Cancer: NICE (symptom based)- what s new November 2016

Transcription

1 Cancer: NICE (symptom based)- what s new November 2016 Dr Katy Gardner, Dr Cathy Hubbert, Macmillan GP Cancer Leads, Liverpool CCG See stalls for more information and local pathways (Cheshire & Merseyside)

2 COULD IT BE CANCER? Now 3% threshold

3 HISTORY AND EXAM INVESTIGATE REFER REVIEW SAFETY NET

4 SYMPTOMS: NICE recognises that: Patients present with symptoms /signs or combinations: BMJ /CRUK charts

5 Non site specific symptoms of concern: WEIGHT LOSS: many cancers APPETITE LOSS: remember lung and ovary DVT is back! Several cancers include: urogenital, breast, colorectal, lung, pancreas FATIGUE: FBC, Ca125, CXR -(40+ ever smoked/ asbestos)

6 INVESTIGATIONS: some highlights FBC for PLATELETS, WBC, ANAEMIA IRON STUDIES ELECTROPHORESIS and BJP Ca 125 CALCIUM (myeloma) GLUCOSE ( pancreas, endometrial) ULTRASOUND/CT URINE visible/non visible haematuria *Recurrent infection can be significant

7 RAISED PLATELETS: in up to 30% of some cancers: Lung: >40 consider CXR Upper GI: >55 naus/vom/wt loss/ dyspepsia/abd pain: consider OGD Endometrial: >55 haematuria/vag disch: consider US Consider age/other risks

8 Iron Deficiency Anaemia (IDA) New importance in NICE.. No cut-off threshold 60+ IDA: Refer 2ww <50 IDA + rectal bleeding: consider ref to lower GI >55 anaemia +abdo pain: consider OGD (upper GI cancer)

9 Ix for Myeloma Persistent bone pain: esp back pain, or unexplained fracture: do FBC, ESR, Ca 60+ with hypercalcaemia/ WBC: do electrophoresis and BJP within 48hr As well as myeloma think about bony secondaries

10 When to check CA125 (Females) Abdo/pelvic pain/distention (persistent) age 50 IBS symptoms age 50 Change in bowel symptoms Urine urgency (persistent) age 50 Examine patient! NICE: Do CA125/US BUT locally: do Ca125 first: If Ca125, arrange US abdo/pelvis: mark URGENT suspected ovarian cancer. Put CA125 result on form. Will have US within 2 weeks

11 When to request US CONSIDER -Routine: F 55, Vaginal discharge (new/ platelets/haematuria (endometrial) F 55 haematuria + anaemia or platelets or glucose (endomterial) (AS WELL AS 2ww urology if visible haematiuria) M Unexplained or persistent testicular symptoms (BUT possible urgent!) URGENT: unexplained lump increasing in size (sarcoma)

12 When to request urgent CXR OFFER: 40 ever smoked +1 unexplained symptom (2 if never smoked): Cough, fatigue, SOB, chest pain, weight loss, appetite loss Asbestos exposure + 1 of above CONSIDER: >40 persistent/ recurrent chest infection, finger clubbing, LN: supraclavicular or cervical, pleural disease, thrombocytosis (Suspicious CXR: straight to CT pathway in Liverpool )

13 When to request urgent OGD Dysphagia 55 + weight loss + one of : Upper abdominal pain/ reflux/ dyspepsia CONSIDER if Upper abdominal mass consistent with stomach cancer (BUT consider CT ) See stalls for local pathways

14 When to arrange routine OGD CONSIDER if >55 and: Dyspepsia: treatment resistant Anaemia (normo/micro) + upper abdominal pain Nausea or vomiting + any of: weight loss /reflux/dyspepsia/upper abdo pain Raised platelets + naus vom wt loss /reflux/dyspepsia/upper abdo pain Hematemesis (use clinical judgment!)

15 When to request urgent CT: (think pancreas) CONSIDER: 60 + weight loss + one of: diarrhoea, constipation, back pain, abdominal pain, nausea, vomiting, new onset diabetes. Straight to CT pathways at Aintree & RLBUHT- and St Helens and Knowsley (for weight loss/ vague symptoms that don t fit 2ww see handout)

16 Faecal Occult Blood FOB in NICE for: 50 unexplained abdo pain or weight loss < 60 change in bowel habit or IDA >60 with anaemia not nec IDA BUT may not be available locally -debate ongoing. So what can we do? Examine / do bloods. IDA -- to IDA clinic if available or colorectal Wt loss - see CT or does any other pathway fit? If you think FOB and sx don t fit other urgent pathways-consider 2 ww GI referral.

17 Weight loss (recap) plus: Ever smoked/ h/o asbestos- cough/ fatigue/ SOB / chest pain/ appetite loss- CXR Abdo pain/ rectal bleeding- lower GI Upper abdo pain/ reflux/ dyspepsia or raised platelets/ nausea/ vomit- OGD Diarrhoea/ abdo/ back pain/ n/ v/ constipation/ new onset DM- CT Splenomegaly/ lymphadenopathy- Haematology F esp 50+ Ca125- ovarian

18 Fatigue (recap) plus: 40 or > Ever smoked/h/o asbestos/ cogh/ weight loss/sob/ chest pain/ appetite loss CXR* Persistent unexplained and age FBC within 48 hrs F 50 or > wt loss, change in bowel habit- Ca 125 Remember to examine the patient! *can be normal in up to 20% lung Ca think CT

19 Children & Young Adults Refer within 48 hr: Abdo mass /enlarged abdo organ/ unexplained visible haematuria Refer within 2w: absent red reflex FBC (48h): unexplained bruising/bleeding/pallor/lymphadenopathy/ fever/ infection/ fatigue US (48h): lump unexplained/ increasing X ray (48h): bone pain/ swelling Consider Parental concern 19

20 Tumour Specific Pathways Most = broader e.g Colorectal o 50y: unexplained rectal bleed o 40y: weight loss and abdo pain Clinical judgement key encourage GPs to refer, consider, investigate Controversial: ENT clinicians keep persistent sore throat etc. and remember HPV Some Oral lesions advises dentist but not all have one so refer 2ry care

21 Tumour Specific Pathways Useful Tools -worth CPD time to familiarise and know where to look! Eg Macmillan, GP Update, BMJ/CRUK charts GP UpdateCancer course

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23 NICE emphasises Communicate: Patient preferences Potential risk and benefits Explain: referred to cancer service (but most referred do not have cancer) Inform on possible diagnosis (benign & malignant) Where, when, what, who? Further information/written, support, language Patient friendly letter/ CRUK leaflet (see stalls)

24 NICE emphasises: Safetynet Responsibility for reviewing/acting on results of investigation. Keep pt under review Or: Explicitly pass on responsibility. Awareness false negatives (CXR and FOB) New symptom, patient concerned, recurs, persists or worsens. HAVE YOU GOT FIALSAFE SYSTESM IN PLACE?

25 LOCAL INITIATIVES include Colorectal Clinics AO advice pilot Direct to CT Brain MRI Ovarian 50+ pathway See stalls! Ask CRUK team

26 Acute Oncology- Is it Cancer? advice see stalls for full algorithm

27 Direct to CT Aintree/ RLBUHT(similar New NICE Plus Patient has symptoms which give GP high index of suspicion of cancer but History/examine/ usual investigations don t fit 2ww.. Any age pathway Whitson) See Handouts. NB on local Trusts

28 Brain -Direct to MR coming soon Adults with progressive, sub-acute loss of CNS function* NICE says do MRI New referral forms for Walton Neuro being prepared. (Criteria/contraindications: see CCG websites) *Now: If Direct MRI not available refer 2ww or ring Walton helpline (available through switchboard)

29 Ovarian pathway: F age 50+ Cheshire and Merseyside-see stalls

30 Risk assessment tools: (Macmillan/Qcancer. Now in Emis) For common cancers: Estimates lifetime risk of cancer Based on multiple risk factors *Does not align perfectly with NICE Down to clinical judgements/patient preferences We feel: Useful if person presents with symptoms and you are thinking cancer

31 Do 3 things! Examples 1. Safety-netting: ensure systems in place 2. RCGP/national cancer audit 3. SEA:

32 For more information contact your primary care cancer team : Dr Katy Gardner katyagardner@btinternet.com Dr Cathy Hubbert cathy.hubbert@livgp.nhs.uk Dr Debbie Harvey Debbie.Harvey@southseftonccg.nhs.uk Dr Paul Morris Paul.Morris@knowsleyccg.nhs.uk Dr Graeme Allan graeme.allan@talk21.com Dr Hong Tseung hong.tseung@nhs.net Tomas Edge (CRUK) tomas.edge@cancer.org.uk Louise Roberts (CRUK) louise.roberts@cancer.org.uk