Optimising symptomatic cancer diagnosis in primary care Dr Fiona Walter The Primary Care Unit Cambridge Institute AWAY DAY 25 th June 2014 of Public Health.

Optimising symptomatic cancer diagnosis in primary care

Dr Fiona WalterThe Primary Care Unit

Cambridge Institute AWAY DAY 25th June 2014of Public Health

How has our primary care cancer diagnosis research influenced policy and practice?

NIHR DISCOVERY programme (PG) 2010-5 MelaTools programme (CS) 2013-8

Charities Cancer Research UK/ NAEDI Pancreatic Cancer Action

Team Linda Birt, Angelos Kassianos, Silvia

Mendonca, Katie Mills, Helen Morris, Chantal Smeekens, Juliet Usher-Smith

‘Exemplar of the work of the PCU’

BACKGROUND

1995-99 2000-02 2005-0720

25

30

35

40

45SWE

NOR

DEN

UK

AUS

CAN

Lung Cancer 1yr RS

1995-99 2000-02 2005-0765

70

75

80

85

90 AUS CAN SWE NOR DEN UK

AUS

NOR

DEN

UK

CAN

SWE

Colorectal Cancer 1yr RS

ICBP: Coleman et al, Lancet 2011

The National Awareness and Early Diagnosis Initiative

(NAEDI)              

METHODS- Model of Pathways to Treatment

Walter et al, JHSR&P 2012, Scott et al, BJHP 2013

METHODS- Aarhus Statement

Weller et al, BJC 2012

PUBLIC AWARENESS

Factors influencing time to presentation: Appraisal: lack of knowledge Help-seeking: avoidance, fatalism, reluctance to seek help (including

embarrassment, wasting the doctor’s time)

Be Clear on Cancer campaigns- lung, colorectal cancer

Early evidence of effects on: Awareness GP consultations Use of diagnostic tests Urgent referralsPreliminary results suggest: Impact on stage at diagnosis Trigger presentation

PUBLIC AWARENESS- skin cancer

Walter et al. BMJ Open, in press

Be Clear on Cancer campaigns- skin cancer Melanoma interview study

63 adults aged 29 - 93 Interviewed with 10 weeks of diagnosis

Key results Common features: change in

size, shape, colour Unassuming features: ‘just a

little spot’ Subtly different patterns of

features: ‘vertical growth’ Normal explanations: life

changes

PATIENT PATHWAYS- Symptom Study

What symptoms and other patient factors are associated with later presentation or later stage at diagnosis of lung, colorectal, pancreas cancer?

Prospective cohort study: patient questionnaires and nested qualitative in-depth interviews

Setting: East and North East England, patients referred to urgent, routine & investigative clinics

Inclusion criteria: aged ≥40 with symptoms suspicious of colorectal, lung, pancreatic cancer

Recruitment: when referred, mailed SYMPTOM questionnaire

Further data collection: from primary care and hospital records relating to participants’ symptoms and diagnosis

RECRUITMENTTo end May 2014

COLORECTAL 2506

LUNG 996

PANCREAS 334

Inhibiting

Facilitating

“And if I should be out and I get this sort of urge to go to the toilet, I have to go otherwise I’ve pooed myself. .. very embarrassing” (female, 77 years, NC)

“that was probably the thing that put me off going more than anything in the first instance was the embarrassment of that sort of thing. .. I don’t suppose anybody likes, whether it’s a doctor or not, playing around what you consider as your private parts” (Male, 66 years, CRC)

Looking for symptom relief Perceived seriousness and/or

anxiety about cancer Loss of privacy e.g. wind, faecal

incontinence (or fear of) Lack of embarrassment

Prompt help-seeking

Socio-cultural norms Symptom monitoring Embarrassment of investigations

PATIENT VIEWS- ‘private nature of symptoms’me personally, the way I was brought up, one, you don’t talk about downstairs, and two, you don’t look at downstairs. So, when people ask me questions like “Is it in the stool?” or anything like that, I tend not to look, I do now, but I didn’t then” (Female, 54 years, NC)

PATIENT VIEWS- diagnostic tests & referrals

Banks et al. Lancet Onc 2014

PIVOT study- Bristol, Exeter, East of EnglandClinical vignettes presented on a tablet in GP waiting rooms

RISK ASSESSMENT TOOLS for GPs

CAPER studies Main output: risk assessment

tools (RATs) Piloted in 152 practices in

England over a 6-month period, and resulted in: Increase in referrals for

suspected cancer Increase in number of

colonoscopies Increase in number of

colorectal cancers diagnosed

Hamilton et al BJGP 2013

MELANOMA CLINCIAL DECISION SUPPORT

Walter et al, BMJ 2012

DIAGNOSTIC TECHNOLOGIES

Kadri et al, BMJ 2010

PRIMARY CARE CANCER DIAGNOSIS RESEARCH

CURRENT Methodological frameworks Public awareness Patient pathways- symptoms Patient views- diagnostics Risk assessment tools

E-clinical decision support Diagnostic technologies

devices, informatics, biomarkers

NEXT… Other behavioural approaches

e.g. patient self-monitoring New investigative & referral

routes Socio-economic inequalities Diagnostic technologies

devices, informatics, biomarkers

Pre-symptomatic diagnosis

THANK YOU [email protected]