1. Strength Through Partnership Central South Coast Cancer Network Dr Richard Roope, CSCCN Primary Care Lead Cancer Early Diagnosis Meeting 8.2.2012

2. Strength Through Partnership Central South Coast Cancer Network Macmillan GP Roles

3. Strength Through Partnership Central South Coast Cancer Network CSCCN Central South Coast Cancer Network Southampton & West (Vacant) Northeast Charlotte Hutchings Portsmouth & Southeastern (Vacant) Isle of Wight David Issacs Network Leadership/coordination (RMR)

4. Strength Through Partnership Central South Coast Cancer Network Macmillan GP Roles Advert to all practices in SHIP area Interviews on 20.2.12 & 22.2.12

5. Strength Through Partnership Central South Coast Cancer Network Macmillan GP Roles Mainland Awareness and Early Diagnosis - Survivorship - End of Life – Charlotte Hutchings Isle of Wight Awareness and Early Diagnosis) Survivorship)David Issacs End of Life)

6. Strength Through Partnership Central South Coast Cancer Network CCG Engagement

7. Strength Through Partnership Central South Coast Cancer Network CCG Engagement Approach made to all CCGs to establish lead for cancer. Opportunity to meet up to discuss role of network and work streams

8. Strength Through Partnership Central South Coast Cancer Network RCGP events 19.1.12 – Early Detection of Cancer Study Day

9. Strength Through Partnership Central South Coast Cancer Network RCGP events 30+ GPs from across SHIP area Case studies including RAT tool

10. Strength Through Partnership Central South Coast Cancer Network RCGP events Feedback What actions do you now intend taking? Talking to my partners re safety netting and circulate the guidelines for urgent referrals Look at practice NCIN profile for cancers Set up a follow up system for patients with symptoms potentially needing referral for cancer Use RAT tool for bowel/lung cancers Share information with partners Teaching for patient group Audit our cancer care

11. Strength Through Partnership Central South Coast Cancer Network RCGP events Next meeting planned for 5.7.12

12. Strength Through Partnership Central South Coast Cancer Network Target events

13. Strength Through Partnership Central South Coast Cancer Network Target events Portsmouth 25.1.2012

14. Strength Through Partnership Central South Coast Cancer Network Target events Portsmouth 25.1.2012 Break out groups x2 70 GPs attended Full feedback not yet collated

15. Strength Through Partnership Central South Coast Cancer Network LMC Event Afternoon meeting on 25 th April 2012 E-mailed to all GPs in Wessex LMC patch

16. Strength Through Partnership Central South Coast Cancer Network LMC Event Afternoon meeting on 25 th April 2012 Early cancer diagnosis leads to better outcomes - everything the GP wanted to know but was afraid to ask! E-mailed to all GPs in Wessex LMC patch

17. Strength Through Partnership Central South Coast Cancer Network LMC Event Avoidable deaths pa if survival in England matched the best in Europe Breast ~2000 Colorectal~1700 Lung~1300 Oesophagogastric~950 Kidney~700 Ovary ~500Brain 225 NHL/HD 370Melanoma 190 Bladder 290Cervix 180 Myeloma 250Oral/Larynx 170 Endometrial 250Pancreas 75 Leukaemia 240

18. Strength Through Partnership Central South Coast Cancer Network LMC Event 54 booked within 2 hours....

19. Strength Through Partnership Central South Coast Cancer Network Practice Profiles – Dec 2011

20. Strength Through Partnership Central South Coast Cancer Network Practice Profiles – Dec 2011 qqqqqqqqqqq qqqqqqqqqq

21. Strength Through Partnership Central South Coast Cancer Network IndexMinMaxRange 2ww per 100,000 33132009.67 2ww Age standardised 0.222.3010.45 % 2ww conversion 0%31.25% % of cancers via 2ww 0%100% Huge variation of practice across SHIP – 2 week wait referrals CWT 20010/11

22. Strength Through Partnership Central South Coast Cancer Network IndexMinMaxRange Emergency presentations per 100,000 1 26162562.5 % of cancer presentation via emergency route 2 0%57.14% Huge variation of practice across SHIP – Emergency presentation 1.HES 20010/11 2.RtD 2008

23. Strength Through Partnership Central South Coast Cancer Network Huge variation of practice across SHIP – Emergency presentation

24. Strength Through Partnership Central South Coast Cancer Network Huge variation of practice across SHIP – Emergency presentation

25. Strength Through Partnership Central South Coast Cancer Network Huge variation of practice across SHIP – Emergency presentation

26. Strength Through Partnership Central South Coast Cancer Network Huge variation of practice across SHIP – Emergency presentation

27. Strength Through Partnership Central South Coast Cancer Network Practice Profiles – Dec 2011 Variable take up Isle of Wight 100% IOW>Portsmouth>Hampshire>Southampton

28. Strength Through Partnership Central South Coast Cancer Network Practice Audit

29. Strength Through Partnership Central South Coast Cancer Network Audit A challenge... Money available New staff appointed – personal approach

30. Strength Through Partnership Central South Coast Cancer Network Risk Assessment Tool

31. Strength Through Partnership Central South Coast Cancer Network Agenda Item 2.2

32. Strength Through Partnership Central South Coast Cancer Network Agenda Item 2.3

33. Strength Through Partnership Central South Coast Cancer Network Mousemat and Desk Easel Risk Assessment Tool

34. Strength Through Partnership Central South Coast Cancer Network Ratmat:

35. Strength Through Partnership Central South Coast Cancer Network Risk Assessment Tool Gate keeper role UK general practice is regarded by many to be the best in the world The gatekeeper role has brought many benefits to patients, not least by ensuring the correct specialist is seen It has also brought disadvantages, arising from GPs desire and more recently, external pressure to use resources appropriately. Potential for collusion with patient: Do I really need to….? In cancer this means not investigating the low-risk symptom – and NICE tells us not to. However this may contribute to poor cancer outcomes in the UK. (cf Denmark)

36. Strength Through Partnership Central South Coast Cancer Network Background How do GPs decide who to refer? Some is from what has been learnt during training and CPD Some from sixth sense Some from advice – like NICE Some from patient pressure Some from reading up research

37. Strength Through Partnership Central South Coast Cancer Network Risk Assessment Tool Colorectal Cancer This is one of the four commonest cancers, and possibly the one with most to benefit from improvements in diagnosis. Half of patients never have a NICE-qualifying symptom Only a quarter are diagnosed via 2-week rule clinics A quarter present as emergencies Earlier diagnosis may give a stage shift or prevent some of the emergencies Dukes A 93% 5ys: Dukes D 7% 5ys

38. Strength Through Partnership Central South Coast Cancer Network RAT – Colorectal Cancer Constipation Diarrhoea Rectal bleeding Loss of Weight Abdominal pain Abdominal tenderness Abnormal rectal exam Haemoglobin 10-13g/dl Haemoglobin < 10 g/dl 0.40.92.41.21.1 1.50.972.3 PPV as a single symptom 0.81.12.43.01.51.72.61.22.6 Constipation 1.53.43.11.92.4112.22.9 Diarrhoea 6.84.73.14.58.53.63.2 Rectal bleeding 1.43.46.47.41.34.7 Loss of Weight 3.01.43.32.26.9 Abdominal pain 1.75.82.7>10 Abdominal tenderness Implement the Risk Assessment Tool (RAT) Positive predictive value

39. Strength Through Partnership Central South Coast Cancer Network Patient pathway: Awareness Presentation Investigation Referral Diagnosis

40. Strength Through Partnership Central South Coast Cancer Network Helps to decide which patients below the risk level implied by NICE guidance may benefit from urgent investigation Uses a combination of symptoms, signs and investigations. Generates the proportion of patients with the listed symptom(s)who have that cancer type Using the RAT tool

41. Strength Through Partnership Central South Coast Cancer Network Used to supplement NICE guidelines For patients 40 Is used after first and subsequent patient visits Using the RAT tool

42. Strength Through Partnership Central South Coast Cancer Network RAT – Colorectal Cancer Constipation Diarrhoea Rectal bleeding Loss of Weight Abdominal pain Abdominal tenderness Abnormal rectal exam Haemoglobin 10-13g/dl Haemoglobin < 10 g/dl 0.40.92.41.21.1 1.50.972.3 PPV as a single symptom 0.81.12.43.01.51.72.61.22.6 Constipation 1.53.43.11.92.4112.22.9 Diarrhoea 6.84.73.14.58.53.63.2 Rectal bleeding 1.43.46.47.41.34.7 Loss of Weight 3.01.43.32.26.9 Abdominal pain 1.75.82.7>10 Abdominal tenderness Implement the Risk Assessment Tool (RAT) Positive predictive value Amber and red suggests 2WW referral. Yellow and no colour best managed by review within 1º Care

43. Strength Through Partnership Central South Coast Cancer Network RAT – Lung – Non-smokers Implement the Risk Assessment Tool (RAT) Lung Cancer Assessment Tool for Non –Smokers Male Female Cough Fatigue Dyspnoea Chest pain Loss of weight Loss of appetite Thrombocytosis Abnormal spirometry Haemoptysis 0.4 0.70.81.10.91.6 2.4PPV alone 0.6 0.8 1.81.62.01.22.0Cough 0.560.90.81.01.21.84.03.3Fatigue 0.91.22.0 2.34.9Dyspnoea 0.91.8 2.01.45.0Chest pain 1.22.36.11.59.2Loss of weight 1.70.92.7>10Loss of appetite 3.6>10Thrombocytosis >10Abn. spirometry 17Haemoptysis

44. Strength Through Partnership Central South Coast Cancer Network RAT – Lung - Smokers Implement the Risk Assessment Tool (RAT) B Lung Cancer Assessment Tool for Smokers Male Female Cough Fatigue Dyspnoea Chest pain Loss of weight Loss of appetite Thrombocytosis Abnormal spirometry Haemoptysis 0.90.81.21.32.11.84.24.04.5 PPV alone 1.31.01.40.92.32.86.53.63.9 Cough 1.21.41.32.02.32.4>106.1 Fatigue 1.52.23.15.52.4>106.9 Dyspnoea 1.44.47.6>10 4.1 Chest pain 1.75.0>10 Loss of weight 2.7 Loss of appetite 12Haemoptysis

45. Strength Through Partnership Central South Coast Cancer Network

46. Strength Through Partnership Central South Coast Cancer Network Risk Assessment Tool Embedding in 2WW referral form Likely to highlight a learning need. Likely to change practice. Likely to engender earlier diagnosis. Likely to result in more 2WW referrals etc. Likely to reduce emergency presentations

47. Strength Through Partnership Central South Coast Cancer Network Agenda Item 2.4

48. Strength Through Partnership Central South Coast Cancer Network Primary Care Safety Netting

49. Strength Through Partnership Central South Coast Cancer Network Safety-netting –Practice system if patient fails to attend for investigation or clinic? –Practice system if results/correspondence go to ground? –Not sufficient to say: Come back if it doesnt get better

50. Strength Through Partnership Central South Coast Cancer Network Safety-netting

51. Strength Through Partnership Central South Coast Cancer Network Safety-netting - Screening Bowel cancer screening DNA notifications –Enter into computer history –Flag record (computerised post-it) so next contact with Primary Care Team patient will be reminded –Letter sent to patient from surgery may be worth GP signing To provoke a response may include phrase along lines of:

52. Strength Through Partnership Central South Coast Cancer Network Safety-netting - Screening Dear We have recently been advised by the National Bowel Screening Programme that you failed to return the test kit for analysis. The Practice firmly believes that this simple test is a valuable aid in detecting any potential signs of bowel cancer cells, and would encourage you to reconsider your decision. You should continue to be aware of any bowel symptoms such as: –A persistent change in bowel habit, especially going to the toilet more often or diarrhoea for several weeks –Bleeding from the back passage without any obvious reason –Abdominal pain especially if it is severe –A lump in your abdomen Please remember that these symptoms do not necessarily mean that you have bowel cancer, but if you have one or more of these symptoms for four to six weeks, you should see your GP. Should you no longer have the test kit and now wish to take part, you can call the Screening freephone number 0800 707 6060 and ask for another. If, after careful consideration, you decide not to take part, please would you let us know by returning the slip below. Your decision will have no impact on any future medical services provided by the Practice. Yours Sincerely, Main and Branch Surgeries I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it. (signed)…………………………………………………

53. Strength Through Partnership Central South Coast Cancer Network Safety-netting - Screening I do not wish to take part in bowel cancer screening, and am aware this may delay the diagnosis of bowel cancer were I to develop it. (signed)…………………………………………………

54. Strength Through Partnership Central South Coast Cancer Network Safety-netting – Investigations if cancer is on differential diagnosis Blood tests (if checking for tiredness, shortness of breath) CXR USS for ?ovarian cancer Systems in practice so if result not received can be followed up.

55. Strength Through Partnership Central South Coast Cancer Network Safety-netting – 2ww referrals A surprising number of 2ww referral patients who fail to attend/postpone Make sure patient understands that referral is to exclude the possibility of cancer Have system to follow up/flag up any DNAs at 2ww appointments (similar to screening DNAs) May be regarded as good practice to ask patient to have GP follow up 4 weeks after referral to 2ww, as by then the diagnosis is likely to have been met.

56. Strength Through Partnership Central South Coast Cancer Network Other elements of safety-netting include: Communicating the existence of uncertainty Outlining exactly what the patient needs to look out for How to seek further help and What to expect about time course

57. Strength Through Partnership Central South Coast Cancer Network Patient Pathway: LAEDI - 2012 - Summary Awareness Presentation Investigation Referral Diagnosis New Practice Profiles: Target Meetings RCGP/LMC Meetings Practice visits Safety netting National Bowel cancer awareness: Jan 2012 Nationwide Multiple Media Primary Care RAT launch January 2012 Pan network 2ww referral forms Lung Cancer Education Day 21.3.12 Engaging with CCGs Summer 2012 Be Clear on Cancer Lung cancer

58. Strength Through Partnership Central South Coast Cancer Network CSCCN LAEDI Programme: Any questions?