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Aligning Research with Clinical Service Delivery Dr Tom Crosby Medical Director Wales Cancer Network November 2016 Will cover.... Cancer Services in Wales Cancer Delivery Plan and Conference Highlights Benefits of research and service working together Research priorities for the Network research community The Good Peer review and National Audit as service quality review systems Radiotherapy developments The Bad (Patchy progress) Acute oncology Primary care ‘oncology’ Cancer Pathway Improvement work Equitable treatment access The Ugly Cancer information systems Regional cancer services planning and commissioning Outcome Indicators and Measures 100% Patient experience 50% 58 31 8 3 1 Good Fair Poor 0 Excellent Very Good Cancer Survival Health Equality for Wales UK Cancer incidence projections to 2035 Smittenaar et al, BJC 2016 How Do We Get Better? Better treatments? Better systems? Cancer Priorities 2014/15 Simplify organisational structure – Primary Care Oncology – SEA, Prehab, Pathway, Awareness campaign, Access to surgery Patient Centred Care – Established Framework for Cancer Lung Cancer Initiative – Single Cancer ‘Network’ Key worker, HNA, Care plans Single Suspected Cancer Pathway – Hidden waits, single pathway, pathway improvement Organisational Structures WG NHS Wales Cancer Implementation Group Wales Cancer Network Wales Cancer Research Community Local and Specialist Commissioning (eg WHSSC) (inc 1000 lives) Framework for Cancer F4C CSGs Lung breast etc COSC SACT LHBs DoPs DoFs CIG Priorities 2015/16 Cancer Diagnostics – Primary Care Oncology – SEA, Prehab, Pathway, Awareness campaign, Access surgery Patient Centred Care – Established Framework for Cancer Lung Cancer Initiative – Diagnostic Centres, Direct primary care access Key worker, HNA, Care plans Single Suspected Cancer Pathway – Hidden waits, single pathway, pathway improvement Refreshed 2016-2020 Key Elements •Early Diagnosis Initiative •Patient Centred Centre Programme •Cancer Information Framework •Cancer Performance Framework •Cancer Research Strategy for Wales Detecting Cancer Earlier Detecting Cancer Early Bowel Screening Home FOB test kit every two years for adults aged 60-74 in England & Wales Adapted technologies may be offered in future 70% 60% 50% 40% 30% 20% 10% 0% Q1 - least deprived Q2 Q3 Q4 Q5 - most deprived Bowel screening uptake by deprivation quintile and gender, 2010-11 Cancer awareness and delay Patient delay in the Symptom awareness in the UK UK 100 % anticipating >2 weeks before help-seeking % correctly recognise symptom 90 100 90 80 70 60 80 70 60 50 50 40 40 30 20 30 20 10 10 0 0 Persistent cough Persistent cough Unexplained bleeding Rectal bleeding Unexplained lump Breast changes Quaife S, Forbes L, Ramirez A, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Brit J Cancer 2014; 110: 12-8. Opportunities Significant Event Audit BMJ Education Advice and Referral support systems Evidence I: countries where GPs are more willing to test have better cancer outcomes Evidence I: countries where GPs are more willing to test have better cancer outcomes PRIFYSGOL BANGOR / BANGOR UNIVERSITY WICKED (Wales Interventions and Cancer Knowledge about Early Diagnosis) Develop and evaluate an intervention for GPs and their teams to achieve: • • • prompter referral of suspected cancer earlier and cost-effective diagnosis of symptomatic cancer improved survival The Danish 3-Legged Model Silkeborg Diagnostic Centre Increase in 1-year relative survival Our Learning Gatekeeper system and downgrading • • Vested et al suggest from their research that there is a correlation between relative one-year survival and the existence of a gatekeeper system. Encourage referrals and low conversion rate Clinical Responsibility and onward referral • Role of Co-ordinator is key for patient pathway management and for point of contact for patient Our Learning (continued…) Use Radiologist to their full potential – In Aarhus, Radiologists are encouraged to act as diagnosticians and refer onwards to the next pathway step as per their clinical judgement The Welsh infrastructure requires investment – Diagnostic workforce and equipment Evidence V: cancer doesn’t stop growing once it produces symptoms Examine what what happens between the diagnostic scan and the staging scan in treatment of ENT cancer. In a SR of 44 studies, the increase in local recurrence was 14% (CI 9-21%) per month gap between scans. So treatment delays can worsen prognosis – and quite quickly. Current performance Jun-13 USC Sep-13 NUSC 75% USC Dec-13 NUSC USC Mar-14 NUSC USC Jun-14 NUSC USC NUSC 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 95% 95% 95% 98% 99% 99% 99% 99% 93% 99% 85% 99% 87% 100% 87% 100% 77% 98% 80% 96% 80% 100% 80% 100% 81% 100% 82% 100% 79% 100% 64% 84% 74% 97% 92% 99% 90% 93% 80% 97% 66% 96% 71% 99% 84% 98% 81% 97% 73% 98% 78% 99% 87% 99% 90% 99% 88% 98% 89% 99% 94% 80% 100% 100% 100% 60% 100% 97% 99% 96% 99% 98% 100% 97% 99% 97% 100% 99% 73% 97% 79% 98% 80% 99% 91% 98% 84% 99% 77% 95% 85% 95% 94% 96% 91% 96% 85% 96% Total number who started treatment (USC Pathway) Area Sep 13 Dec 13 Mar 14 Jun 14 Wales 89 86 97 92 Abertawe Bro Morgannwg 27 29 27 29 Aneurin Bevan 6 5 5 7 Betsi Cadwaladr 28 28 28 22 Cardiff and Vale 12 8 22 17 Cwm Taf 8 7 10 11 Hywel Dda 8 9 5 6 Improving Patient Waiting Times through Velindre Improvement Programme (VIP) Before After Improvement Median wait 26 days 14.5 days 79% Average wait 24.5 days 15.4 days 59% EXAMPLE Lung Cancer Pathway 14 15 CT Bronchoscopy 1 18 17 2 33 14 Agreed Pathway (Days ) Patient No 14 : Last patients 1OPA /RACC 3 15 31 62 Refer to treating Trust Therapist Clinic DTT 1 st Treatment Treatment type 24 24 37 37 Chemo 32 41 42 56 68 Teletherapy 28 27 35 35 49 46 Teletherapy 60 60 81 91 Teletherapy 50 51 69 76 Chemo 27 28 42 49 Chemo 35 64 74 76 Teletherapy CT Guided biopsy 21 PET 23 MDT Discussion 31 Post MDT Clinic 4 S 5 21 18 5 S 13 15 14 6 5 13 18 7 13 38 37 8 2 11 8 17 43 63 72 Chemo 9 14 15 14 21 32 33 41 Chemo 10 6 22 14 23 24 33 38 Chemo Colorectal Cancer 62 Day Pathway Webex 42 54 59 EXAMPLE Lung Cancer Pathway 14 15 CT Bronchoscopy 1 12 14 2 13 25 13 13 Agreed Pathway (Days ) Patient No 14 : Last patients 1OPA /RACC 3 15 31 62 Refer to treating Trust Therapist Clinic DTT 1 st Treatment Treatment type 16 18 26 42 Chemo 30 35 55 65 Teletherapy 20 22 25 30 48 Teletherapy 18 28 30 55 Teletherapy 30 50 55 68 Chemo 21 30 38 50 Chemo 20 24 34 55 Teletherapy CT Guided biopsy 21 PET 27 23 MDT Discussion 31 Post MDT Clinic 4 S 6 8 14 5 S 12 16 19 6 5 13 18 7 12 13 15 8 5 11 14 17 41 53 63 Chemo 9 13 16 18 21 31 34 48 Chemo 10 6 12 14 18 22 30 39 Chemo Colorectal Cancer 62 Day Pathway Webex 19 15 25 Lung Results 4 key questions for patients What are my options? What are the benefits and harms? Do I really need this? What can I do myself? Wales first Six 1. Scans and X-rays aren’t usually needed for straightforward back pain. 2. In advanced incurable cancer, the risks and benefits of chemotherapy need to be considered carefully. 3. For most people with reflux and indigestion, long-term use of Proton Pump Inhibitor (PPI – stomach acid suppressants ) medicines (omeprazole & lansoprazole) is best avoided. 4. In the very frail and the terminally ill, there should be very careful consideration of whether long-term medicines need to be continued. 5. In iron-deficiency anaemia, blood transfusions are usually not needed unless the Haemoglobin level is below 70g/l. 6. Daily blood glucose monitoring is usually not needed for most cases of Type 2 Diabetes. Working Together Benefits of Research-Service Collaboration Service and outcomes better in research rich environment Raise standards of care Introduce service developments earlier and better through detailed protocols and high quality assurance systems Support costs of access to high quality care Supports concept of precision medicine Study of Chemoradiotherapy in Oesophageal Cancer with PET and dose Escalation A randomised Phase II/III trial to study radiotherapy dose escalation in patients with oesophageal cancer treated with definitive chemoradiation with an embedded Phase II trial for patients with a poor early response using positron emission tomography (PET) All cancer trials information in one place? http://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial Refreshed 2016-2020 Key Elements Research •Cancer research strategy for Wales •Increased number and availability of commercial and non commercial studies •Recruitment irrespective of organisational boundaries •Improve participation in research across disciplines through dedicated time •Support targeted consenting of patients tissue for WCB Thank you! Diolch! [email protected]