Transcript Funders - Cambridge Institute of Public Health

Optimising symptomatic cancer
diagnosis in primary care
Dr Fiona Walter
The Primary Care Unit
Cambridge Institute
of Public Health
AWAY DAY
25th June 2014
How has our primary care cancer diagnosis
research influenced policy and practice?
‘Exemplar of the work of the PCU’
 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
45
BACKGROUND
SWE
CAN
40
AUS
NOR
35
DEN
UK
30
25
20
1995-99
2000-02
2005-07
Lung Cancer 1yr RS
The National
Awareness and Early
Diagnosis Initiative
(NAEDI)
90
AUS
CAN
SWE
NOR
DEN
UK
AUS
85
SWE
CAN
80
NOR
DEN
75
UK
70
65
1995-99
2000-02
2005-07
Colorectal Cancer 1yr RS
ICBP: Coleman et al, Lancet 2011
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 referrals
Preliminary results suggest:
 Impact on stage at diagnosis
 Trigger presentation
PUBLIC AWARENESS- skin cancer
 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
Walter et al. BMJ Open, in press
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
RECRUITMENT
To end May 2014
COLORECTAL
2506
LUNG
996
PANCREAS
334
me personally, the way I was
brought up, one, you don’t talk
private nature
symptoms’
aboutof
downstairs,
and two, you
don’t look at downstairs. So,
“that was probably the thing that
when people ask me questions
put me off going more than
like “Is it in the stool?” or
anything in the first instance was
anything like that, I tend not to
the embarrassment of that sort of
look, I do now, but I didn’t
thing. .. I don’t suppose anybody
then” (Female, 54 years, NC)
likes, whether it’s a doctor or not,
PATIENT VIEWS- ‘
Inhibiting
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
 Socio-cultural norms
 Symptom monitoring
 Embarrassment of investigations
“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)
Facilitating
PATIENT VIEWS- diagnostic tests & referrals
PIVOT study- Bristol, Exeter, East of England
Clinical vignettes presented on a tablet in GP waiting rooms
Banks et al. Lancet Onc 2014
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

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
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]