Frede Olesen. Frede Olesen

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1 Professor, DrMedSc, GP, FRCGP(hon.) The Research Unit for General Practice, Aarhus University Chairman of the board of The Danish Cancer Society

2 The pathway to better results Support to realtives Terminal care Palliation Follow up, recurrence Treatment Rehabilitation Confirmed detailed diagnosis Primary diagnostic procedures, waits, available service Symptoms which symptoms predictive value Crisis Perceived symptoms, treshold for contact to Gen. Practice Screene Need for GP Lifestyle, health promotion, prevention

3 The disease journey Today s focus Palliation Support to realtives Terminal care Follow up, recurrence Treatment Rehabilitation Confirmed detailed diagnosis Primary diagnostic procedures, waits, available service Symptoms which symptoms predictive value Crisis Perceived symptoms, treshold for contact to Gen. Practice Screene Need for GP Lifestyle, health promotion, prevention

4 Waits are unacceptable: Cancer as an acute disease the 3-point strategy from the Danish Cancer Society in : Improved acces to relevant diagnostic investigations without waits when required by the front line care in a heath care system (general practice) Reduce double gatekeeping 2: Diagnostic centres at all major hospitals Multidisciplinary acute assessment by specialists without waits A patient can be referred with the diagnosis: I suspect serious disease, but I do not know which disease cancer is a possibility 3: Fast track clinical pathways when a specific cancer is considered The fast track packages have been developed by multidisciplinary cancer groups in a process led by the National Board of Health Regional multidisciplinary cancer groups implement the strategy FROM 2007 MASSIVE POLITICAL AND MANAGEMENT FOCUS ON CANCER AS AN ACUTE DISEASE

5 Waits are unacceptable: Cancer as an acute disease the 3-point strategy from the Danish Cancer Society in : Improved acces to relevant diagnostic investigations without waits when required by the front line care in a heath care system (general practice) Reduce double gatekeeping 2: Diagnostic centres at all major hospitals Multidisciplinary acute assessment by specialists without waits A patient can be referred with the diagnosis: I suspect serious disease, but I do not know which disease cancer is a possibility 3: Fast track clinical pathways when a specific cancer is considered The fast track packages have been developed by multidisciplinary cancer groups in a process led by the National Board of Health Regional multidisciplinary cancer groups implement the strategy

6 Waits are unacceptable: Cancer as an acute disease the 3-point strategy from the Danish Cancer Society in : Improved acces to relevant diagnostic investigations without waits when required by the front line care in a heath care system (general practice) Reduce double gatekeeping 2: Diagnostic centres at all major hospitals Multidisciplinary acute assessment by specialists without waits A patient can be referred with the diagnosis: I suspect serious disease, but I do not know which disease cancer is a possibility 3: Fast track clinical pathways when a specific cancer is considered The fast track packages have been developed by multidisciplinary cancer groups in a process led by the National Board of Health Regional multidisciplinary cancer groups implement the strategy

7 Worldwide: we all appreciate the good sides of fast track pathway packages for serious disease But: it is dangerous as the only approach to first line diagnostics! The problem: can only be used, when cancer is very likely

8 Why did the Danish Cancer Society demand the 3-step strategy

9 Diagnostic scan Progression in tumor-size, but stage unchanged (T4) Treatment planning scan A patient with 19 days between scans. Note the bone destruction AR Jensen et al. Radiother Oncol 2007

10 Diagnostic scan Progression in N-site, but stage unchanged (N3) Treatment planning scan A patient with 47 days in between scans. Note growth of the lymph node metastasis and appearance of a contralaterale metastasis AR Jensen et al. Radiother Oncol 2007

11 Time intervals and milestones in early diagnosis Diagnostic delay Weller, Vedsted, Rubin G, et al. The Aarhus statement: improving design and reporting of studies on early cancer diagnosis. Br J Cancer. 2012;106: doi: /bjc

12 System-related delay before or whether the system reacts appropriately? Delay in days % percentile: 32 days Median: 55 days 75% percentile: 93 days Patients Delay > 1 year = 365 days Rikke Pilegaard Hansen. PhD. 2008; Aarhus University

13 When do we classify cancer stage? Danish patients are diagnosed in a later stage One of the most frequent statements made, but we do not know if it is true If you make health care planning based on this assumption you may make great mistakes The blind spot is the length of the clinical pathway Danish patients are in a later stage, when treatment starts!!! This may be due to late presentation, late suspicion of cancer and a slow clinical pathway within the health care system To which extent does a slow clinical pathway influence prognosis?

14 The missing link in the diagnosis of serious disease What do we know about the journey from first symptom to start of the specific tratment? Can we improve and shorten the diagnostic proces? A major hitherto neglected research focus The Danish Cancer Society and the Novo Nordic Foundation have initiated and funded this reseach including the Research Centre for early diagnosis of cancer i Aarhus the CaP centre led by Prof. Peter Vedsted Silkeborg and Vejle Hospitals led the development of new thinking about organisation of the diagnostic process within the hospital A special focus on service in the first line diagnostic process

15 Positive predictive value of alarm symtoms in GP - a GP must investigate or refer between 13 and 50 patients to find one cancer in patients with alarm symptoms Blood in the urine Difficulty in swallowing Blood in sputum Men Women N Cancer PPV 3 year Cancer PPV 3year ,4% 162 3,4% ,7% 81 2,4% ,5% 81 4,3% Blood in stools ,4% 154 2,0% Jones R et al. BMJ 2007;334;1040

16 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

17 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

18 E.g. Presenting symptoms in 1900 consecutive newly diagnosed cancer patients Nielsen, Hansen, Vedsted. Ugeskr Læger. 2010;172:

19 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

20 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

21 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

22 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

23 A wrong way of analysing data Dødsrisiko efter 3år Ventetid uger

24 A slow diagnostic process influences prognosis - a UK estimate: lives/year -in Denmark with 5.5 mill. inhab.: /year

25 The 3-step model for improvement If it is simple : Access to quick and correct diagnostic tests If it is difficult: Access to comprehensive diagnostic service If we think we know: The fast track package, when we know the way forward

26 Let us share our experiences and learn more

27 Total delay (mean) Patient, Fordeling doctor af and patient, system læge delay og system in a cohort delay - Only 50% present with obvious signs of cancer The focus for this conference Alarm 49,7% 49.7% Almen 23.9% Ukarakteristisk 26.4% Lægens svar vedr. symptomtolkning General 23,9 % Non char. symptoms 26,4% Patientdelay Systemdelay Prim Doctor Lægedelay PHC Systemdelay Sec

28 The cancer journey Todays focus Palliation Support to realtives Terminal care Follow up, recurrence Treatment Rehabilitation Confirmed detailed diagnosis Primary diagnostic procedures, waits, available service Symptoms which symptoms predictive value Crisis Perceived symptoms, treshold for contact to Gen. Practice Screene Need for GP Lifestyle, health promotion, prevention

29 The hospital as service provider to general practice in a comprehensive seamless health care system

30 The ultimate aim: a better general approach to appropriate and quick diagnosis in a health care system. A large locomotive for general improvements in early diagnosis of serious disease

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