Danish Three-Legged Strategy for Early Diagnosis - an integrating approach

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Ethelbert Glenn
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1 Danish Three-Legged Strategy for Early Diagnosis - an integrating approach Peter Vedsted Professor, Director

2 Lower 1-year survival in Denmark

3 Local stage for breast or lung cancer % lung cancer in local stage % breast cancer in local stage - Walters S, et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, Thorax doi: /thoraxjnl Walters S, et al. Breast cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK, : a population-based study. Br J Cancer; 2013:1 14.

4 Development in 1-year survival for women Excl. non-melanoma skin cancer and breast Engholm G, et al. Danish Cancer Society. NORDCAN

5 Development in 1-year survival for men Excl. non-melanoma skin cancer and prostate Engholm G, et al. Danish Cancer Society. NORDCAN

6 It is difficult to be a GP

The reality 90% of cancers are diagnosed based on symptoms More than 80-85% starts in general practice Sources e.g.: - Elliss-Brookes L, et al. BJC 2012, 1220 1226. - Allgar et al.

7 The reality 90% of cancers are diagnosed based on symptoms More than 80-85% starts in general practice Sources e.g.: - Elliss-Brookes L, et al. BJC 2012, Allgar et al. British Journal of Cancer 2005;92: Hansen et al. BMC Health Serv Res. 2011;11: Emery JD, et al. Nat Rev Clin Oncol. 2014;11: Vedsted P, et al. Scand J Prim Health Care. 2009;27:193-4.

GP High quality cancer diagnosis = Integrate primary

8 General practice is stating point for cancer diagnosis But the healthcare system must support the GP High quality cancer diagnosis = Integrate primary and secondary care Green T, Atkin K, Macleod U. Br J Cancer. 2015

9 Nothing new in that!

10 The GP as fire-detector Following 6% of consultations, GPs suspected a serious disease 10% of these patients got a new serious disease in 2 months Hjertholm P, et al. Br J Gen Pract 2014

11 Better than alarm symptoms! - Shapley M. Br J Gen Pract Hamilton W, et al. BJC Jones R, et al. BMJ 2007

12 Urgent referral is effective but Urgent referral for cancer suspicion Has given shorter diagnostic intervals For those 40% diagnosed through urgent referral 60% are not primarily referred to the expedited route! - Jones R, et al. BMJ 2007;334; Meechan D, et al. BJGP 2012 DOI: /bjgp12X Elliss-Brookes, et al. BJC 2012, Jensen H, et al. BMC Cancer 2014;

13 The GP s gut-feeling and risk of cancer Did gut-feeling influence the decision to refer? Risk of cancer No 16.0% The healthcare system must support the GP when A little 11.2% symptoms are not indicative of cancer Some 14.8% Much 23.6% Very much 34.0% Ingeman et al. BMC Cancer (2015) 15:421 Ingeman et al, Submitted

14 Patients replace the fire-detector Is this due a lack of access to investigations when symptoms are not clearly indicative of cancer? Grooss K et al. Br J Gen Pract. 2016;66:e491-8.

15 Difficult symptom pattern e.g. multimorbiditet Heart failure Stroke/TIA Atrial fibrillation Coronary heart disease Painful condition Diabetes COPD Hypertension Cancer Epilepsy Asthma Dementia Anxiety Schizophrenia/bipolar Depression % 20% 40% 60% 80% 100% Percentage of patients with each condition who have other conditions This condition only This condition + 1 other + 2 others + 3 or more others Barnett et al, Lancet 2012

16 The GPs see three types of symptoms! Symptom type % of cancer patients Alarm symptom 50 Serious but non-specific 20 Vague or common 30 Jensen H, et al. BMC Cancer 2014;14:636 Nielsen T, el al. Ugeskr Læger. 2010;172:

17 The 3-legged strategy for cancer diagnosis Alarm symptom (the obvious) Urgent referral for specific cancer Serious, non-specific symptoms (the difficult) Urgent referral to Diagnostic centre Vague symptom (the common) Quick and direct access to investigations - Vedsted, Olesen. A differentiated approach to referrals from general practice to support early cancer diagnosis the Danish three-legged strategy. Br J Cancer Vedsted, Olesen. Early diagnosis of cancer--the role of general practice. Scand J Prim Health Care. 2009;27: Olesen, Hansen, Vedsted. Delay in diagnosis: the experience in Denmark. Br J Cancer Dec 3;101 Suppl 2:S Rubin, Vedsted, Emery. Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract. 2011;61: Jensen H, et al. Cancer suspicion in general practice, urgent referral and time to diagnosis. BMC Cancer. 2014;14:636

18 Urgent referral for specific alarm symptoms Urgent referral for non-specific, serious symptoms Yes-No-investigations

Urgent referral to Diagnostic center If the GP cannot allocate the patient to a specific route The GP performs a triage function: Imaging and blood tests If no explanation, then referral Within 8

19 Urgent referral to Diagnostic center If the GP cannot allocate the patient to a specific route The GP performs a triage function: Imaging and blood tests If no explanation, then referral Within 8 days A responsible consultant + one case-coordinator Multidisciplinary team of specialists Outpatient pit-stop 22 days until final diagnosis

20 The triage blood tests (in total 27) No clear direction cancer/not cancer Very useful in combination with the clinical picture Naeser E, et al. Submitted

21 Triage imaging at referral to Diagnostic Centre Triage imaging Patients % Supplementary CT-scan % of all Chest x-ray + abdominal ultrasound % % Insufficient or no triage imaging % % Total % % Naeser E, et al. Under preparation

22 Results of triage imaging Triage imaging Number of patients % Chest x-ray % Normal % Supplementary CT-scan % Abdominal ultrasound % Normal % Supplementary CT-scan % CT of thorax, abdomen and pelvis % Normal % Non-malignant finding/control % Suspicion of malignant disease % Naeser E, et al. Under preparation

23 Diagnoses when referred to Diagnostic centre 11% gets a cancer diagnosis 49% get another new, important diagnosis Naeser E, et al. Under preparation

24 The non-malignant diagnoses Diagnostic groups New diagnosis Rheumatology % Gastroenterology % Endocrinology 84 10% Haematology 73 8% Respiratory medicine 61 7% Infectious 56 6% Cardiology 47 5% Gynaecology 42 5% Orthopaedics 32 4% Vascular 30 3% Otorhinolaryngology 21 2% Urology 19 2% Side effects 18 2% Neurology 17 2% Dermatology 17 2% Surgical complications 17 2% Nephrology 16 2% Ophthalmology 12 1% Psychiatry 5 1% Total number of patients % 77% Naeser E, et al. Under preparation

Good clinicians in a supportive health system Acknowledge the difficulties of the GPs clinical cancer diagnosis Turn our head towards where the

25 Good clinicians in a supportive health system Acknowledge the difficulties of the GPs clinical cancer diagnosis Turn our head towards where the need for investigations begin Integrate primary and secondary care in high quality cancer diagnostics The 3-legged strategy for cancer diagnosis

Good clinicians in supportive healthcare systems

Good clinicians in supportive healthcare systems the Danish three-legged strategy for cancer diagnosis 3rd NAEDI Research Conference London 2015 Peter Vedsted Professor Research Centre for Cancer Diagnosis