The Clerk s tale EARLY DIAGNOSIS: LOOKING BACK FROM THE ONCOLOGY CLINIC Peter Johnson Professor of Medical Oncology, University of Southampton Chief Clinician, Cancer Research UK A 47 year-old lady Diabetic for several years, but otherwise well previously Severe and worsening back pain for 4 months Weight loss of 8 kg Requiring morphine to sleep 7 visits to GP surgery over 3 months CA125 measured and raised. Referred for imaging... 1
Wait for hospital appointment Operation Refer for opinion Sent for scan Next GP appointment Operation cancelled No beds Return with scan results Can t get GP appointment Sent for blood tests Refer for surgery Refer for biopsy Symptoms Wait for histology Return with biopsy result The usual responses... May 2014: Latest figures show nationally the NHS has met and exceeded seven out of eight cancer waiting time standards. But there is variation in meeting the challenging standards, and national performance against one of the targets has dipped November 2014: We're referring 51% more patients for cancer treatment than 2010, and have invested 0.75bn in better early diagnosis and treatment to make progress towards our ambition to be the best country for cancer care in Europe March 2015: "We have invested an extra 750m on cancer services, including early diagnosis and innovative radiotherapy. November 2016: Early and fast diagnosis is crucial in improving patient outcomes and experience. Getting pathology test results to patients quickly is a key part of this. That's why we have invested over 2.5bn on efficient and robust pathology services across the NHS 2
Nearly 1000 people a day are diagnosed with cancer in the UK Cancer: Years of Life Lost 2009-2011 CANCER SURVIVAL IN THE UK HAS DOUBLED TO 50% IN THE LAST 40 YEARS. OUR AIM IS TO REACH 75% IN THE NEXT 20 YEARS. Source: http://www.cancerresearchuk.org/health-professional/cancer-statistics/survival/common-cancers-compared 3
Compared to abroad? Early stage: better survival All Cancers http://scienceblog.cancerresearchuk.org/2015/0 8/05/cancer-survival-in-england-is-improvingbut-still-lagging-behind-similar-countries/ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 388160/fourth_annual_report.pdf (last accessed 21.1.17 4
Why do we lag behind other Health Systems? Primary Care could (should?) have a part to play throughout the cancer pathway, and is well placed to do so if adequately resourced Findings from the International Cancer Benchmarking Partnership: 62-year-old man with COPD, heavy smoker for over 40 years. Presented with respiratory symptoms As gatekeepers the gate needs to be wider Outcomes closely linked to readiness to act Patients fear wasting GP time 1 year OS 5 year OS Prevention Tobacco Food Immunisations Exercise Environment Treatment Surgery Chemotherapy Radiotherapy Comorbidity Psychology Early detection Awareness Health care seeking Screening Access Survivorship Follow-up Late effects Rehabilitation Health promotion Diagnosis Investigations Access Technology Decision support End of life Basic palliation Specialised Social Bereavement British Journal of Cancer (2013) 108, 292 300 BMJ Open (2015);5:e007212 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates 5
Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Axis Title When it comes to recruiting for GP vacancies, three in ten GP partners (31%) have been unable to fill vacancies in the last 12 months. Breaking the diagnostic system... 180,000 160,000 162356 90.0% 88.0% 140,000 86.0% 120,000 100,000 80,000 60,000 77076 84.0% 82.0% 80.0% GP Urgent Referrals Patients beginning treatment following GP Urgent Referral Performance against Two Month Wait from GP Urgent Referral to a First Treatment for Cancer 40,000 20,000 8025 (2.9%) 12808 (4.3%) 78.0% 0 76.0% BMA GP survey 20.12.16 6
WE HAVE LESS IMAGING EQUIPMENT AND FEWER TRAINED STAFF IN THE UK In intention-to-treat analyses, colorectal cancer incidence in the intervention group was reduced by 23% (hazard ratio 0 77, 95% CI 0 70 0 84) and mortality by 31% (0 69, 0 59 0 82). Lancet 21 Feb 2017: 17 years follow-up In intention-to-treat analyses, colorectal cancer incidence was reduced by 26% (HR 0 74 [95% CI 0 70 0 80]; p<0 0001) in the intervention group versus the control group and colorectal cancer mortality was reduced by 30% (0 70 [0 62 0 79]; p<0 0001) in the intervention group versus the control group. 7
How has that been going?... Maybe a simple ultrasound or blood test could find early ovarian cancer? Over 200 000 people, 11 years follow-up CA125 vs TV Ultrasound vs No screening No significant difference in overall mortality from ovarian cancers Possible suggestion of lower mortality in outer years Least deprived CCGs Most deprived CCGs Trend over time 8
When cells go bad... Dr Josephine Bunch DNA Heterogeneous and complex... Using various new mass spectrometry imaging techniques, the team led by Dr Bunch will develop a new way to map tumours in unprecedented detail from the whole tumour to individual molecules in cells. The work could lead to new ways to diagnose and treat cancer. Dunn, Old, Schreiber. Immunity Volume 21, Issue 2 2004 137 148 9
per case The economic case for prevention and earlier diagnosis A multi-stage problem: The cost of someone accessing a smoking cessation service who successfully quits, is approx. 220 Every 1 spent on smoking cessation saves 10 in lifetime health care costs and health gains** 35000 30000 25000 20000 15000 10000 5000 0 29114 13078 7952 220 Quit smoking Stage 1 Stage 4 Pembrolizumab Cancer is complex. Early cancer is probably not simpler. We have a poor grasp of the biology The maths of population screening are generally against us We have calibrated our healthcare system to try and stop people using it We have failed to train adequate numbers of the professionals we need We are wasting money on catching up with a struggling diagnostic service * HSCIC. (2012). Statistics on NHS Stop Smoking Services England, April 2011 to March 2012. ** Public Health England. Comprehensive local tobacco control: why invest? 10
A multi-modal attack More sophisticated biological understanding (don t wait for the magic bullet) Shared ownership of the problem (patients, primary, secondary care) A radically different approach to diagnostic services (MDCs?) A proper plan for workforce development...this might even pay for itself in the long run. 11