The primary care perspective Dr Richard Roope

The primary care perspective Dr Richard Roope RCGP & CRUK Clinical Lead for Cancer CRUK Senior Clinical Advisor (Prevention and Early Diagnosis)

The challenges within primary care

Cancer in the primary care setting 90% of cancers are diagnosed based on symptoms More than 80-85% are seen in general practice A GP may see 8/9 new diagnoses cancer 30-40 patients living with cancer

Stages before treatment Patient notices symptom Patient presents to the doctor Doctor recognises cancer is a possibility and refers for investigations Definitive investigations undertaken Treatment begins <62 days for 95% of urgent referrals

Three groups of symptoms Symptom group % Alarm symptom 50 Serious, non-specific 20 Common 30 Jensen H, et al. BMC Cancer 2014;14:636

The 3-legged strategy for cancer diagnosis Alarm symptom (the obvious) Urgent referral, specific cancer Serious, non-specific symptoms (the difficult) Diagnostic centre Vague symptoms (the common) Quick and direct access Vedsted, Olesen. A differentiated approach to referrals from general practice to support early cancer diagnosis the Danish three-legged strategy. BJC. 2015

Refer or investigate What do we know about the propensity of GPs to refer in England? ICBP Module 3 - system differences 60% Willingness to act at the first consultation - lung Latest international data suggests GPs in the UK: Are less likely to send a patient for tests or to refer them at their first consultation Report having among the lowest access to specialist advice Feel more strongly about protecting their patients from over investigation, and preventing a secondary care overload Rose PW, Rubin G, Perera-Salazar R, et al. Explaining variation in cancer survival between eleven jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey. BMJ Open accepted for publication 50% 40% 30% 20% 10% 0% Highest Second highest England Jurisdictions

It is not all bad.

PHE Press release 16.9.15: Cancers are being diagnosed earlier in England It is not all bad. www.gov.uk/government/news/cancers-are-being-diagnosed-earlier-in-england

PHE Press release 10.11.15: Big data driving earlier cancer diagnosis in England It is not all bad. www.gov.uk/government/news/big-data-driving-earlier-cancer-diagnosis-in-england

It is not all bad.

NICE Cancer guidance

NICE Cancer guidance First guidance to include data from Primary Care

The old urological guidance

The likelihood of cancer? This is generally measured as a Positive Predictive Value (PPV) It has a simplicity, and is easily understood by all stakeholders The values are available for many common cancers, and for their presentations It brings equity (both across cancers and within different presentations of a single cancer) though this is a debatable benefit. Being numerical, it can be incorporated into GP software It allows change should the chosen value be deemed incorrect

What level should it be? Patients have a central view here And they are very keen to be tested, even when the overall chance of cancer is low

Bladder Kidney Shephard EA, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Clinical features of bladder cancer in primary care. British Journal of General Practice. Sep 2012;62(602):598-604. Shephard E, Neal R, Rose P, Walter F, Hamilton WT. Clinical features of kidney cancer in primary care: a case-control study using primary care records. British Journal of General Practice. 2013;63(609):e250-e255.

The new: bladder (based on 7 studies) Some differences: An age limit for haematuria, or haematuria/uti An older age for microscopic haematuria The older patient with many UTIs

The new: renal (based on 5 adult studies) They are the same as bladder, other than the multiple UTI recommendation

The new: prostate (based on 5 studies) Not much difference: with the only real issue being we suggest to GPs when to do a PSA

The new: endometrial (based on 6 studies) Haematuria can be a presenting symptom for endometrial cancer

Odds ratios (and 95% CIs) for negative experience for patients with three or more pre-referral consultations with a general practitioner, compared with patients with 1-2 consultations (reference). Questions ordered by effect size with evaluative questions on the left and report questions on the right. Evaluative questions Report questions Mendonca SC et al. Eur J Cancer Care 2015. Epub 30 JUL 2015 DOI: 10.1111/ecc.12353 http://onlinelibrary.wiley.com/doi/10.1111/ecc.12353/epdf

Very wide variation by cancer in the % patients who saw GP three or more times Lyratzopoulos et al, Lancet Oncology, 2014

Adjusted ORs (women vs. men) of 3+ pre-referral consultations Women particularly more likely to have 3+ pre-referral consultations for urinary tract cancers Lyratzopoulos et al., Lancet Oncology 2012

Women experience more consultations even in the presence of haematuria Bladder Renal

2006 BLADDER KIDNEY Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown 0% 4% 0% 5% 17% 20% 27% 28% 7% 29% 12% 4% 30% 17%

2013 BLADDER KIDNEY Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown 0% 2% 1% 2% 18% 21% 26% 1% 40% 12% 2% 17% 27% 31%

Goal BLADDER KIDNEY Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown Two Week Wait GP referral Other Outpatient Inpatient Elective Emergency presentation Death Certificate Only Unknown 0% 2% 1% 2% 18% 21% 26% 1% 40% 12% 2% 17% 27% 31%

Goal We have done well but the best is still to come

Goal