Download Cancer: Early Detection

Cancer: early detection or ‘Big C to little c’
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Brief
> Early Detection
> Diagnostic techniques and prevention – less invasive ways of diagnosing
Screening programmes & impact on claims
Geographical factors & impact. Environmental factors
> Claims have requested:
> Screening programmes: we are aware of breast, cervical, bowel, prostate, are there
others planned
> How effective are the programmes (bearing in mind recent publicity re false positives, and
number of people receiving possibly unnecessary treatment) Does more screening =
more claims queries?
> What impact might the following factors have: age, family history, geography?
> UW have requested:
> Prostate cancers - They are aware of recent developments in treatment; including genetic
testing and hormone treatments that aren't covered by the manuals. An update on these
developments would be very useful as would help on establishing stagings
> Family history - A family history of 2 or more family members with cancer is an area not
fully covered by the manuals. Instruction here would be useful as would details of any
familial links that we should know about.
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Improving outcomes: a strategy for cancer
> The late diagnosis of cancer is seen as the key reason for this,
which is why £450 million of the £750 million will be used to
improve early diagnosis.
> This funding will:
> give GPs increased access to, and support in, interpreting key
diagnostic tests
> support GPs in commissioning cancer services
> cover the increase in testing and the treatment costs in secondary
care as more people are diagnosed
> support campaigns that raise awareness of the signs and
symptoms of cancer as well as getting symptomatic patients to see
their GP earlier
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Cancer survival
Despite recent improvements in cancer care, survival rates in
England are still lagging behind other countries
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Why is early diagnosis important?
> 90% of cancers present with symptoms
> Many at an advanced stage
> Principle that earlier diagnosis will mean:
• more diagnosed at earlier stage
• Easier to treat
• Less mortality
• Less morbidity less cost
• ‘lives saved’
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Delays to diagnosis
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Delayed diagnosis of cancer
Thematic review
Data from the first Scottish Primary Care Group report showing the
average number of days delay in cancer diagnosis in primary care. This
shows that patients have symptoms for a significant period of time
before seeking help
and that there can be considerable delay in
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referral, particularly for some tumour typ
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Percentages of cases by stage of selected cancer
sites diagnosed in 2009 in the East of England
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Lead time or increase in life expectancy
Cancer
starts
Detectable by
screening
Symptoms
Death
Time
Survival after diagnosis
from symptoms
Survival after diagnosis from screening
Apparent increase in survival
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Improving early detection
>
>
>
>
Public education re symptoms
Faster referral to hospital
Faster appointment times– 2 week targets
Faster investigation
> Screening
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Screening Principles
>
>
>
>
>
>
>
>
The condition is an important health problem
Its natural history is well understood
It is recognisable at an early stage
Treatment is better at an early stage
A suitable test exists
An acceptable test exists
Adequate facilities exist to cope with abnormalities detected
Screening is done at repeated intervals when the onset is
insidious
> The chance of harm is less than the chance of benefit
> The cost is balanced against benefit
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Cancer Screening UK
> Breast
> Colorectal
1988 - Mammography every 3 years from age 47 to
73
1989 - Smears from age 25 every 3 years, from
age 50 every 5 years
2006 - Faecal Occult blood test every 2 years 60-68
> Prostate
No screening in place
> Cervical
> Lung cancer Watch this space!
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Cervical Screening
> 73.6% have been screened in the previous 3.5 years
> 97% were of satisfactory quality.
> 90.8% had a negative result,
> 7.9% had a low grade cell change
> the remaining 1.3% had high grade cell changes.
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Cervical cancer incidence Scotland
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Cervical Screening England
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Time from screening to availability of report (%)
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Relative risk of cervical cancer as a function of
time since last operationally negative smear.
doi:10.1038/sj.bjc.6600974
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Cervical screening turnaround times
50
45
Q1
Q2
Q3
Q4
Average turnaround time (days)
40
35
30
25
20
15
10
5
0
Scotland
(Former)
Argyll &
Clyde*
Ayrshire &
Arran
Fife
Forth Valley
Grampian
Greater
Glasgow*
Highland*
Lanarkshire
Lothian
Tayside
http://www.isdscotland.org/Health-Topics/Cancer/Cervical-Screening/
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Breast Cancer screening
http://femaleimagination.files.wor
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| [date]
dpress.com/2011/02/paulettesedgwick-breast-cancer.jpg
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Breast Cancer Screening Scotland
Standard
Attendance rate (percentage of women
invited)
Appointment
type5
All routine appointments
Routine- Initial screen
(Prevalent) in response to first
Invasive cancer detection rate (per 1000 invitation
women screened)
Routine- Subsequent screen
(Incident) (previous screen
within 5 years)
Routine- Initial screen
(Prevalent) in response to first
Small (<15mm) invasive cancer
invitation
detection rate (per 1000 women
Routine- Subsequent screen
screened)
(Incident) (previous screen
within 5 years)
Routine- Initial screen
(Prevalent) in response to first
Non-invasive cancer detection rate (per invitation
1000 women screened)
Routine- Subsequent screen
(Incident) (previous screen
within 5 years)
Standardised Detection Ratio (SDR)
Routine-All initial screens
(observed invasive cancers detected
(Prevalent) and Subsequent
divided by the number expected given
screen (Incident) (previous
the age distribution of the population)
screen within 5 years)
Routine- Initial screen
(Prevalent) in response to first
Presentation for [client/prospect] | [date]
invitation
Benign biopsy rate (per 1000 women
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screened)
Routine- Subsequent
screen
Age group
Minimum
Standard
Target
Results
2010/11
50-70 years
>= 70%
80%
74.7%*
50-52 years
>= 2.7
>= 3.6
5.8*
53-70 years
>= 3.1
>= 4.2
7.4*
50-52 years
>= 1.5
>= 2.0
3.1*
53-70 years
>= 1.7
>= 2.3
4.1*
50-52 years
>= 0.4
-
1.6*
53-70 years
>= 0.5
-
1.6*
50-70 years
>= 0.85
>= 1.0
1.69*
50-52 years
< 3.6
< 1.8
1.5*
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Breast cancer overdiagnosis
http://jms.rsmjournals.com/content/17/1/25
/F2.large.jpg
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Breast Cancer Mortality Scotland
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http://www.bmj.c
om/highwire/files
tream/423608/fie
ld_highwire_frag
ment_image_l/0.j
pg
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Prostate cancer screening UK
Conclusions
> The harms from prostate cancer screening using PSA are
currently likely to outweigh the benefits.
> In this circumstance screening for prostate cancer cannot be
justified on the current evidence.
> The main reasons are:
> • PSA is a poor test for prostate cancer and a more specific and
sensitive test is needed
> • Currently we are unable to correctly identity those cancers which
will progress and those which are indolent and may be safely
watched.
> • The data relating to incidence prevalence and treatments is poor
and renders planning very difficult.
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Prostate cancer screening - US latest
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Lung Cancer screening Scotland 2012
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> Joe is a 60–year old male who began smoking cigarettes in college at
age 18. While his smoking habits have fluctuated over the years, for
the most part Joe has consistently smoked 20 cigarettes (a pack) a
day for 42 years and continues to do so.
> When Joe reviewed the Male 5-Year Risk Table he needed to identify
how many pack years he had smoked. To do that, Joe followed the
following formula:
> Number of packs smoked per day x Number of years he smoked
1 pack per day x 42 years of smoking (Age 18 to 60)
Total number of pack years = 42
>
Joe’s Current Age 60
Joe’s Pack Years 42
Joe’s Current Status Still smoking
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> In Joe’s case with a 4.3% (4%) risk for his age and smoking
history group a positive result indicated:
> 1 out of 14.3 people who test positive from a CT diagnostic
imaging scan will truly have the presence of lung cancer.
> 1 out of 7 people with positive results from the EarlyCDT™-Lung
test will truly have the presence of lung cancer.
> 1 out of 4.3 people who test positive from both the EarlyCDT™Lung test and a CT scan will truly have the presence of lung
cancer.
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> How Does a Positive for my Risk Group compare to a Low
Risk Group?
> When Joe compared his Risk Group or 4.3% to a lower Risk
Group of 0.2% he clearly understood the difference in PPV
between the two risk groups.
> Low Risk Group of 0.2%
PPV for CT Scan only of 1 in 278.2
PPV for EarlyCDT™-Lung only of 1 in 125.8
PPV for EarlyCDT™-Lung and CT Scan of 1 in 70.3
> Joe’s Risk Group of 4.3%
PPV for CT Scan only of 1 in 14.3
PPV for EarlyCDT™-Lung only of 1 in 7
PPV for EarlyCDT™-Lung and CT Scan of 1 in 4.3
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substitute for such advice. It may not be duplicated or forwarded without the prior consent of the Gen Re.
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