Download Quantitative Faecal Immunochemical Test (qFIT) pilot study

Colorectal cancer
Quantitative Faecal
Immunochemical
Test (qFIT) pilot study
• If detected early, people have an excellent chance of surviving
colorectal cancer. More than 9 out of 10 people will survive 5 or
more years after an early diagnosis.
• 2nd leading cause
of cancer death
in UK
qFIT is currently being evaluated as a decision tool at different stages of the
colorectal cancer pathway:
Bowel Screening
Programme ‘rule-in’ test
Symptomatic
Asymptomatic
Low risk patients - ongoing NICE consultation
Surveillance
High risk patients - qFIT
• A potential strategy for reducing the time to diagnosis and
therefore first treatment.
• Patients who are referred to a hospital are contacted by a nurse
specialist over the phone, rather than having to attend hospital
for an outpatient appointment before their examination is booked.
The qFIT pilot study, led by the UCLH Cancer Collaborative, is the
largest pilot in the UK and will evaluate whether a cheap qFIT test
could be a reliable ‘rule-out’ test of colorectal cancer in primary care for
patients with suspicious lower abdominal symptoms.
Asymptomatic
Triaged Straightto-Test (tSTT)
• Colorectal (or bowel) cancer is the fourth most common cancer
in the UK, with 40,000 new cases diagnosed each year.
PILOT- ‘rule-out’ test
• 4% of patients
that undergo
colonoscopy have
cancer
Our pilot builds upon growing evidence on the validity of this test for symptomatic
patients - a normal qFIT showing no evidence of blood in a stool sample rules out
the presence of colorectal cancer with over 95% accuracy. If we demonstrate similar
results in London, the qFIT test could help stem the increasing need for endoscopy
resources and will support NICE guidelines for colorectal cancer offering a cheap
and reliable test as a decision tool for colorectal investigation.
• More than 90%
chance of successful
treatment if
diagnosed early
• 93% seen within
14 day wait target
72.8% seen within
62 day wait target
• An average of 10 days reduction in time from referral to first
examination (2ww patients). Biggest beneficiaries will be 18ww
patients who could see 60-80% reduction in waiting times.
• 240,000 urgent
GP referrals for
suspected cancer
• High patient and GP satisfaction and lower ‘did not attend’ (DNA) rates.
• The UCLH Cancer Collaborative is supporting the roll-out of tSTT by
mapping out and addressing constraints, monitoring implementation and
sharing best practice across the sector.
• 44% increase on
current endoscopic
activity in the next
15 years
Patient with lower abdominal
symptoms at GP
Manage the patients in primary care
Urgent referral (2ww)
Consultant triage
Non-urgent referral (18ww)
Nurse Specialist telephone triage
Lower GI investigation
Day 14
Lower GI investigation
Normal/ Benign Condition
Diagnosis
Discharged
Outpatient appt
Normal/ Benign Condition
Pathology found
Discharged
Pathology found
Non-cancer
Cancer
Follow -up appt
Decision to treat
Diagnosis
Discharged
Non-cancer
Cancer
Follow- up appt
Decision to treat
Day 31
Day 62
Treatment
Treatment
Lung cancer
Nearly half of cancers in England are diagnosed at an
advanced stage, when they are harder to treat successfully.
Around one in four of cancers in the UK are diagnosed
through emergency admission to hospital.
Most patients diagnosed in this way have lower chances of
survival compared to other patients.
• 24-50% of patients with intra-abdominal cancer
are often diagnosed after attending emergency
departments with late stage disease.
‘Straight-to-test’ pathway
Day 1
Outpatient appt
Why is
early diagnosis
important?
Multi-disciplinary
Diagnostic
Centre pilot
Traditional pathway
• O
verall in England, just under half of patients are
diagnosed when their cancer is at a late stage.
For lung cancer patients, late diagnosis is worse
with more than 75% of patients being diagnosed
at either stages 3 or 4.
Early and late Cancer Diagn
• As part of the national Accelerate, Coordinate, Evaluate
(ACE) Programme, the UCLH Cancer Collaborative has
piloted two Multi-disciplinary Diagnostic Centres (MDCs).
All cancers
Stage of cancer diagnosed, England 20
• MDCs are designed to offer rapid diagnosis for patients
with so call ‘vague’ symptoms such as abdominal pain and
weight loss that do not point to a specific underlying cancer
type. This route can also be used for those who are too
unwell to wait two weeks for a first appointment.
and late
Cancer
Diagnosis
Early and Early
late Cancer
Early
Diagnosis
and late
Cancer Diagnosis
Stage of cancer
diagnosed,
England
2013 England 2013Early
Stage of cancer diagnosed,
England
Stage
2013of cancer
diagnosed,
• The main achievement of the pilot to date has been the proven
feasibility of MDC implementation with good patient satisfaction
All cancers
All
cancers
and pathway metrics.
All cancers
Early
(stage I+II)
All cancers
Colorectal
Lung
Colorectal
Future
Late Early
(stage(stage
III+IV) I+II)
LateEarly
(stage
III+IV)
(stage
I+II)
Breast
Lung
Colorectal
Late
(stage
BreastIII+IV)
Colorectal
46%
54%
Late
(stage III+IV)
(stage I+II)
Lung
Breast
Lung
Lung
Early
Early
and
and
late
late
Cancer
Cancer
Diagnosis
Diagnosis
46%
54%
46%
54%
54%
84% 16%
84% 16%
84% 16%
• G
reater Manchester Cancer Vanguard Innovation
and 46%
77%
23%
55%
77% 23%
55%
77% Stage
45%
23%
45%
23%
UCLH Cancer Collaborative are intending to launch
Stage
of
cancer
of
cancer
diagnosed,
diagnosed,
England
England
2013
2013
55%
77%
45%
46%
54%
further MDC pilot sites in 2017 alongside the ACE
Malignant Melanoma
Malignant Ovarian
Melanoma
Ovarian
Malignant Melanoma
Ovarian
Programme, to understand:
EarlyEarly
Late Late
55%
77
45%
23%
(stage
(stage
I+II) I+II)
- the importance of clinically led triage in ‘straightening’ the pathway.
(stage
(stage
III+IV)
III+IV)
All cancers
All cancers
Breast
Breast
- the role of diagnostic Clinical Nurse Specialist, and
Colorectal
Lung Lung
Non-Hodgkin Lymphoma
Non-Hodgkin
Lymphoma
91%9%
91%9%
57%
57%
43% Colorectal
- how MDCs can deliver the proposed 28 day pathway.
Non-Hodgkin43%
Lymphoma
91%9%
57%
43%
•
Around 70% of lung cancer patients will survive for at least a year if
diagnosed at the earliest stage compared to around 14% for people
• We believe with scaling MDC we may provide the model for use for other more specific
46% 46%
54% 54%
diagnosed
with the most advanced stage of disease.
two week wait pathways.
Malignant Melanoma
HOW
MDCsCOULD
COULD
IMPROVE
EARLY DIAGNOSIS
CANCER DIAGNOSIS
HOW MDCs
IMPROVE
EARLY CANCER
CURRENT
SYSTEM
1ST GP
VISIT
PROPOSED
MDC SYSTEM
ACCESS
POINT
Patient with
non-specific
but concerning
symptoms
1ST
SPECIALIST
65%
35%
Could be GP or other professional
referral as well as self-referral
eg internet, telephone
TIME
WAITING
TIME
WAITING
3RD
SPECIALIST*
GP REFERRAL
Returning to the GP after
visiting each specialist
slows down the diagnosis
and increases the likelihood
of patient disengagement
Pilot will
determine
the best
configuration
for specialists
*If more
medical
specialists
seen, pattern
continues
until a result
is declared
Nothing found Late Cancer
‘watchful wait’
diagnosis
Other
diagnosis
years (2015). Available at: https://fingertips.phe.
org.uk/profile/cancerservices
Nothing found
‘watchful wait’
3. Department of Communities and Local
Government. Index of Multiple Deprivation
(2015) via Public Health England. Available
at: https://fingertips.phe.org.uk/profile/
cancerservices
Rapid turnaround
of triage tests
and investigative
diagnostic tests
leads to earlier
diagnosis
Earlier Cancer
diagnosis
5. Annual Population Survey via Public Health
England Local Tobacco Control Profiles. Adult
Smoking Rates (2015). Available at: http://www.
tobaccoprofiles.info/
based on the average of 4 quarters’ data
calculated by CRUK covering 2015/16. Available
at: https://www.england.nhs.uk/statistics/
statistical-work-areas/cancer-waiting-times/
UCLH MDC pilot results
2. PHE/NCRAS CancerData. Mortality (annual
average number of deaths 2012-2014). Available
at: https://www.cancerdata.nhs.uk/mortality/
35%
6. Active People Survey via Public Health England
Health Outcomes Framework. Adult Overweight
and Obesity (2012-2014). Available at: http://
www.phoutcomes.info/
7. Quality Health. National Cancer Patient
Experience Survey – CCG Results (2015).
Available at: http://www.ncpes.co.uk/index.php
9. NCIN Cancer Outcome Metrics. Patients
diagnosed with cancer through emergency
presentation as a proportion of patients
diagnosed through all routes (2014/15). Available
at: http://www.ncin.org.uk/cancer_type_and_
topic_specific_work/topic_specific_work/
cancer_outcome_metrics
Were the results of the test explained
to you in a way you could understand?
I did not have an
explanation but
would have
liked one (2)
I should have been
I should have been
seen a bit sooner
seen a bit sooner
(1)
(1)
82.8%
82.8%
I was
seen
soon
I was
seen
as as
soon
as as
I thought
was
necessary
I thought
was
necessary
(24)
(24)
77% 77%
Yes, to
65% 65%
10. These data were compiled by the Cancer
Intelligence Team at CRUK using the latest
data from Public Health England based on the
proportion of cancers diagnosed early (stage
1 and 2) of those where stage of diagnosis is
known (2013-2014). Available at: http://www.
ncin.org.uk/publications/survival_by_stage
11. Spend and Outcomes Framework Tool
2015. CCG Programme Budgeting (2013/14).
Available at: http://www.yhpho.org.uk/default.
aspx?RID=49488
• We also identified a small cohort of patients who, though aware their GP suspected cancer, chose
to delay completing the pathway – 3 patients stopped engaging with the service after initial hospital
appointment; 2 patients chose to delay imaging investigation until after their extended trips abroad.
I should have been
I should have been
seen a lot sooner
seen a lot sooner
(4)
(4)
35% 35%
Other
diagnosis
• 29 of 50 patients were interviewed by phone about their experience with the MDC. Majority (62.1%)
saw their GP once prior to referral.
How
you
feel
about
the
length
How
dodo
you
feel
about
the
length
time
you
had
wait
before
ofof
time
you
had
toto
wait
before
your
first
hospital
appointment?
your
first
hospital
appointment?
55% 55% 23% 23%
RESULT
RESULT
Source:
Edmund Fuller et al. Br4. JPublic
Gen
2016;66:176-177
HealthPract
England. Population
aged over 65
8. NHS England. Cancer Waiting Times. Figures
REFERENCES
1. PHE/NCRAS CancerData. Incidence (annual
average number of cases 2012-2014). Available
at: https://www.cancerdata.nhs.uk/incidence/
45% 45%
65%
• A
significant
number of lung cancers are diagnosed at stage 4 and often during
emergencyMalignant
presentation.
This
represents around 40% of lung cancer diagnoses
inOvarian
Malignant
Melanoma
Melanoma
Ovarian
the UCLH Cancer Collaborative area of north east and north central London and
91%9%
west Essex.
2ND
SPECIALIST
GP REFERRAL
3RD GP
VISIT
35%
Non-Hodgkin
Non-Hodgkin
Lymphoma
Lymphoma
91%9%
91%9%
GP REFERRAL
2ND GP
VISIT
65%
Non-Hodgkin Lymphoma
TRIAGE
TESTS
SPECIALISTS IN
SECONDARY CARE
35%
Ovarian
some extent
(5)
Did not need an explanation (1)
How likely are you to recommend
How
likely are
to recommend
our service
to you
friends
and family?
our service 3.6%
to friends
and family?
Don’t know (1)
nor unlikely (5)
Yes,
completely
(20)
(22)
Likely or extremely
likely to recommend
our service.
3.6% Don’t know (1)
17.9%
Neither likely
17.9%
nor unlikely
Neither
likely (5)
72.4%
78.6%
17.9%
Likely
17.9%
(5)
Likely
(5)
60.7%
Extremely
60.7%
likely
Extremely
(17)
likely
(17)
Lung cancer programme
• The primary objective of the UCLH Cancer Collaborative lung cancer programme
is to identify and implement a model for improving the earlier diagnosis of lung
cancer.
• The programme will target and invite people in the UCLH Cancer Collaborative
area at high risk of lung cancer – asymptomatic people with a smoking history
and aged 55-77 years.
Compassion and
personal care. It’s the
staff. They really care
and it shows.
• Lung health checks will be offered to these people and, based on their risk
profile, a low dose CT scan as well.
I wouldn’t call them
nurses; they’re
guardian angels.
• Around 80% of lung cancer deaths are associated with smoking, therefore brief
advice and referral to smoking cessation services will also be provided to those
with an active smoking status.
The Cancer Vanguard is a partnership between Greater Manchester Cancer Vanguard Innovation, RM Partners and UCLH Cancer Collaborative
65%
43% 43%
4
57