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Towards Earlier Cancer Diagnosis Hamish Whitaker GP Tutor Guildford Context • 25% deaths in developed world from cancer • Most present to primary care with symptoms, even if a screening test exists • Early symptoms shared with benign disease • Average full time UK GP will have a new cancer diagnosed in one of their patients each month Context • UK cancer mortality record poor compared to other countries • Current estimate 7500-10000 lives lost annually due to late diagnosis • Two week rule and easier access to investigations has made little difference Why the delay? • Patient delay – eg only 41% patients report rectal bleeding to GP • Positive predictive value of colorectal cancer with bleeding is 0.1%- but 2-3% by the time presented to GP (and 5-7% by time get to 2ary care) • Do UK GPs have too high a threshold for selecting patients for referral? • Pressure from PCT and 2ary care not to refer, criticism of inappropriate use of guidelines Breast cancer • 75% breast cancers identified following presentation of symptoms • Screening much less impact • Little evidence to guide referral exists • Breast pain and lumps commonest symptoms • 8% women with breast lump reported to primary care are cancer- but depends on age (0.5% if < 25 yrs) Breast cancer • Breast pain cancer risk 0.9% overall • Younger women higher risk of inflammatory breast cancer • Present with swelling redness and warmth, may appear rapidly and therefore be mistaken for infection • Poor prognosis Lung cancer • Prognosis generally poor – does early diagnosis make a difference? • Usually spread by the time symptoms presented • Only 20% UK patients eligible for surgical resection • Screening little impact – current study on annual cytology and CT in COPD smokers, and spiral CT Lung cancer • Italian spiral CT trial- can detect nodules of 0.5cm (CXR smallest 3cm) • High false positive rate • Encouraging symptom awareness • Study in Doncaster to encourage reporting cough and early CXR increased rate of cancers diagnosed in stage 1 or 2 from 11% to 19% after campaign Lung cancer • 25% lung cancers have normal CXR • But CXR cheap and easy to obtain • Estimate if CXR all smokers over 60 with cough would speed the time to diagnosis by 9 months in 25% of cancer cases • Haemoptysis is relatively uncommon in lung cancer- only 40% report it • Haemoptysis risk is 2.4-7.5% depending on age Lung cancer • Cough , dyspnoea , weight loss, fatigue , chest pain, loss of appetite commoner symptoms than haemoptysis • But even more common in benign conditions- positive predictive value 1% • UK delay in diagnosis 51 days; Sweden 26 days • Low threshold for CXR good strategy Colorectal cancer • Current UK guidelines 6 weeks of bleeding or bleeding with diarrhoea for TWR • Over 60 risk of cancer > 2% for any bleeding so are current guidelines correct? • Iron deficient anaemia- men <11 women <10 – risk of cancer 7.7% and 13.3% respectively • Abdominal pain , constipation and diarrhoea much lower predictive value (<1%) • Problem is colonoscopy more expensive , some risk, uncomfortable Colorectal cancer • CT colonography misses 1 in 10 lesions larger than 1cm – which colonoscopy picks up • Biomarkers may help in future- matrix metalloproteinase-9, free DNA in rectum possibilities for future • Risk scores – CAPER and SELVA- but both lead to too many false positives and excessive interventional investigation Colorectal cancer • GPs often do get it right • “change in bowel habit” means diarrhoea or constipation and reasonable chance of bowel cancer • Has 4% predictive value for cancer in 80yr old , whereas constipation or diarrhoea has 0.7% and 1.2% • Unclear what these soft features are that GP uses to label as change in bowel habit Prostate cancer • Debate re importance of early diagnosis • Screening trials show little benefit to mortality • Treating small cancers gives small mortality gain , but possible complications ; incontinence/ impotence • Treatment of larger cancers or spread less controversial- and these usually cause symptoms Prostate cancer • Suggests definitely appropriate to search for cancer if LUTS • But positive predictive value only 3% for cancer • Impotence can be an early symptom of cancer – rare • Remember PSA in back pain in men Ovarian cancer • Symptoms are common and early- and often missed • Fatigue, bloating, abdominal pain, urinary frequency • Combination of Ca125 and TV ultrasound probably best initial investigation Other cancers • Oesophageal cancer 5.7% risk in men with dysphagia • Urinary tract cancer 7.4% risk in men with haematuria (women 3.4%) • <2% lymphadenopathy presented in 1ary care malignant • Brain tumour risk with headache 0.1% Tumour markers • Over 50% tumour markers requested in primary and secondary care inappropriate – and requests for PSA in women and CA125 in men not unusual! • Key points 1/measuring more than one not helpful (except germ cell HCG and AFP) • 2/ not helpful in non specific symptoms – often raised in benign disease also Tumour markers • Main uses in monitoring cancersresponse to treatment or detecting recurrence • Not helpful in screening asymptomatic individuals • Except AFP for hepatocellular ca in cirrhosis from Hep B or C • Ca125 for ovarian cancer (with TVUS) and PSA debatable Tumour markers • PSA - prostate ; also elevated in BPH , prostatitis , UTI , cycling! PR doesnt raise . Finasteride reduces PSA • C125- ovary . Also raised in endometriosis, menstruation, colitis, laparoscopy, SLE. In conjunction with TVUS. Can be negative despite cancer – refer if suspicious Tumour markers • CEA colon cancer – only useful for monitoring • CA153 breast cancer – monitoring • CA19-9 pancreatic cancer – can aid diagnosis • HCG and AFP germ cell tumours – can aid diagnosis and AFP in hepatocellular ca Tumour markers • Calcitonin ; medullary thyroid cancer- can aid diagnosis • Thyroglobulin ; follicular /papillary thyroid cancer -can aid diagnosis • Paraproteins eg Bence Jones – myeloma; useful in diagnosis • Ref BMJ 2009 ; 339:b3527 Conclusions • GPs may have too high a threshold for investigation • Gatekeeper role may inhibit early diagnosis, and financial pressures may be increasing this • Two week rule does not appear to have made a significant impact on speeding cancer diagnosis