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Routes to Diagnosis of Cancer
in London, 2006 - 2013
Katherine Henson, NCRAS, Presentation for London Public Health
Knowledge and Intelligence Network meeting,18th February 2016
Introduction
•
Routes to diagnosis is a national work stream
•
Categorisation of the route the patient follows to the point of diagnosis
•
Work stream aim: examine demographic, organisational, service and
personal reasons for delayed diagnosis
•
Work stream includes a report of major resections: proportion of patients
who have had surgery to remove a cancer
•
London viewpoint:
• There are unique geographies in London – need to understand the variations
• Interest in patients who received a major resection for their tumour -- examine the
variation in this key cancer treatment depending on their route to diagnosis
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Data sources
Uses routinely collected data sources to work backwards through patient
pathways to examine the sequence of events that led to a cancer diagnosis:
• Hospital Episode Statistics
• Cancer Waiting Times
• Screening data
• Cancer registration data
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Description of each route
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Route
Description
Screen Detected
Detected via the breast, cervical or bowel screening programmes
Two Week Wait
Urgent GP referral with a suspicion of cancer
GP Referral
Routine and urgent referrals where the patient was not referred under the Two
Week Wait referral route
Other Outpatient
An elective route starting with an outpatient appointment: either self-referral,
consultant to consultant, other referral
Inpatient Elective
Where no earlier admission can be found prior to admission from a waiting list,
booked or planned
Emergency Presentation
An emergency route via A&E, emergency GP referral, emergency transfer,
emergency consultant outpatient referral, emergency admission or attendance
Death Certificate Only
No data available from Inpatient or Outpatient HES, CWT or Screening and with
a death certificate only diagnosis flagged by the registry in the NCDR
Unknown
No data available from Inpatient or Outpatient HES, CWT or Screening within set
time parameters or unknown referral
Routes to Diagnosis of Cancer in London, 2006 - 2013
National publications
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Routes to Diagnosis of Cancer in London, 2006 - 2013
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60%
50%
40%
30%
20%
20%
10%
10%
0%
0%
Routes to Diagnosis of Cancer in London, 2006 - 2013
Unknown
70%
Emergency
presentation
70%
Inpatient Elective
80%
Other Outpatient
80%
GP referral
90%
Two Week Wait
90%
Screening
100%
12-month relative survival
100%
All routes
Unknown
Emergency
presentation
Inpatient Elective
Other Outpatient
GP referral
Two Week Wait
Screening
All routes
12-month relative survival
Lung Cancer Relative Survival
Prostate Cancer Relative Survival
60%
50%
40%
30%
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Routes to Diagnosis of Cancer in London, 2006 - 2013
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Routes to Diagnosis of Cancer in London, 2006 - 2013
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Routes to Diagnosis of Cancer in London, 2006 - 2013
London results
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Routes to Diagnosis of Cancer in London, 2006 - 2013
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Routes to diagnosis for all malignant neoplasms (excl. NMSC)
by year, persons, London
35%
30%
25%
20%
15%
10%
5%
0%
2006
12
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Big four cancers
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Routes to diagnosis for lung cancer by year, persons, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2006
14
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Routes to diagnosis for colorectal cancer by year, persons, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2006
15
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Routes to diagnosis for colorectal cancer by year, persons, London
50%
45%
40%
35%
30%
25%
20%
Complete roll-out in London
15%
10%
5%
0%
2006
16
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Routes to diagnosis for breast cancer by year, females, London
60%
50%
40%
30%
20%
10%
0%
2006
17
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Routes to diagnosis for breast cancer by year, females, London
60%
Symptomatic TWW introduced
50%
40%
30%
20%
10%
0%
2006
18
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Routes to diagnosis for prostate cancer by year, males, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2006
19
2007
2008
2009
2010
Routes to Diagnosis of Cancer in London, 2006 - 2013
2011
2012
2013
Variation by demographic factors
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Routes to diagnosis for all malignant neoplasms (excl. NMSC) by year
and age at diagnosis, persons, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Screen
detected
Two Week
Wait
GP referral
Under 50
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Other
Outpatient
50-59
60-69
Routes to Diagnosis of Cancer in London, 2006 - 2013
Inpatient
Elective
70-79
Emergency
presentation
80-84
85+
Death
Certificate
Only
Unknown
Routes to diagnosis for all malignant neoplasms (excl. NMSC) by year
and deprivation status, persons, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Screen
detected
Two Week
Wait
GP referral
Other
Outpatient
1-least deprived
22
2
Routes to Diagnosis of Cancer in London, 2006 - 2013
3
Inpatient
Elective
4
Emergency
presentation
5-most deprived
Death
Certificate
Only
Unknown
Routes to diagnosis for all malignant neoplasms (excl. NMSC) by year
and ethnicity, persons, London
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Screen
detected
Two Week
Wait
Asian
23
GP referral
Black
Chinese
Other
Outpatient
White
Routes to Diagnosis of Cancer in London, 2006 - 2013
Inpatient
Elective
Mixed
Emergency
presentation
Other Ethnicity
Death
Certificate
Only
Unknown
Unknown
Major resections
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Proportion of patients who underwent a major resection for each
route, all malignant neoplasm (excl. NMSC), London, 2006-2013
Percent of patients who underwent a major resection
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Screen
detected
25
Two Week
Wait
GP referral
Other
Outpatient
Routes to Diagnosis of Cancer in London, 2006 - 2013
Inpatient
Elective
Emergency
presentation
Death
Certificate
Only
Unknown
Percent of patients who underwent a major resection
Overview of resection proportions for emergency presentation, TWW
and GP referral routes, London, persons, 2006-2013
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Emergency presentation
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Two Week Wait
GP referral
London emergency presentation
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Emergency presentations for 11 cancer sites by year, persons, London
70%
60%
*
50%
40%
*
30%
20%
10%
*
0%
2006
28
2007
2008
2009
2010
2011
2012
Bladder
Brain
Female breast cancer
Colorectal
Kidney
Lung
Melanoma
Non-Hodgkin lymphoma
Ovary
Prostate
Uterus
Routes to Diagnosis of Cancer in London, 2006 - 2013
2013
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Routes to Diagnosis of Cancer in London, 2006 - 2013
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Routes to Diagnosis of Cancer in London, 2006 - 2013
Conclusion
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Overall trends are similar to the national picture
•
Number of patients diagnosed through the emergency route has decreased
to 23% in 2013, which is in-line with national figures
•
Biliary tract cancer and cancer of unknown primary most commonly
diagnosed through emergency (56%) followed by AML (54%) then brain
cancer (53%) in 2013
•
Proportion diagnosed as TWW has increased:
• 30% diagnosed through TWW and 26% by GP referral in 2013, compared to 18%
and 29%, respectively, in 2006
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•
83% of those diagnosed through screening had a major resection,
compared to 12% through emergency presentation (early vs late stage?)
•
In 11 out of 16 cancer sites, TWW route had the greatest proportion of
patients receiving a major resection
Routes to Diagnosis of Cancer in London, 2006 - 2013
Acknowledgements
Simon Lewry (LKIS for London)
Sam Johnson (NCIN)
Isabella Carneiro (NCIN)
Anna Fry (NCIN)
Thank you!
Any questions?
Peer-reviewed paper in the British Journal of Cancer
Technical document explaining how Routes are calculated
National workbooks of updated data
NCIN-CRUK Major resection report
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Routes to Diagnosis of Cancer in London, 2006 - 2013