1. Nice suspected cancer referral guidance 2015
Dr Imogen Staveley, Camden CCG cancer clinical lead

3. Stand up if you have read the NICE Guidance
Introduction
Overview from Public Health (slides provided by Gemma Lyons)
NICE Guidance 2015 (update from 2005)
GP direct access testing
What to do NOW and in the FUTURE
Stand up if you have read the NICE Guidance

4. Incidence
It is estimated that 6,000 people living in Camden have had a diagnosis of cancer 2015
On average, 824 people were diagnosed with cancer in Camden each year
The most common cancers in Camden are breast, prostate, bowel and lung cancer.
Source:
Projections of cancer prevalence from the National Cancer Intelligence Network, 2014 (
pooled incidence of cancer from the HSCIC (Incidence of all cancers: directly standardised rate, all ages, annual trend, MFP), 2015

5. Incidence by cancer type
Significantly lower incidence of urological cancer in Camden than England, after adjusting for the difference in age between the two populations.
The other main cancer types show no significant difference with England.

6. Mortality from Cancer in Camden
Cancer is the biggest cause of death in Camden 2013
354 deaths (178 early deaths in people aged under 75 years) each year from cancer in Camden
Lung cancer is the biggest cause of cancer death, followed by breast and bowel cancer
Cancer deaths by cancer type, Camden
Source:
pooled mortality from all cancer from the HSCIC (Mortality from all cancers: directly standardised rate, all ages, 3-year average, MFP), 2015
pooled premature mortality (<75) from all cancer from the HSCIC (Mortality from all cancers: directly standardised rate, <75 years, 3-year average, MFP), 2015

7. Mortality by cancer type
Camden has the 12th lowest all cancer mortality rate out of 32 London CCGs, after adjusting for the differences in age.
Mortality rates for each of the major cancer types in Camden are similar to the national averages
(see overall comparison on next slide)

8. Mortality from all cancer, London CCGs

9. One-year cancer survival rate, London CCGs

10. Cancer screening - comparison
Camden breast screening coverage declined in 2015 to be the lowest rate in London, at 56%
Camden’s screening rates for cervical, breast and bowel cancer are still significantly lower than London and England averages.

11. Incidence, mortality & survival
Cancer is the biggest cause of death in Camden
Camden has the 12th lowest all cancer mortality rate out of 32 London CCGs, after adjusting for the differences in age
Cancer survival rates are improving in England and Camden
Incidence, mortality & survival
43% of cancers estimated to be preventable
Main preventable risk factors are smoking, diet and alcohol
Deprived residents are more likely to have these risk factors
Public Health commissions lifestyle services to tackle these
Risk factors & prevention
Screening rates are lower than London average & below targets
Breast screening rates have dropped to lowest in London
National & local campaigns raise awareness of cancer signs/symptoms
Screening & early diagnosis

12. Largely the same as before (2005)
Haematological cancer
Breast cancer
Skin cancer: Dermoscopy if available to consider moles that don’t meet criteria for 2ww referral
Head & neck cancer: minor changes only e.g. community dentists
can do 2WW
Skin 2wk refs still suspected melanoma and squamous cell cancer only.
BCC routine refs,unless high risk site eg face T zone
-Dermatoscopy added as option

13. Mr X – 43 years old ♂
Presents to the GP with crampy abdominal pain present for 4 weeks
What would you ask?

14. Mr X – 43 years old ♂
Presents to the GP with crampy abdominal pain present for 4 weeks
What would you ask?
Urinary symptoms – no
Change in bowel habit - no
PR bleeding – no
Vomiting – no
Weight loss – yes 3kg in last month
What would you do?

15. Mr X – 43 years old ♂
Presents to the GP with crampy abdominal pain present for ? weeks
What would you ask?
Urinary symptoms – no
Change in bowel habit - no
PR bleeding – no
Vomiting – no
Weight loss – yes 3kg in last month
What would you do?
2WW (in the past for >40yrs rectal bleeding & looser stool for >3 weeks)

16. Changes to 2ww referral criteria (I)
Colorectal cancer suspected, 2WW referral if:
Abdominal pain & unexplained weight loss
60yr+
Iron deficiency anaemia or change in bowel habit
40yr+
50yr+
Unexplained rectal bleeding
Turn to the person next to you and discuss which age matches which symptom

17. Changes to 2ww referral criteria (I)
Colorectal cancer suspected, 2WW referral if:
Abdominal pain & unexplained weight loss
40yr+
Unexplained rectal bleeding
50yr+
Iron deficiency anaemia or change in bowel habit
60yr+
n.b. patients diagnosed at stage 1+2 have 97% chance of survival compared to 7% of patients with advanced cancer.
For greater detail see:

18. Changes to 2ww referral criteria (I)
Controversial:
Colorectal cancer suspected, 2WW referral if FOB positive for blood if<60yrs & iron deficiency anaemia or change in bowel habit
When logistics allow: Upper GI cancer suspected, direct access 2WW OGD NOT 2WW referral
For more detail:

19. Ms A - 46 years old♀
7 weeks of IMB Stopped the POP one year ago Normal vaginal examination Would you refer on 2WW?

20. Ms A - 46 years old♀
7 weeks of IMB Stopped the POP one year ago Normal vaginal examination Would you refer on 2WW? NO – IMB has been taken out of 2WW referral criteria
Gynaecological suspected cancer:
2WW referral if Post Menopausal Bleeding (LMP>12mths ago)
CA125 + pelvic USS if ovarian cancer suspected (London advise simultaneously)
Consider pelvic USS if 55yr+ with new unexplained vaginal discharge
For more information:

21. Changes to 2ww referral criteria (II)
Suspected bladder cancer:
≥45yrs & unexplained (no UTI) visible (macroscopic) haematuria or visible haematuria that persists or recurs after treatment of UTI
≥60yrs & unexplained non-visible (microscopic) haematuria & either dysuria or ↑WBC on blood testing
Consider non-urgent referral for bladder cancer in people aged ≥60yrs with recurrent or persistent UTI.

22. Changes to 2ww referral criteria (III)
Suspected Lung Cancer, 2WW referral if:
CXR findings that suggest lung cancer
≥40yr with unexplained haemoptysis
(CXR same day as 2WW referral done)

23. “the proportion diagnosed through the GP 2WW referral route increased from 22% (2006) to 28% (2013)”
“in 2006, 25% cancers diagnosed as emergency, in %”

24. GP investigations (I) Gastroscopy within 2 weeks if:
dysphagia OR aged ≥55yrs weight loss & any of dyspepsia or reflux
2WW Abdominal CT scan to detect pancreatic cancer if:
over ≥60yr weight loss AND any of
diarrhoea/vomiting/back pain/abdominal pain/nausea/vomiting/new onset DM
Consider PSA blood test and rectal examination if:
lower urinary tract symptoms
new erectile dysfunction
visible haematuria

25. GP investigations (II)
CXR if ≥ 40yrs
+ 1 of cough/fatigue/sob/chest pain/weight loss/appetite loss
if ever smoker, OR
+2 of cough/fatigue/sob/chest pain/weight loss/appetite loss
if never smoker
Consider CXR if persistent or recurrent chest infection/clubbing/raised platelets/supraclavicular lymphadenopathy or persistent cervical lymphadenopathy/chest signs consistent with lung cancer

26. GP investigations (III)
USS if suspect soft tissue sarcoma, x-ray if suspect bone sarcoma
MRI brain scan within 2wks (CT scan if MRI contraindicated)
New erectile dysfunction or urinary symptoms offer PSA

27. Symptoms
Individual symptoms may be from a number of cancers. Remember to look out for them e.g.
Appetite + weight loss - Positive Predictive Value
4.3% any cancer
2.3% lung cancer
DVT – Positive Predictive Value
3.49% any cancer
0.9% lung cancer

28. What can GPs do now & what is to come?
If you suspect cancer, but 2WW criteria NOT entirely met, do still refer (use London Cancer 2WW form and state reason)
Use CHOOSE & BOOK to get actual appointment when possible (better patient experience & fewer DNAs)
When no appointments on choose & book, either form or fax or defer to provider on choose and book
Ensure patient AVAILABLE for appointments for 2 weeks & AWARE that is appointment for possible cancer
Some GP direct access tests already available e.g. CXR, US, MRI Brain (must be within 2WW), PSA, CA125,
TO COME: 2WW gastroscopy, 2WW CT scan abdomen
GPs will need systems for follow-up of diagnostics

29. Camden Specific updates
Multidisciplinary Diagnostic Centre (MDC)
Cancer joining Long-term Conditions Locally Commissioned Service
Community pharmacy campaign
Continued awareness raising amongst community groups
Local media campaign
New primary care facilitator – Christine Harding.
GI audit has been reported on
BMJ OnExamination Camden Specific Cancer modules are only available for one further year and you have to register before the end of this November if you want access – if you have lost your login details.

30. Lifestyle Programmes from 1 April 2016
All joint across Camden & Islington
One provider to deliver community smoking cessation across both boroughs
Smoking Cessation
One provider to deliver weight management & EoR
Cancer exercise programme incorporated into EoR
Adult weight management & Exercise on Referral
One provider to deliver community-based checks across both boroughs
NHS Health Checks

31. Christine Harding 07826537310 Christine.harding3@nhs.net
Session (code)
Details
Length
Delivery options
Date available
Cancer data (GP1)
Overview and discussion of local cancer data – including practice level data
30-45mins
- Individual GP practice meeting
- Cancer practice profiles ed to practice
Now
Cancer decision support tools (GP2)
Introduction to using QCancer on EMIS
30-40mins
Individual GP practice meeting
Winter 2015
New 2WW forms (GP3)
Overview of guidance on new 2WW forms
30mins
2016 tbc
New NICE Guidelines for cancer (GP4)
Summary of new guidance plus links to useful resources
Safety netting workshop (GP5)
Interactive workshop with scenarios covering communication; consultations, practice systems & coding
1hr 30mins
- Group of practices
- GP training practice
SEA workshop (GP6)
Interactive workshop including examples of ‘good’ and ‘bad’ SEAs; completing an SEA; case study examples; sharing learning from practice SEAs
Christine Harding

32. GI Audit
Many patients are being seen regularly; this does not support the idea that access is a major barrier to cancer detection.
What is not clear is whether patients present the relevant symptoms or whether their clinicians are eliciting new & worrying symptoms when they are looking after a number of other conditions at the same time.
What is noticeable from the data about symptoms is that there appear to be a lot of patients who had no symptoms at all or only had 1-2 symptoms. Clearly this information is dependent on the detail in the original notes & the quality of the data recording but does suggest that patient awareness is critical & that clinicians need to be very alert to any possible suggestion of new symptoms.

33. GI Audit II
In the patients with upper GI cancers progressive weight loss +/- dysphagia accounted for 60% of the cases. This accords with a recent audit in the RFH in which weight loss & dysphagia were the commonest presenting symptoms.
In the lower GI cancers change of bowel habit+/- bleeding from back passage abdominal pain or constipation accounted for 66% of the cases.
In the majority of cases these symptoms did not appear to have been of long duration & in most cases once these classic symptoms presented GPs were using 2WW protocols to refer patients. However the less specific symptoms of upper GI malignancy seem less likely to make patients attend & the first symptoms were quite late such as marked weight loss & dysphagia.
Mild anaemia did not always result in a referral & there was no clear protocol for repeating tests.
Follow-up of mild or vague symptoms was varied. There might be potential for developing a guideline for the management of patients who are NOT being referred on a 2WW pathway to ensure that they are followed up consistently& there is a low threshold for referral if symptoms persist.

34. Summary Updates 2005 guidance
Based on patient symptoms not risk factors
Recommendations NOT requirements i.e. all referral forms need option for referral when cancer suspected outside criteria
Consider GP direct access to testing

35. Resources:
Guidelines: Suspected cancer: Recognition and Referral E-learning: BMJ Learning Quick tips: referral for suspected cancer - your summary of the 2015 NICE guideline (10 mins) Pulse learning Key Questions live: NICE cancer guidelines Journals: Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance Suspected cancer (part 2—adults): reference tables from updated NICE guidance Toolkit: Macmillan Rapid Referrals Guideline

39. Questions?
Camden CCG Cancer Clinical Lead: Public Health and Screening: