National Cancer Diagnosis Audit Yorkshire and Humber Regional Feedback. ( With some local data added in!) 2014 Cancer Diagnoses. Audit 2017. Did not get enough practices taking part to get a CCG level report.

Audit Summary The NCDA gathered primary and secondary care data from patients diagnosed with cancer in 2014 across England to understand pathways to cancer diagnosis 439 practices took part in the England audit (this is 5.4% of all practices in England) 17,043 patient records were collected (this is 5.7% of all patients diagnosed with cancer in 2014) The audit is also taking place in Scotland and North Wales 6 practices locally took part covering 38% of SRCCG population. 2 practices have shared their reports. SMG – 110 patients. Eastfield – 45 patients. Remember that with all this data – the numbers involved are small so the confidence intervals will be huge – think of them as a guide only!

AUDIT Objectives The audit seeks to gather data about Interval length from patient presentation to diagnosis Use of investigations prior to referral What the referral pathways for patients with cancer are and how they compare with those recorded by the cancer registry In future, the 2014 audit data will Help to understand the patterns of cancer diagnosis for all cancer types across the UK, prior to the 2015 NICE guidance on cancer referrals (NG12) Help with assessing the impact of the new guidelines

Benefits for Practices Enabling more efficient and effective pathways to diagnosis Improving patient experience and outcomes Highlighting good practice Highlighting diagnostic challenges Identifying patients for SEAs Opportunity for case study discussion and peer review Demonstrating quality improvement for GP appraisal, revalidation and CQC inspection Opportunity to influence local commissioning decisions

Demographics of Cancer patients in 2014 AUDIT National Y&H Gender Male Female 50.1% 49.9% 51.2% 48.8% Age (Age group with the biggest proportion) 65-74 years (28.6%) Median – 69 years 29.4% Median – 70 years Ethnicity White Non-white Not known 81.3% 4.3% 14.5% 90.7% No information on deprivation taken which would have been interesting. SMG data Male 53.6% Median age 73 White 81.3%. Eastfield data Female 51.1% Median age 75 White 100%.

Cancer Types Diagnosed in 2014 AUDIT Y & H National SMG East. Breast 239 14.5% 2714 15.9% 19.1% 11.1% Prostate 230 13.9% 2130 12.5% 16.4% 8.9% Lung 232 14% 2132 10% 17.8% Bowel 201 12.2% 1969 11.6% 12.7% 20% Other cancer types 46 41.8% 8098 47.5% SMG have a higher breast cancer rate – but the screening may have just been done. Eastfield appear to have a higher bowel cancer rate ( but this only represents 9 patients so ? Significance). Bowel screening rate in 2014 dipped at Eastfield to 54%. ? If relevant??

Cancer Stage 42.9% of cancers in 2014 were diagnosed at an early stage (stage 0, 1 or 2) in Y+H compared to 41.9% in practices taking part in the NCDA nationally. Insert the figure from your report “Cancer Stage – All cancers” here Data for the whole of England for cancer diagnoses in 2014 show*: 25% were stage 1 16% were stage 2 14% were stage 3 20% were stage 4 *Cancer Research UK – Cancer Statistics Some variation though across practices – remembering that the numbers are small so ? Significance. SMG Eastfield Early stage 42.7% 33.3% Late stage 40.9% 44.4%

Place of presentation The most common place where patients first presented with symptoms later attributed to the cancer was the GP surgery – 70.8% in Y&H, 67.5% England,77.3% SMG, 73.3% Eastfield. Insert the figure from your report “Place of Presentation – All cancers” here Higher numbers than the England average present to us in primary care first. Opportunity here….

Primary Care Interval The primary care interval is the time from first presentation (with a symptom later attributed to cancer) to referral. The median primary care interval for Y&H was 5 days. The median primary care interval for Eastfield was 0 days The median primary care interval for SMG was 7 d ays. Nationally this was 4 days. Add information about the length of the primary care interval to this slide. You can find this information in the Primary Care Interval summary paragraph and in the Primary Care Interval section in your report. Number 1 – length of median primary care interval for your practice (in days) Number 2 – length of median primary care interval for cluster (in days) You may wish to discuss how your practice compares nationally / to the cluster median value. The primary care interval should be as short as possible, but there may be good reasons for some longer intervals, such as waiting for test results of investigations ordered in primary care. Is there anything you could do to shorten your intervals further? How long do test results usually take to come back? What processes are in place to chase up test results? What safety-netting approaches are being used to ensure patients are followed up? Remember to emphasise that the national figures are only for practices that took part in the NCDA. This may therefore not reflect the actual national picture in 2014.

Primary Care Consultations The median number of primary care consultations before the referral that led to a cancer diagnosis was 1 in Y&H – same as for England. The proportion of patients who had less than 3 consultations prior to referral was ; England Y&H SMG Eastfield 66.2% 65.3% 48.2% 55.6% Significant variation though with SMG and Eastfield averaging 2 consultations before referral. The range though is huge – Y+H 0-39 consultations - SMG 0-39 consultations. - Eastfield 0-22 consultations. Suggesting that patients are being seen several times before a referral is made. Generally, the number of consultations before referral should be low, but there may be good reasons for higher numbers of consultations as practices are encouraged to use more primary care investigations. Therefore, investigations being done and test results being discussed might explain higher numbers of consultations. Is there anything you could do to reduce the number of consultations? What investigations are being ordered (see next slide) and are they appropriate? What processes are in place to chase up test results? Remember to emphasise that the national figures are only for practices that took part in the NCDA. This may therefore not reflect the actual national picture in 2014.

Investigations in primary care There are a number of investigations (such as blood tests, PSA and chest x-rays) that may be ordered in primary care to explore potential symptoms of cancer before referral National Y&H SMG East. Proportion with no investigati on 34.5% 33.9% 37.1% 45.6% Most referrals are made on the basis of symptoms and signs though – nil investigation needed prior to referral. The most common investigation was blood tests across England, locally and the practices.

Referral Types From Primary Care “Type of referral” is what the GP considered to be the type of referral that led most directly to a diagnosis of cancer The most common type of referral that led to a diagnosis of cancer was 2WW England 51.% Y+H 54.9% SMG 47.3% Eastfield 51.1% Add information about referrals to this slide. You can find this information in the Referrals section in your report. Most common referral type – type of referral done for the biggest proportion of patients that led to cancer diagnosis Per cent 1 – percentage of patients that were referred through this route You may copy and paste the bar graph showing the types of referrals from your report onto this slide to stimulate discussions about the types of referrals being used. You can use the additional information about emergency referral routes in the report to discuss in more detail how patients at your practice were referred as emergencies and whether there is anything that could have been done differently. There were different types of emergency referral routes captured in the audit and an emergency referral may not be an inappropriate route, therefore it will be important to discuss the types of emergency referral route. Consider referring to recent publication Zhou et al. Diagnosis of cancer as an emergency: a critical review of current evidence. 2017 Jan;14(1):45-56. Note: The “Type of referral” is what the GP considered to be the type of referral that led most directly to a diagnosis of cancer. The “Route to diagnosis” is based an algorithm that NCRAS has developed which looks through many datasets to determine what the final route to diagnosis was. The GP then had the opportunity to confirm whether they believed this to be true or enter the route they thought.  For the majority of patients, the patients were referred by TWW and were diagnosed by this route, but there are cases where this could be different. For example, if a patient was referred by TWW but actually ended up being diagnosed in A&E. Also the route to diagnosis shows when the patient was diagnosed at death and no referral would have taken place. The use of the two variables together shows the intention of the referral but also what actually happened.

Route to diagnosis “Route to diagnosis” is based on an algorithm which looks through many datasets to determine what the final route to diagnosis was The most common route to diagnosis was 2WW. England – 38% Y&H - 46.2% SMG - 36.4% Eastfield - 44.4% Insert the figure from your report “Route to Diagnosis – All cancers” here Note: The “Type of referral” is what the GP considered to be the type of referral that led most directly to a diagnosis of cancer. The “Route to diagnosis” is based an algorithm that NCRAS has developed which looks through many datasets to determine what the final route to diagnosis was. The GP then had the opportunity to confirm whether they believed this to be true or enter the route they thought.  For the majority of patients, the patients were referred by TWW and were diagnosed by this route, but there are cases where this could be different. For example, if a patient was referred by TWW but actually ended up being diagnosed in A&E. Also the route to diagnosis shows when the patient was diagnosed at death and no referral would have taken place. The use of the two variables together shows the intention of the referral but also what actually happened.

Avoidable delays The audit asked GPs to provide details if they felt a patient had experienced an avoidable delay. Insert the figure from your report “Avoidable Delays – All cancers” here The proportion of patients with no avoidable delay in Y&H was 65.7% compared to 64.4% for practices taking part in the NCDA nationally. The most common type of avoidable delay reported in our area was primary care. Although 50% patients with avoidable delays at Eastfield were thought to be secondary care.

Take home messages. Think “could this be cancer?” Use the two week wait system for referral. Refer quickly. Don’t let investigations or clinical doubt slow you done. Undertake Significant Event Analysis on emergency diagnoses of cancer to see if there is any learning. Think about doing the next NCDA when asked!