - examples)
• Persistent bone pain, unexplained fracture: do Fbc + ESR
• 60+ with hypercalcaemia/↓wbc: electrophoresis and BJP
within 48h
• Palpable abdominal mass <16 (used to be under 1y)
NICE Guidance
• Implementation will take a while
NICE Guidance
• Electronic Clinical Decision Support tools
• 2 week referral forms will change
• Commissioners and Trusts: engage with new
pathways
• Guidance from RCGP to follow
NICE Guidance
Summary:
• Why? To address our lowly cancer outcomes rank
• How? To lower threshold/readiness to refer with
consistency
• When? Gradual roll out over next few months
NICE Guidance
Summary:
• Results?
NICE Guidance
Summary:
• Results?
• Better medicine – earlier diagnosis (not just of cancer)
• Fewer consultations
• Better outcomes
• Less complaints
• Less £££
NICE Guidance
Summary:
• Results?
• Earlier Diagnosis
Early diagnosis
• We have done amazingly, rising to the challenge of 2011
Early diagnosis
• We have done amazingly, rising to the challenge of 2011
• We can do even better, individually
Early diagnosis
• We have done amazingly, rising to the challenge of 2011
• We can do even better, individually
• As a wider health community we could do so much more
…if resourced properly:
We need to spend money now…
to save money (and misery) later
Early diagnosis
Early diagnosis
Thank you
Early diagnosis
Any questions?