Investigating Symptoms of Lung Cancer An evidence based Guide for general practitioners

Transcription

1 Medicine, Nursing and Health Sciences Investigating Symptoms of Lung Cancer An evidence based Guide for general practitioners Dr Kay Jones Professor Danielle Mazza Dr Samantha Chakraborty Prof essor Ian Olver Dr Helen Zorbas on behalf of the Guide Expert Advisory Panel GP12. The RACGP Conference for General Practitioners October 2012 Gold Coast Convention and Exhibition Centre This project is funded by the Australian Government represented by Cancer Australia

2 In 2007 lung cancer was the leading cause of cancer deaths in Australia 1 Strategies to increase awareness of lung cancer in general practice may facilitate diagnosis at an earlier stage thereby improving survival rates 1 Australian Institute of Health and Welfare (2010). Australia s health Canberra, AIHW. Australia s Health Series no

3 What factors contribute to a delay in diagnosis? Symptoms can be nonspecific or non-existent Management of co-morbid conditions Absence of recent evidencebased Australian guidance Patient factors such as nihilism and stigma 3

4 Aim To provide GPs with evidence based guidance on investigating and referring patients with symptoms of lung cancer 4

5 Method: The ADAPTE Process Phases Tasks Results Set Up phase Prepare for ADAPTE framework Adaptation Phase Finalisation Phase Define health questions Search and screen guidelines Assess guidelines Decide and select Draft guideline report External review Plan for future review and update Produce final guideline 71 guidelines found 13 assessed 3 selected 42 responses received To be reviewed in 5 yrs In production! 5

6 The three guidelines used Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. New Zealand Guidelines Group 2009 The diagnosis and treatment of lung cancer. National Institute of Clinical Excellence (NICE) 2011 Diagnosis and management of lung cancer. American College of Chest Physicians

7 7

8 Draft 8

9 Symptoms and signs Recommendation 1 Investigate symptoms of lung cancer in patients with the following risks 1 Lifestyle factors: tobacco smoking, former tobacco smoking Environmental factors passive smokers radon in homes occupational exposure, e.g. previous exposure to asbestos, diesel exhaust air pollution Personal factors Age family history of lung cancer smoking-related chronic obstructive pulmonary disease previous lung disease history of cancer especially head and neck cancer 1 Australian Institute of Health and Welfare & Cancer Australia. Lung cancer in Australia: an overview. Canberra: AIHW;

10 Symptoms and Signs Recommendation 2 Urgently refer a patient for a chest X-ray if they have: * unexplained haemoptysis OR * any of the following unexplained, persistent symptoms and signs (lasting more than 3 weeks or less than 3 weeks in patients with known risk factors): new or changed cough * chest and/or shoulder pain shortness of breath * hoarseness weight loss/loss of appetite * unresolved chest infection abnormal chest signs * finger clubbing cervical and/or supraclavicular lymphadenopathy features suggestive of metastasis from a lung cancer signs of pleural effusion * cough 10

11 Investigations Recommendation 3 Review previous chest X-rays and other relevant imaging tests in every patient with a pulmonary nodule(s) that is visible on chest X-ray Recommendation 4 Refer any patient with risk factors for lung cancer, who has clinical and chest X-ray features of pneumonia for a repeat chest X-ray within six weeks to confirm resolution Recommendation 5 After urgent referral for chest X-ray, ensure the chest X-ray is completed, reported and reviewed as soon as possible 11

12 Investigations Recommendation 6 Perform chest computed tomography (CT) in every patient with a pulmonary nodule(s) that shows change on chest X-ray or if no previous imaging available Recommendation 7 Review previous imaging tests in every patient with a pulmonary nodule(s) that is/are visible on chest CT scan Recommendation 8 In the general practice setting sputum cytology is not recommended for the investigation of lung cancer due to its low sensitivity and increased risk of delay 12

13 Investigations Recommendation 9 If a chest X-ray is normal and symptoms persist, refer tohe patient for a chest CT scan Recommendation 10 If a chest CT scan is normal and symptoms persist, refer the patient to a respiratory physician (or a designated specialist with expertise in lung disease) 13

14 Referral Recommendation 11 Immediately refer a patient to an emergency department if any of the following are present: massive haemoptysis Stridor Recommendation 12 Urgently refer a patient to a specialist linked to a lung cancer multidisciplinary team, while awaiting results of a chest CT, if the patient has: persistent haemoptysis and are smokers or former smokers aged 40 years, or older or who have other risk factors signs of superior vena caval obstruction Or A chest X-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation) 14

15 Referral Recommendation 13 Urgently refer a patient to a specialist linked to a lung cancer multidisciplinary team if a chest X-ray or CT scan suggests lung cancer (including pleural effusion and slowly resolving consolidation Recommendation 14 Urgently refer a patient to a specialist linked to a lung cancer multidisciplinary team, while awaiting results of a chest CT scan, if the patient has a normal chest X-ray, but there is a high suspicion of lung cancer Recommendation 15 Consider immediate telephone contact with an appropriate speciality service when the patient has a high index of suspicion of lung cancer 15

16 Referral Recommendation 16 Ensure referrals: * are made in a timely manner, and * provide relevant and sufficiently detailed information to the specialist, including the most appropriate way to contact the patient Recommendation 17 Ensure that the patient is aware of the timeframes, where available for * receiving an acknowledgement of the referral, or * being seen by a specialist or an investigation service Recommendation 18 When a patient presents with signs or symptoms suggestive of lung cancer, provide information that clearly describes: * where the patient is being referred * by whom the patient will be seen * what a patient can expect from the specialty service 16

17 Referral Recommendation 19 Advise patients to carry their previous imaging results when they attend for a new chest X-ray or chest CT scan Recommendation 20 Advise patients to stop smoking and advise the patient why this is important Recommendation 21 Offer nicotine replacement therapy and other therapies to assist patients to stop smoking Recommendation 22 Address the patient s needs for continuing support while the patient is waiting for a referral appointment(s). Include inviting the patient to contact the GP again if the patient has concerns or further questions before their specialist appointment. 17

18 Referral Recommendation 23 Where possible, provide culturally-appropriate information and support. Recommendation 24 Store information between healthcare professionals about: the management plan what the patient has been told what the patient has understood (where possible) the involvement of other agencies and healthcare professionals any advance decision made by the patient with regard to end-of-life care other relevant patient information 18

19 Next Steps Publish and disseminate the Guide Undertake a targeted implementation strategy 19

20 Project Team Professor Danielle Mazza, Project Leader, Monash University Dr Kay Jones, Project Manager, Monash University Dr Samantha Chakraborty, Research Fellow, Monash University Steering Group A/Prof David Barnes, National Lung Cancer Advisory Group member Mr Stewart Barnet, National Lung Cancer Advisory Group member Ms Linda Christenson, Consumer, National Lung Cancer Advisory Group member A/Prof Chris Hogan, RACGP representative Ms Liz King, Cancer Australia Prof Ian Olver, Cancer Council Ms Sue Sinclair, Cancer Australia Expert Advisory Panel Prof Danielle Mazza (Chair), Monash University A/Prof David Barnes, Respiratory Physician, Cancer Australia Mr David Copley, Aboriginal and Torres Strait Islander Representative Dr Vinod Ganju, Medical Oncologist Dr Rona Hiam, GP, Cancer Australia Dr Ken Lau, Radiologist Ms Teresa Leonardi OAM, Consumer Representative Ms Margaret McKenzie, CanNET Representative Dr Vivienne Milch, GP, Cancer Australia Mr Ashleigh Moore OAM, Consumer Representative, Chair Cancer Voices SA Dr Siven Seevanayagam, Thoracic Surgeon Dr Julie Thompson, GP, Cancer Australia Dr Helen Zorbas, Cancer Australia CEO 20