Raising awareness of oesophageal cancer: The regional pilot Professor S. Michael Griffin Northern Oesophago-Gastric Cancer Unit Newcastle upon Tyne

Colorectal adenocarcinoma Small cell lung cancer Stage 1 Stage 3 Stage 1 Stage 3 Stage 1 Stage 3 Oesophageal adenocarcinoma Cancer (2010). Cancer of the esophagus and esophagogastric junction. Rice et al

How to improve outcomes?  Prevention  Earlier diagnosis  Centralisation of services  Patient selection/fitness  Surgical technique  Oncology  Critical care  Enhanced recovery

OESOPHAGO-GASTRIC (O-G) CANCERS  Around 12,900 people in England are diagnosed with O-G cancers each year. This equates to 35 people per day being diagnosed with these types of cancer  People over 50 make up 95% of all diagnoses  Over ¼ of all O-G cases present as an emergency  In England, approximately 10,200 people die from O-G cancers each year  If these cancers are diagnosed at the earliest stage, one-year relative survival is as high as 75-87%. At a late stage, it drops to just 20-21%.  More men than women are diagnosed with these cancers, and die from the disease Incidence data supplied by West Midlands KIT based on NCRS data. Deaths data supplied by West Midlands KIT based on ONS data

OESOPHAGEAL ADENOCARCINOMA  Fastest increasing solid cancer in Western World 1  UK has highest incidence rate in Men in the World 2  NorthEast England and West Scotland highest incidence in the UK  Directly related to Obesity and Reflux  Proven evidence that earlier diagnosis dramatically improves cure rates to above 90%  Early diagnosis of precancerous changes (Barretts Oesophagus) can prevent disease 1 Dan Med J (2012). Barrett’s esophagus. Diagnosis, follow-up and treatment. Bremholm L et. al 2 Oesophagus (2014). Global incidence of oesophageal cancer by histological subtype in Arnold M et. al

“OESOPHAGOOSE”– born 2008

Oesophagoose - evaluation 1850 people questioned in street intercept surveys 39% had seen campaign material

Local Be Clear on Cancer pilots  Seven local pilots across England 1  Data from one pilot shows that during the campaign there was a 17% statistically significant increase in GP visits in the over 55s compared with the same period in Pilot scheme areasControl areas Upper GI 2 week wait referrals ↑ 26% ↑ 16% 2 week wait oesophageal cancer diagnosis ↑ 20%↑ 3% 1 Be Clear on Cancer (2014). Evaluation summary. Available from 2 Source: Mayden (IT healthcare specialist company)

Preparation for the regional Be Clear on Cancer Pilot, Feb10-March  Which symptoms to target? n=788 Heartburn/Indigestion (No dysphagia) Dysphagiap (Chi 2 ) N0N0 21 (28.4%)39 (7.7%)< Stage (37.8%)54 (10.7%)< M+10 (13.6%)120 (23.8%) Curative Intent53 (71.6%)248 (49%) A national panel of experts, including clinicians and patient group representatives, reviewed the data and evidence to decide which symptoms to lead with. Data provided by NOGU with a diagnosis of oesophageal cancer since January 2008

Regional pilot February 10-March Northeast and Cumbria  Bus stop billboards  Newspaper coverage  Postal mailshot  TV advert

Regional Be Clear on Cancer pilot – evaluation 2014  87% exposure within the target audience  13% awareness of advertising about heartburn  31% recall of heartburn in the pilot region when asked about advertising on certain symptoms  Increase in prompted knowledge of heartburn as a definite warning sign of OG cancer  11% pre-campaign vs 31% post-campaign Data source: TNS-BMRB (a market research agency) Data source: TNS-BMRB

Impact on services follow the regional Be Clear on Cancer pilot 2WW: Eight trusts in the regional pilot saw an increase in 2WW referrals over the campaign period, particularly in March 2014 Max average 15 extra 2WW referrals per week per trust. This reduced in April 2014 to on average 7 extra 2WW per week per trust A reduction in the percentage of people seen within the 14 day window also decreased over this time, from 94% in Feb 2014, to 90% in May 2014, with some recovery seen by July 2014 (92%) No additional increase in 2WW referrals was observed in the trusts not covered by the pilot, although a slight decrease in the percentage of people seen within the 14 day window was observed (from a peak of 95% in Feb 2014, to a low of 92% in Jun 2014) Data provided by Department of Health

Impact on services following the regional Be Clear on Cancer pilot Endoscopy: The average increase per week was 16 additional gastroscopies over the course of the pilot (data used from Mar 2014 to Jul 2014) However the range across eight NHS trusts in the pilot areas went from 1 additional gastroscopy per week up to 23 additional gastroscopies Caveat… The region for the pilot has abnormally high activity at baseline levels compared to the rest of the country, even outside the campaign period Average waiting times in the pilot sites showed an increase from Feb 2014 to May 2014, with a slight decrease between Jun Aug 2014 Neither of these trends were observed in the trusts outside of the pilot. Data provided by Department of Health

Things to consider…  High risk patients: Deprivation: Incidence is higher in more socioeconomically deprived areas for both oesophageal and stomach cancers Smoking is the biggest lifestyle risk for oesophageal cancer, accounting for nearly 7 out of 10 cases. It accounts for nearly 1 out of 5 cases of stomach cancer Diet: Approximately 1 in 2 cases of oesophageal and 1 in 3 cases of stomach cancer are linked with consuming too little fruit and vegetables over a long time  The number of prescriptions for PPIs was around 50m in England for the financial year 2013/14  Women are 50% more likely than men to have seen their GP at least 3 times before a referral is made for a suspected oesophageal cancer Data provided by NCIN from a range of sources, details can be provided

Epidemiological study showing increased 2ww referral patterns on resectability rates  Appropriate, informed increase in 2ww referrals would be expected to improve the rate of resectability Gut (2014). Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: Retrospective analysis of Hospital Episode Statistics. Shawihdi et al

Towards improved awareness and early treatment

Summary  Upper GI cancer awareness campaigns can lead to  Improved disease awareness and understanding  Manageable increase in referrals  Increased rates of cancer diagnosis  Longer term evaluation awaited