Download Nice suspected cancer referral guidance 2015

INTRODUCTION
•
•
Overview from Public Health (slides provided by Gemma Lyons)
NICE Guidance 2015 (update from 2005)
•
GP direct access testing
•
What to do NOW and in the FUTURE
Stand up if you have read the
NICE Guidance
INCIDENCE
Rate per 100,000 population
Directly standardised incidence rate of all cancers per 100,000
population, all ages, Camden and England, 2008-2013
1,000
Camden
900
England
 It is estimated that
6,000 people living in
Camden have had a
diagnosis of cancer 2015
 On average, 824 people
were diagnosed with
cancer in Camden each
year 2010-2012
800
700
600
500
 The most common
cancers in Camden are
breast, prostate, bowel
and lung cancer.
400
300
200
100
0
2008
2009
2010
2011
2012
Year
Source: the National Cancer Intelligence Network’s Cancer Commissioning Toolkit, 2014
2013
INCIDENCE BY CANCER TYPE
Age-Standardised Incidence rate by cancer type, 2012
250
Camden CCG
England
Rate per 100,000
200
150
100
50
0
Breast
Lower GI
Lung
Cancer type
Source: the National Cancer Intelligence Network’s Cancer Commissioning Toolkit, 2014
Urology
 Significantly lower
incidence of
urological cancer in
Camden than
England, after
adjusting for the
difference in age
between the two
populations.
 The other main
cancer types show no
significant difference
with England.
MORTALITY FROM CANCER IN CAMDEN
Cancer deaths by cancer type, Camden 2011-2013
 354 deaths (178 early deaths
in people aged under 75
years) each year from cancer
in Camden 2011-2013
Breast
27
Bowel
37
Prostate
19
Lung
81
Head
Oesophagus and neck
14
12
Leukaemia
11
Non-Hodgkin’s
lymphoma
11
Ovary
9
Brain
9
Pancreas
18
Other
88
 Cancer is the biggest cause of
death in Camden 2013
Liver
18
 Lung cancer is the biggest
cause of cancer death,
followed by breast and bowel
cancer
MORTALITY BY CANCER TYPE
Age-Standardised mortality rate by cancer type, 2012
100
Camden CCG
England
 Camden has the 12th
lowest all cancer
mortality rate out of
32 London CCGs,
after adjusting for the
differences in age.
Rate per 100,000
80
 Mortality rates for
each of the major
cancer types in
Camden are similar to
the national averages
60
40
– (see overall
comparison on next
slide)
20
0
Breast
Lower GI
Lung
Cancer type
Source: the National Cancer Intelligence Network’s Cancer Commissioning Toolkit, 2014
Urology
MORTALITY FROM ALL CANCER, LONDON CCGS
Rate per 100,000
500
Age-standardised mortality rate from all cancers, by London CCG,
2012
London average
England average
400
300
200
100
Tower Hamlets
Barking and Dagenham
City and Hackney
Hillingdon
Southwark
Islington
Havering
Wandsworth
Greenwich
Merton
Lambeth
Hammersmith and Fulham
Waltham Forest
Sutton
Bexley
Newham
Lewisham
Croydon
Haringey
Hounslow
Camden
Ealing
Richmond
Bromley
Enfield
Westminster
* West London
Redbridge
Brent
Barnet
Kingston
Harrow
0
London CCG
* includes Kensington and Chelsea and Queen's Park and Paddington.
Source: the National Cancer Intelligence Network’s Cancer Commissioning Toolkit, 2014
ONE-YEAR CANCER SURVIVAL RATE, LONDON CCGS
One-year survival rate (%) of all cancers in people aged 15 and
over, by London CCG, 2012
Percentage
100%
England average
80%
60%
40%
20%
Barnet
* West London
Harrow
Westminster
Richmond
Hounslow
Camden
Kingston
Merton
Enfield
Brent
Bromley
Croydon
Sutton
Bexley
Wandsworth
Hammersmith and Fulham
Hillingdon
Lambeth
Haringey
Lewisham
Ealing
Southwark
Islington
Greenwich
City and Hackney
Waltham Forest
Havering
Redbridge
Tower Hamlets
Newham
Barking and Dagenham
0%
London CCG
* includes Kensington and Chelsea and Queen's Park and Paddington.
Source: the National Cancer Intelligence Network’s Cancer Commissioning Toolkit, 2014
CANCER SCREENING - COMPARISON
• Camden breast
screening coverage
declined in 2015 to
be the lowest rate in
London, at 56%
% screening rate
Screening rates in Camden, compared against London and
England, Public Health Outcomes Framework, 2015
100
90
80
70
60
50
40
30
20
10
0
Target
Camden London England Camden London England Camden London England
Cervical
Breast
Bowel
Incidence,
mortality &
survival
•Cancer is the biggest cause of death in Camden
•Camden has the 12th lowest all cancer mortality rate out of
32 London CCGs, after adjusting for the differences in age
•Cancer survival rates are improving in England and Camden
Risk factors
&
prevention
•43% of cancers estimated to be preventable
•Main preventable risk factors are smoking, diet and alcohol
•Deprived residents are more likely to have these risk factors
•Public Health commissions lifestyle services to tackle these
Screening &
early
diagnosis
• Screening rates are lower than London average & below targets
• Breast screening rates have dropped to lowest in London
• National & local campaigns raise awareness of cancer
signs/symptoms
LARGELY THE SAME AS BEFORE (2005)
• Haematological cancer
• Breast cancer
• Skin cancer: Dermoscopy if available to consider moles that don’t
meet criteria for 2ww referral
• Head & neck cancer: minor changes only e.g. community dentists
can do 2WW
MR X – 43 YEARS OLD ♂
Presents to the GP with crampy abdominal pain present for 4 weeks
What would you ask?
MR X – 43 YEARS OLD ♂
Presents to the GP with crampy abdominal pain present for 4 weeks
What would you ask?
1. Urinary symptoms – no
2. Change in bowel habit - no
3. PR bleeding – no
4. Vomiting – no
5. Weight loss – yes 3kg in last month
What would you do?
MR X – 43 YEARS OLD ♂
Presents to the GP with crampy abdominal pain present for ? weeks
What would you ask?
1. Urinary symptoms – no
2. Change in bowel habit - no
3. PR bleeding – no
4. Vomiting – no
5. Weight loss – yes 3kg in last month
What would you do?
2WW (in the past for >40yrs rectal bleeding & looser stool for >3 weeks)
CHANGES TO 2WW REFERRAL CRITERIA (I)
Colorectal cancer suspected, 2WW referral if:
Abdominal pain &
unexplained weight loss
60yr+
Iron deficiency anaemia or
change in bowel habit
40yr+
Unexplained rectal bleeding
50yr+
Turn to the person next to you and discuss which age matches which symptom
CHANGES TO 2WW REFERRAL CRITERIA (I)
Colorectal cancer suspected, 2WW referral if:
Abdominal pain &
unexplained weight loss
40yr+
Unexplained rectal bleeding
50yr+
Iron deficiency anaemia or
change in bowel habit
60yr+
n.b. patients diagnosed at stage 1+2 have 97% chance of
survival compared to 7% of patients with advanced cancer.
For greater detail see:
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#lower-gastrointestinal-tract-cancers
CHANGES TO 2WW REFERRAL CRITERIA (I)
Controversial:
When logistics allow:
Colorectal cancer
suspected, 2WW referral if
FOB positive for blood
if<60yrs & iron deficiency
anaemia or change in
bowel habit
Upper GI cancer
suspected,
direct access 2WW OGD
NOT 2WW referral
http://www.bmj.com/content/351/
bmj.h42560
For more detail:
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#upper-gastrointestinal-tract-cancers
MS A - 46 YEARS OLD♀
7 weeks of IMB
Stopped the POP one year ago
Normal vaginal examination
Would you refer on 2WW?
MS A - 46 YEARS OLD♀
7 weeks of IMB
Stopped the POP one year ago
Normal vaginal examination
Would you refer on 2WW?
NO – IMB has been taken out of 2WW referral criteria
Gynaecological suspected cancer:
2WW referral if Post Menopausal Bleeding (LMP>12mths ago)
CA125 + pelvic USS if ovarian cancer suspected (London advise simultaneously)
Consider pelvic USS if 55yr+ with new unexplained vaginal discharge
For more information:
http://www.nice.org.uk/guidance/NG12/chapter/
1-recommendations#gynaecological-cancers
CHANGES TO 2WW REFERRAL CRITERIA (II)
Suspected bladder cancer:
•
≥45yrs & unexplained (no UTI) visible (macroscopic)
haematuria or visible haematuria that persists or recurs
after treatment of UTI
•
≥60yrs & unexplained non-visible (microscopic) haematuria
& either dysuria or ↑WBC on blood testing
•
Consider non-urgent referral for bladder cancer in people
aged ≥60yrs with recurrent or persistent UTI.
http://www.nice.org.uk/guidance/NG12/chapte
r/1-recommendations#urological-cancers
CHANGES TO 2WW REFERRAL CRITERIA (III)
Suspected Lung Cancer, 2WW referral if:
CXR findings that suggest lung cancer
≥40yr with unexplained haemoptysis
(CXR same day as 2WW referral done)
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#lung-and-pleural-cancers
“the proportion
diagnosed
through the GP
2WW referral
route
increased from
22% (2006) to
28% (2013)”
“in 2006,
25% cancers
diagnosed as
emergency,
in 2013
20%”
GP INVESTIGATIONS (I)
• Gastroscopy within 2 weeks if:
• dysphagia OR aged ≥55yrs weight loss & any of dyspepsia or reflux
• 2WW Abdominal CT scan to detect pancreatic cancer if:
• over ≥60yr weight loss AND any of
• diarrhoea/vomiting/back pain/abdominal pain/nausea/vomiting/new
onset DM
• Consider PSA blood test and rectal examination if:
• lower urinary tract symptoms
• new erectile dysfunction
• visible haematuria
GP INVESTIGATIONS (II)
•
CXR if ≥ 40yrs
+ 1 of cough/fatigue/sob/chest pain/weight loss/appetite loss
if ever smoker, OR
+2 of cough/fatigue/sob/chest pain/weight loss/appetite loss
if never smoker
•
Consider CXR if persistent or recurrent chest infection/clubbing/raised
platelets/supraclavicular lymphadenopathy or persistent cervical
lymphadenopathy/chest signs consistent with lung cancer
GP INVESTIGATIONS (III)
•
USS if suspect soft tissue sarcoma, x-ray if suspect
bone sarcoma
•
MRI brain scan within 2wks (CT scan if MRI
contraindicated)
•
New erectile dysfunction or urinary symptoms offer
PSA
SYMPTOMS
•
Individual symptoms may be from a number of cancers. Remember to look out for
them e.g.
•
Appetite + weight loss - Positive Predictive Value
• 4.3% any cancer
• 2.3% lung cancer
•
DVT – Positive Predictive Value
• 3.49% any cancer
• 0.9% lung cancer
WHAT CAN GPS DO NOW & WHAT IS TO COME?
•
•
•
•
•
•
•
If you suspect cancer, but 2WW criteria NOT entirely met, do still
refer (use London Cancer 2WW form and state reason)
Use CHOOSE & BOOK to get actual appointment when possible
(better patient experience & fewer DNAs)
When no appointments on choose & book, either email form or fax
or defer to provider on choose and book
Ensure patient AVAILABLE for appointments for 2 weeks & AWARE
that is appointment for possible cancer
Some GP direct access tests already available e.g. CXR, US, MRI
Brain (must be within 2WW), PSA, CA125,
TO COME: 2WW gastroscopy, 2WW CT scan abdomen
GPs will need systems for follow-up of diagnostics
CAMDEN SPECIFIC UPDATES
•
•
•
•
•
•
•
•
Multidisciplinary Diagnostic Centre (MDC)
Cancer joining Long-term Conditions Locally Commissioned Service
Community pharmacy campaign
Continued awareness raising amongst community groups
Local media campaign
New primary care facilitator – Christine Harding.
GI audit has been reported on
BMJ OnExamination Camden Specific Cancer modules are only
available for one further year and you have to register before the end
of this November if you want access – email
[email protected] if you have lost your login details.
LIFESTYLE PROGRAMMES FROM 1 APRIL 2016
All joint across Camden & Islington
Smoking Cessation
•One provider to deliver community smoking
cessation across both boroughs
Adult weight
management &
Exercise on Referral
•One provider to deliver weight management & EoR
•Cancer exercise programme incorporated into EoR
NHS Health Checks
•One provider to deliver community-based checks
across both boroughs
Christine Harding
[email protected]
07826537310
Session (code)
Details
Length
Delivery options
Cancer data (GP1)
Overview and discussion of
local cancer data – including
practice level data
30-45mins
- Individual GP
practice meeting
- Cancer practice
profiles emailed to
practice
Cancer decision
support tools (GP2)
New 2WW forms
(GP3)
New NICE
Guidelines for
cancer (GP4)
Safety netting
workshop (GP5)
Introduction to using QCancer
on EMIS
Overview of guidance on new
2WW forms
Summary of new guidance
plus links to useful resources
30-40mins
Individual GP
practice meeting
Individual GP
practice meeting
Individual GP
practice meeting
Winter
2015
2016 tbc
Interactive workshop with
scenarios covering
communication; consultations,
practice systems & coding
1hr
30mins
- Group of practices
- GP training
practice
Now
SEA workshop (GP6)
Interactive workshop including
examples of ‘good’ and ‘bad’
SEAs; completing an SEA;
case study examples; sharing
learning from practice SEAs
1hr
30mins
- Group of practices
- GP training
practice
Now
30mins
30-40mins
Date
available
Now
Now
GI AUDIT
•
Many patients are being seen regularly; this does not support the idea that
access is a major barrier to cancer detection.
•
What is not clear is whether patients present the relevant symptoms or whether
their clinicians are eliciting new & worrying symptoms when they are looking after
a number of other conditions at the same time.
•
What is noticeable from the data about symptoms is that there appear to be a lot
of patients who had no symptoms at all or only had 1-2 symptoms. Clearly this
information is dependent on the detail in the original notes & the quality of the
data recording but does suggest that patient awareness is critical & that
clinicians need to be very alert to any possible suggestion of new symptoms.
GI AUDIT II
•
•
•
•
•
In the patients with upper GI cancers progressive weight loss +/- dysphagia accounted
for 60% of the cases. This accords with a recent audit in the RFH in which weight loss
& dysphagia were the commonest presenting symptoms.
In the lower GI cancers change of bowel habit+/- bleeding from back passage
abdominal pain or constipation accounted for 66% of the cases.
In the majority of cases these symptoms did not appear to have been of long duration
& in most cases once these classic symptoms presented GPs were using 2WW
protocols to refer patients. However the less specific symptoms of upper GI malignancy
seem less likely to make patients attend & the first symptoms were quite late such as
marked weight loss & dysphagia.
Mild anaemia did not always result in a referral & there was no clear protocol for
repeating tests.
Follow-up of mild or vague symptoms was varied. There might be potential for
developing a guideline for the management of patients who are NOT being referred on
a 2WW pathway to ensure that they are followed up consistently& there is a low
threshold for referral if symptoms persist.
SUMMARY
• Updates 2005 guidance
• Based on patient symptoms not risk factors
• Recommendations NOT requirements i.e. all referral forms need
option for referral when cancer suspected outside criteria
• Consider GP direct access to testing
RESOURCES:
Guidelines:
Suspected cancer: Recognition and Referral http://www.nice.org.uk/guidance/ng12
E-learning:
BMJ Learning Quick tips: referral for suspected cancer - your summary of the 2015 NICE guideline (10 mins)
http://learning.bmj.com/learning/module-intro/.html?moduleId=10053492
Pulse learning Key Questions live: NICE cancer guidelines
http://pulse-learning.co.uk/clinical-modules/cancer/kq-live-nice-cancer
Journals:
Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance
http://www.bmj.com/content/350/bmj.h3036
Suspected cancer (part 2—adults): reference tables from updated NICE guidance
http://www.bmj.com/content/350/bmj.h3044
Toolkit:
Macmillan Rapid Referrals Guideline
http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PCCL/Rapidreferralguidelines.pdf
QUESTIONS?
Camden CCG Cancer Clinical Lead:
[email protected]
Public Health and Screening:
[email protected]
0207 527 1324