Diagnosis and testing in primary care for urological cancers

Transcription

1 The Royal Marsden Diagnosis and testing in primary care for urological cancers Alan Thompson Consultant Urological Surgeon

2 2 The Royal Marsden GP Education Day 7 th July 2017

3 3 The Royal Marsden GP Education Day 7 th July 2017

4 4 The Royal Marsden GP Education Day 7 th July 2017 The Twenty Most Common Cancers: 2014 Number of New Cases, UK

5 5 The Royal Marsden GP Education Day 7 th July 2017

6 6 The Royal Marsden GP Education Day 7 th July 2017 No obvious preventable factors though obesity? higher BMI may be diagnosed later stages 1:8 lifetime risk Age and race Genetics (Height/male pattern baldness/lynch syn) Father 2.1 to 2.4 x Brother 2.9 to 3.3 x Mother breast Ca approx 25% higher Decreased risk -? Parkinsons/DM/HIV/exercise

7 The Royal Marsden GP Education Day 7 th July 2017 Prostate Cancer - Symptoms Prostate gland lies at base of bladder surrounding upper part of urethra. May be asymptomatic Some symptoms due to enlargement with similar symptoms to BPH Occasionally haematospermia or haematuria Symptoms of metastatic disease bone/lymphadenopathy/liver

8 The Royal Marsden GP Education Day 7 th July 2017 Prostate Cancer Diagnosis History Family History Examination General signs of locally advanced or metastatic disease DRE most prostate cancers located in the peripheral zone and may be detected when volume >0.2mls. Suspect DRE absolute indication for prostate biopsy 18% patients can be detected by suspect DRE alone

9 The Royal Marsden GP Education Day 7 th July 2017 Prostate cancer

10 The Royal Marsden GP Education Day 7 th July 2017 Prostate Cancer PSA Kallikrein-like serine protease epithelial cells of prostate / liquifies semen For practical purposes organ but not cancer specific Thus serum levels can be elevated in benign conditions Level of PSA as variable better independent predictor than DRE/TRUS Many men have CaP with normal PSA

11 The Royal Marsden GP Education Day 7 th July 2017 Age related PSA values PSA level (ng/ml) Age (years)

12 The Royal Marsden GP Education Day 7 th July 2017 Risk of CaP in relation to low PSA values PSA level (ng/ml) Risk of CaP (%)

13 The Royal Marsden GP Education Day 7 th July 2017 Prostate Cancer PSA Free/Total ratio Most extensively investigated and most widely used in clinical practice to discriminate between BPH and CaP Used to stratify risk in men with PSA 4-10 and ve DRE +ve biopsy in 56% men with ratio <0.10 but only 8% ratio >0.25 Clinically useless in PSA values >10 PSA Velocity prognostic role in patients with treated Cap PSA Doubling Time or on surveillance program; not diagnosis PSA Density However these PSA derivatives may have an important role when combined such as in the use of nomograms to predict the likelihood of significant prostate cancer

14 14 The Royal Marsden GP Education Day 7 th July 2017 Obvious preventable factors - Smoking 37% - Occupational 6% - Ionising radiation 3% Genetics 1 st degree rel 1.8 x (poss due to shared smoke exposure) Brother 2.9 to 3.3 Mother breast Ca approx 25% higher Decreased risk -? Parkinsons/delayed menarche or menopause/exercise

15 The Royal Marsden GP Education Day 7 th July 2017 Diagnosis - Haematuria Paediatric population 1% Young Adults 5% Adults over 50 10% Macroscopic haematuria is the commonest presentation of bladder cancer Almost all patients will have macro or microhaematuria Degree of bleeding is not proportional to stage of Ca Bleeding due to infection some patients will have necrotic infected element within a tumour not just inflammation

16 The Royal Marsden GP Education Day 7 th July 2017 Bladder cancer - symptoms Commonest symptom is painless haematuria DO NOT IGNORE painful haematuria Pronounced irritative symptoms (? cis/invasive) Loin pain (ureteric obstruction) - rare Pelvic mass & cachexia very rare

17 The Royal Marsden GP Education Day 7 th July 2017 Dipstick testing - pitfalls Dip testing is based on the alteration of a chromagen by the peroxidase activity of haemoglobin False positives - myoglobinuria/oxidising agents/peroxidases False negatives high levels ascorbic acid/nitrite/ ph <5.0 & high specific gravity

18 The Royal Marsden GP Education Day 7 th July 2017

19 The Royal Marsden GP Education Day 7 th July 2017

20 The Royal Marsden

21 21 The Royal Marsden GP Education Day 7 th July 2017 Obvious preventable factors - Smoking 50% higher in smokers - Obesity (BMI 30) 63% higher in men / 95% higher in women Genetics 2-4 % are inherited Height 23% increase per 10cm! Parkinsons increases risk

22 22 The Royal Marsden GP Education Day 7 th July 2017 No obvious preventable factors but.. Undescended testicle x 3-6 (Diethylstilboestrol) HIV/Aids 35-79% increase but maybe not with retrovirals Previous testicular tumour risk 12 x Age 80% occur < 50 years Genetics White > black or asian origin Father - 4 x Brother 8 x Height % per 5 cm increase

23 23 The Royal Marsden GP Education Day 7 th July 2017 Diagnostics History Clinical Examination Genitals Abdomen Supraclavicular Lymphadenopathy Urine Dipstick & Pregnancy Test Tumour Markers Ultrasound

24 The Royal Marsden History GP Education Day 7 th July 2017 Symptoms Hard, painless lump o Partner detection 5-10% scrotal pain o Intra-tumoural haemorrhage o Trauma brings attention to abnormality Metastatic o Weight loss o Shortness of Breath o Back/abdominal pain o Neck lumps

25 The Royal Marsden GP Education Day 7 th July 2017 Key Points in a Scrotal Mass History The Lump How was the it detected (in the bath etc.)? How long has it been there? Is it changing in size? Painful or painless Sexual history Any recent STIs Any lower urinary tract symptoms Any recent testicular trauma Any abdominal or neck lumps (lymphadenopathy) Any SOB or abdominal pain PMH Previous orchidopexy/maldescent of testicle Have they had testicular US scan before/been encouraged to regularly self examine FH of testicular Cancer

26 The Royal Marsden GP Education Day 7 th July 2017 Differential Diagnosis Any cause of scrotal lump/pain Testicular torsion Torted hydatid of Morgagni Epididymal cyst(s) Hydrocoele Varicocoele Epididymitis (orchitis) Hernia Tumour Other findings on Ultrasound Microlithiasis Varicocoele

27 27 The Royal Marsden GP Education Day 7 th July 2017 Hydrocoele

28 28 The Royal Marsden GP Education Day 7 th July 2017 Testicular Tumour

29 29 The Royal Marsden GP Education Day 7 th July 2017 Hernia

30 30 The Royal Marsden GP Education Day 7 th July 2017 Torsion

31 The Royal Marsden GP Education Day 7 th July 2017 Testicular Torsion Torsion of Hydatid

32 32 The Royal Marsden GP Education Day 7 th July 2017 Epidiymo-orchitis abscess

33 33 The Royal Marsden GP Education Day 7 th July 2017 Varicocoele

34 34 The Royal Marsden GP Education Day 7 th July 2017

35 35 The Royal Marsden GP Education Day 7 th July 2017 I m getting old, Jim. Today instead of jumping, I had to stretch gently to a conclusion.

36 36 The Royal Marsden GP Education Day 7 th July 2017 Changes to NICE Guidelines Symptom thresholds lowered Any symptom that has 3% chance or more of being cancer Children and young adults Guidence organised by signs and symptoms GP s recommended to refer directly for tests eg CT and endoscopy Very urgent referrals for some symptoms - < 48hrs Specific recommendations on safety netting

37 37 The Royal Marsden GP Education Day 7 th July 2017 Impacts of changes in NICE Guidance Significant increase in referrals with cost implications Further investment in NHS essential to support this Wider benefits Reduced emergency presentations Decreased treatment costs for patients diagnosed earlier

38 38 The Royal Marsden GP Education Day 7 th July 2017 Benefits of updated Guidance Earlier diagnosis leading to longer survival Reduction in cancers diagnosed by the emergency route Optimised diagnostic processes More appropriate referrals to secondary care for suspected cancer

39 39 The Royal Marsden GP Education Day 7 th July 2017 Impacts on Suspected Cancer Referrals Significant resource impact likely in (30% of all suspected cancer referrals 2013/14) Lung and pleural cancers Upper GI tract cancers Lower GI tract cancers Others no significant changes

40 40 The Royal Marsden GP Education Day 7 th July 2017

41 41 The Royal Marsden GP Education Day 7 th July 2017

42 42 The Royal Marsden GP Education Day 7 th July 2017 Wind up your presentation he s losing bone mass

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44 44 The Royal Marsden GP Education Day 7 th July 2017

45 45 The Royal Marsden GP Education Day 7 th July 2017 And now over to one of our so-called experts