Diagnosing Pancreatic Cancer Challenges and Developments

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1 Diagnosing Pancreatic Cancer Challenges and Developments PCUK 15 TH October 2018 Dr Andrew Millar MDC Clinical Lead UCLH Cancer Alliance Gastroenterologist and Hepatologist North Middlesex University Hospital Royal Free Hospital

2 The Problem of Cancer Diagnosis and Survival in the UK 2

3 BENCHMARKING DATA HIGHLIGHTS A SURVIVAL GAP Although an improving picture, cancer survival in the UK trails behind comparable countries Source: International Cancer Benchmarking Partnership M1-5 year survival, Published 2011 Providing increased impetus amongst professionals in the UK to improve early diagnosis Slide courtesy of Sara Hiom CRUK

4 UK HEALTH SYSTEM IS NOT SET UP FOR EARLY DIAGNOSIS The UK, versus other comparable countries, has: Focus on Alarm Symptoms Less investigation of low risk symptoms Less access to diagnostics and specialists Source: International Cancer Benchmarking Partnership M3 - Survey Published 2015 Amended slide courtesy of Sara Hiom CRUK

5 Background Current cancer pathways are unsustainable and not fit for purpose Key findings of 2ww referrals NICE guidance (NG12) 2ww pathways - 3% cancer conversion Most cancers (>50%) are not diagnosed on 2ww pathway In the last 3 years 2ww referrals have risen by 17% A quarter (25%) diagnosed on routine pathways A fifth (21%) are diagnosed via A&E Source: Collated by Centre for Cancer Outcomes. In strictest confidence for NHS internal use only. CRUK website: 5

6 Early Diagnosis of Pancreatic Cancer The problem (opportunity) of symptoms 6

7 Hard for Patients Symptom appreciation - Hard to be Clear on Cancer when the symptoms are so common (and GP access?) Greater public and healthcare professional awareness of the combinations of subtle and intermittent symptoms, and their evolving nature, is needed to prompt timelier help-seeking and investigation among people with symptoms of pancreatic cancer Mills K et al. BMJ Open 2017;7 7

8 Hard for Doctors The NG12 Symptom Based Infogram 1 Assessing and referring adult cancers. Image from Suspect cancer (part 2- adults) BMJ 2015;350:h3044

9 Why is PDAC so difficult to diagnose in primary care? >30,000,000 consultations for abdominal symptoms per year in the UK Early symptoms non-specific 0.02% are pancreatic cancer GP access to CT scanning No adequate diagnostic biomarkers NG12 / 2WW guidance is better for specific symptoms

10 The Problem of Symptoms in Pancreatic Cancer Non-specific symptoms abdominal pain, weight loss, backache, fatigue, (NSCS) & new NIDDM Symptom Study 93% of patients had relevant symptoms up to 2 years before diagnosis 1 Delay is similar to other cancers with non-specific symptoms also diagnosed late 2 Patients often seen multiple times by GP Av Consequence - Symptomatic PDAC usually stage 3-4 How can we improve this? 1 Keane MG, et al. BMJ Open Dengsø KE et al J Neoplasm. 2017; 5: 2 3 Lacey K et al Med J Aust 2016; 205 (2):

11 Diagnosis of Pancreatic Cancer Symptomatic 95% Symptom Appraisal patient understanding Help-seeking patient attitude, accessibility Diagnostic HCW attitude, availability of tests, referral pathways, waiting times Asymptomatic 5% Screening identification of high risk people Surveillance of identified lesions e.g. IPMN 11

12 Symptomatic Cancer Anderson Model of Patient Delay Walter et al J Health Serv Res Policy Vol 17 No 2 April

13 Benefits of Early Diagnosis Increase survival by increasing resection rates currently 20% operable, 5% 5-year survival If we could detect earlier survival would improve ~30mm - survival 10-20% <20mm - survival 30-60% <10mm survival 75%-100% Reduce emergency presentation worse outcomes Improve Patient Experience - even if survival unchanged Earlier chemotherapy may prolong life or improve QoL Opportunity but detectable disease progresses rapidly Stage T1 progresses to T4 in just over a year 1 1 Yu J et al. Gut 2015;64:

14 Key Points on Diagnosis CT scan before ERCP latter with brushings If no diagnosis FDG-PET / EUS latter with cytology CT or MRI for cysts - refer if jaundice/solid/dilated PD EUS for cysts with aspiration for Cytology and CEA 14

15 Key points on Surveillance Surveillance for pancreatic cancer to people with: Hereditary pancreatitis and a PRSS1 mutation BRCA1, BRCA2, PALB2 or CDKN2A (p16) mutations and one or more first-degree relatives with pancreatic cancer Peutz Jeghers syndrome 2 or more first-degree relatives, across 2 or more generations Lynch syndrome (mismatch repair gene [MLH1, MSH2, MSH6 or PMS2] mutations) and any first-degree relatives Surveillance by MRI / EUS / CT 15

16 Current imaging diagnostic tests CT scan misses 23% of small cancers 1 MRI identifies 80% those not seen at CT 2 FDG-PET best sensitivity (89%) EUS sensitive and allows needle aspiration but limited availability None of these yet widely available in primary care increasing however 1 Wong J.C et al Clin. Gastroenterol. Hepatol. 2008;6: Kim J.H et al Radiology. 2010;257:

17 Biomarkers active research area Reproduced from Zhang X et al Am J Cancer Res 2018;8(3):

18 Multi-Disciplinary Diagnostic Centres 18

19 Symptomatic Cancer Anderson Model of Patient Delay Walter et al J Health Serv Res Policy Vol 17 No 2 April

20 What are MDCs? MDC pathway: avoiding the hospital pinball machine 20

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22 What are MDCs? MDC pathway What is an MDC? Main Diagnostic tests Benefits Future 1. Fast track diagnostic centre/clinic for suspected cancer where existing 2WW pathway is unclear or not suitable 2. MDC runs within a hospital and uses current hospital infrastructure 1. CT 2. Bloods 3. Endoscopy 4. Colonoscopy 5. MRI 6. PET CT 7. ERCP 1.Named CNS contact from time referral is received 2.Fast access to diagnostics 1. If shown to be beneficial will be rolled out nationally 2. Opportunity to support more DIRECT and STRAIGHT TO TEST 22

23 MDCs align with national and local strategy Danish Model more GP access to tests Potential benefits of MDCs Area of benefit Diagnosis within 28 days Rationale Aligns with national strategy? Aligns with NCL strategy? Rapid access to diagnostics Improves patient experience Improve quality and outcomes Improve patient experience Aid treatment within 62 days Reduction in A&E cancer diagnosis Diagnosis through appropriate setting Earlier diagnosis in pathway Will improve survival rates Cancer diagnosis following ED poorer outcome, even when controlling for other factors 1 Better use of hospital resources Patients benefit from CNS support Better access to diagnostic tests and specialist cancer and holistic support Reduction in cost Reduction in number of wasted consultations 1 - Plaser TR et al 2013; Schneider C et al Reduce number of GP visits Reduce incorrect referrals Meets needs of primary care 23

24 THERE ARE 10 MDCS ACROSS ENGLAND Airedale, Wharfdale & Craven MDC site: Airedale General Hospital Greater Manchester MDC sites: Manchester University NHS Foundation Trust (Wythenshawe Hospital) and The Northern Care Alliance (Royal Oldham Hospital) Oxford MDC site: Oxford University Hospital Trust (Specialist Cancer Centre) Leeds MDC site: St James University Hospital (Specialist Cancer Centre) London MDC sites: North Middlesex University Hospital, University College London Hospital (Specialist Cancer Centre), Southend University Hospital, Queens (BHRUT) and the Royal Free Hospital A common dataset agreed across the projects Comparator data for each project area; only partial data and largely retrospective audits National Cancer Diagnosis Audit used to create a proxy comparator pathway for NSCS patient cohort Collection of MDC data is ongoing (expect final cut-off for evaluation to be end July 2018) A national approach allows different NHS settings to be explored and creates a larger MDC referral data set for analysis

25 Project overview North London MDC referral criteria and MDC sites Who to refer Current main indications 1. New unexplained abdominal pain 2. Unexplained weight loss 3. Painless jaundice 4. New and persistent unexplained nausea / loss of appetite 5. GP has concern /gut feeling of an underlying gastrointestinal (GI) cancer Royal Free UCLH North Middlesex Barts Health BHRUT 25

26 Diagnostics Project overview Case study Patient referred in June Referral received Referral triaged by CNS Day Patient seen in MDC Day 3 CT 4 ERCP / bile duct brushing Day 3-5 Upper GI MDT 4 Patient informed of diagnosis Day Imaging sent to RLH for discussion Patient seen by surgeon and informed of care plan Day 9-41 Diagnosed within 28 days: treated in 41 days 7 Surgery 26

27 MDC Performance Data 27

28 NATIONAL FIGURES - CANCER DIAGNOSES BY MDC UNTIL END FEB MDC 2018 Greater Manchester Number of cases Number of cancers Conversion rate Airedale Royal Oldham Wythenshawe Leeds London Queen (BHRUT) North Middlesex Royal Free UCLH Oxford Total 1,

29 Percentage MDC outcomes National figures - Diagnosis of MDC patients Cancer Diagnosis 30 Non-cancer Diagnosis Broad Description N % Diseases of the digestive system Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Diseases of the respiratory system Diseases of the genitourinary system 31 7 Neoplasms (benign) 28 7 Diseases of the musculoskeletal system and connective tissue 20 5 Diseases of the circulatory system 19 5 Certain infectious and parasitic diseases 14 3 Endocrine, nutritional and metabolic diseases 14 3 Mental, Behavioural and Neurodevelopmental disorders 14 3 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Congenital malformations, deformations and chromosomal abnormalities Diseases of the nervous system 4 1 Diseases of the skin and subcutaneous tissue 2 0 Injury, poisoning and certain other consequences of external causes 2 0 Factors influencing health status and contact with health services 2 0 Grand Total

30 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 No of patients North London MDCs April 18- Oct 18 Referral numbers and reason Number of patients referred between April 17 Sept 18 Referral reason Ma Apr y Jun Jul Aug Sep Oct -17 Nov -17 Dec -17 Ma Jan- Feb r Ma Apr y Jun Jul Aug Sep UCLH BHRUT NorthMid Royal Free UCLH NMUH BHRUT RFH Referral numbers in August- September are lower E-referral s has gone live Source: UCLH, North Middlesex, Royal Free and BHRUT data

31 North London MDCs April 18- Oct 18 Diagnosis and cancer conversion rate Cancers Non cancer All Test normal North Mid BHRUT UCLH Royal Free North Mid BHRUT UCLH Royal Free Cancer conversion rate Site Number of referrals Cancer conversion rate Time to cancer diagnosis (mean) UCLH % 36.8 North Mid % 25.5 BHRUT % 36.1 Royal Free % 42.6 Cancer conversion rate at ULCH is currently on 4.95 % this may increase still awaiting outcomes for 2 more patients. Time to cancer diagnosis very good with North Middlesex currently averaging on 25.5 days. All sites need to improve in data entry of outcome status and date communication. Source: UCLH, North Middlesex, Royal Free and BHRUT data

32 North London MDCs April 18- Oct 18 Types of Cancer TOTAL ULCH BHRUT NORTH MID ROYAL FREE Highest number are Pancreatic, Colon and Lung cancer with total of 8 (16%) each Source: UCLH, North Middlesex, Royal Free and BHRUT data

33 North London MDCs Patient Experience Patient experience 80% of patients are extremely likely to recommend the MDC service to family and friends % felt they received their first hospital appointment as soon as was necessary 89.3% felt their test results were explained in a way they could understand 0 Extremely likely Likely Neither likely or unlikely Don t know Not likely 78.6% felt they waited a reasonable amount of time while attending clinics and appointments

34 MDC Challenges and Opportunities Challenges Creating the team clinicians and CNS Trust support - Clinic space and consultant time GP education Integrating into CCG and Trust referral systems Excessive inappropriate referrals conversion rate Currently speeds diagnosis but not improving stage Opportunities Model of care clarified and to be enhanced Strong CCG/GP support 2WW pathway on ERS Pathway for rejected referrals developing Develop A&E pathway Is potential model for FDS London Research Network developing 34

35 So what do we need? Better awareness of the pattern of cancer symptoms Manage population risk obesity, smoking, alcohol (pancreatitis) Faster diagnostic pathways (MDCs) Identify high risk population and screening/surveillance methods Hereditary pancreatic cancer (5-10% of PC) IPMN surveillance all need monitoring New diagnosis of Diabetes 1% > 50 yrs in 3 years 1 Acute pancreatitis % in 2 years 2, 3 Chronic pancreatitis 1 and 4% risk of PD over 1 and 20 yrs 4 Other genetic syndromes Lynch, Peutz-Jeghers Better biomarkers 1 Chari S.T. et al Gastroenterology. 2005;129: Kimura Y. et al. Intern. Med. 2015;54: Munigala S. et al. Clin. Gastroenterol. Hepatol. 2014;12: Lowenfels A.B.et al International Pancreatitis Study Group. N. Engl. J. Med. 1993;328:

36 The Future for Early Diagnosis of Pancreatic Cancer Patient awareness GP training and direct access to tests Blood / Urine biomarkers Rapid diagnostic pathways - MDCs Increase screening and surveillance Thank you