Danish Three-Legged Strategy for Early Diagnosis - an integrating approach Peter Vedsted Professor, Director
Lower 1-year survival in Denmark
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, 2004-2007. Thorax. 2013. doi: 10.1136/thoraxjnl-2012-202297. - Walters S, et al. Breast cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK, 2000-2007: a population-based study. Br J Cancer; 2013:1 14.
Development in 1-year survival for women Excl. non-melanoma skin cancer and breast Engholm G, et al. Danish Cancer Society. NORDCAN
Development in 1-year survival for men Excl. non-melanoma skin cancer and prostate Engholm G, et al. Danish Cancer Society. NORDCAN
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. British Journal of Cancer 2005;92:1959 70 - Hansen et al. BMC Health Serv Res. 2011;11:284. - Emery JD, et al. Nat Rev Clin Oncol. 2014;11:38-48. - Vedsted P, et al. Scand J Prim Health Care. 2009;27:193-4.
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
Nothing new in that!
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
Better than alarm symptoms! - Shapley M. Br J Gen Pract 2010 - Hamilton W, et al. BJC 2009 - Jones R, et al. BMJ 2007
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;1040 - Meechan D, et al. BJGP 2012 DOI: 10.3399/bjgp12X654551. - Elliss-Brookes, et al. BJC 2012, 1220 1226. - Jensen H, et al. BMC Cancer 2014;
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
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.
Difficult symptom pattern e.g. multimorbiditet Heart failure 3 9 14 74 Stroke/TIA 6 14 18 62 Atrial fibrillation 7 13 16 65 Coronary heart disease 9 16 19 56 Painful condition 13 21 21 46 Diabetes 14 20 19 47 COPD 18 19 17 47 Hypertension 22 24 19 35 Cancer 23 21 17 39 Epilepsy 31 23 16 29 Asthma 48 20 12 21 Dementia 5 13 18 64 Anxiety 7 17 20 56 Schizophrenia/bipolar 13 21 21 46 Depression 23 22 18 36 0% 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
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;172:2827-31
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. 2015 - Vedsted, Olesen. Early diagnosis of cancer--the role of general practice. Scand J Prim Health Care. 2009;27:193-4. - Olesen, Hansen, Vedsted. Delay in diagnosis: the experience in Denmark. Br J Cancer. 2009 Dec 3;101 Suppl 2:S5-8. - Rubin, Vedsted, Emery. Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract. 2011;61:317-8. - Jensen H, et al. Cancer suspicion in general practice, urgent referral and time to diagnosis. BMC Cancer. 2014;14:636
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 days A responsible consultant + one case-coordinator Multidisciplinary team of specialists Outpatient pit-stop 22 days until final diagnosis https://sundhedsstyrelsen.dk/da/sygdom-ogbehandling/kraeft/pakkeforloeb/~/media/3aaca5b705b44eaf84f62b9fbb16ac7a.ashx
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
Triage imaging at referral to Diagnostic Centre Triage imaging Patients % Supplementary CT-scan % of all Chest x-ray + abdominal ultrasound 1038 85% 407 39% Insufficient or no triage imaging 181 15% 164 91% Total 1219 100% 571 47% Naeser E, et al. Under preparation
Results of triage imaging Triage imaging Number of patients % Chest x-ray 1058 100% Normal 914 86% Supplementary CT-scan 127 14% Abdominal ultrasound 1075 100% Normal 805 75% Supplementary CT-scan 270 25% CT of thorax, abdomen and pelvis 357 100% Normal 167 30% Non-malignant finding/control 204 37% Suspicion of malignant disease 186 33% Naeser E, et al. Under preparation
Diagnoses when referred to Diagnostic centre 11% gets a cancer diagnosis 49% get another new, important diagnosis Naeser E, et al. Under preparation
The non-malignant diagnoses Diagnostic groups New diagnosis Rheumatology 161 18% Gastroenterology 157 18% 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 885 100% 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 need for investigations begin Integrate primary and secondary care in high quality cancer diagnostics The 3-legged strategy for cancer diagnosis