East Midlands Cancer Clinical Network Improving Lung Cancer Outcomes. Dr Paul Beckett Royal Derby Hospital

Transcription

1 East Midlands Cancer Clinical Network Improving Lung Cancer Outcomes Dr Paul Beckett Royal Derby Hospital

2 Number of resections Five year net survival Background to the Workshop Survival for lung cancer is improving but remains poor in comparison to other cancer types % 16% 14% 12% 10% Significant proportion of lung cancer diagnoses made after an emergency presentation Hybrid-based prediction 8% 6% 4% 2% 0%

3 Routes to Diagnosis Elliss-Brookes et al, British Journal of Cancer (2012) 107, doi: /bjc

4 Routes to Diagnosis Elliss-Brookes et al, British Journal of Cancer (2012) 107, doi: /bjc

5 National Lung Cancer Audit 133,530 cases of NSCLC who presented : 19% referred non-electively This route of referral was strongly associated with: more advanced disease stage (e.g. in Stage IV OR: 2.34, 95% CI: , p < 0.001) worse performance status (e.g. in PS 4 OR: 7.28, 95% CI: , p < 0.001) worse socioeconomic status extremes of age These patients were more likely to have died within 1 year of diagnosis: Multivariate hazard ratio of 1.51 (95% CI: ) Beckett et al, Lung Cancer Mar;83(3): doi: /j.lungcan

6 Role of Primary Care In most (of 222) cases, patients had contact with their practice before diagnosis, primarily in the period immediately before admission. Accounts of protracted primary care contact generally demonstrated complexity, often related to comorbidity, patient-mediated factors or reassurance provided by negative investigations. Learning points identified by practices centred on the themes of presentation and diagnosis, consultation and safety-netting, communication and system issues, patient factors and referral guidelines. Mitchell et al, British Journal of Cancer (2015) 112, S50 S56 doi: /bjc

7 Cancer-specific variation in emergency presentation Among patients with the same cancer, the risk for emergency presentation varies notably by sex, age and deprivation group. The findings suggest that, beyond tumour biology, diagnosis through an emergency route may be associated both with psychosocial processes and with difficulties in suspecting the diagnosis of cancer after presentation. British Journal of Cancer (2015) 112, S129 S136 doi: /bjc

8 CADIAS Study Observational, prospective case-controlled study looking at the current pathway and organisational clinical and patient factors to first diagnosis emergency lung and colorectal cancer presentation. New diagnosis of lung or colorectal cancer made during an admission which followed presentation via emergency department or the Acute Assessment/Medical Unit in the hospitals involved. Patients who have been referred by their GP to secondary care with suspected cancer, but who have not yet received or attended the relevant appointment. Patients in whom cancer is diagnosed incidentally during an emergency admission for an unrelated medical problem. CADIAS (East of England):

9 CADIAS Study Barriers to symptomatic presentation: Patients own perceptions (66%) Primary care factors (25%) 80% stage 3 or 4 at diagnosis 48% PS 0-1 at diagnosis Transport difficulties (9%) Reported co-morbidities: Mean number 1.4 Three or more co-morbidities 44% Five or more co-morbidities 16% CADIAS (East of England):

10 CADIAS What has been learned? - SYSTEM Patients referred for 2WW but they had deteriorated before being seen. Patients seen after being referred by 2WW but who were admitted shortly thereafter when their condition deteriorated. Patients previously been referred or admitted to hospital but who had been discharged or had been diagnosed with another condition. Patients who waited a considerable amount of time for an appointment after an urgent referral or had not receiving a clinic appointment at all. CADIAS (East of England):

11 CADIAS What has been learned? - PATIENTS Associated recent life events (co-morbidities/ poor health, bereavement, relationship problems, financial problems) cancer diagnosis greater. Very little advice sought from anyone for the trigger symptom. Generally patients did not go to their GP as they thought the problem was not serious enough or to waste the GPs time. 10.4% of patients found making an appointment difficult. 30% considered the trigger symptom was serious attributed this to lifestyle or age related. Both lung and colorectal patients had previously presented at their hospital with cancer symptoms or as emergency on more than one occasion. More than 35% of these saw their GP more than 6 occasions in 12 months & more likely to see as many as 3 GPs. CADIAS (East of England):

12 CADIAS Specific learning for GPs Atypical presentation. Most cancers present atypically and do not follow conventional 2WW criteria. Vague symptoms. Can be only presenting symptom, e.g. otherwise unexplained weight loss. Symptom persistence. Often denote serious pathology. Cancer vigilance. Think cancer. Continuity of care. Fragmented care leads to delays in diagnosis. Safety netting. Ensure patients know how, why and when to comeback. Investigation: thresholds, delay and false reassurance. Have low thresholds, particularly for CXRs; normal investigations do not preclude cancer in another site. Communication breakdown. Failsafe mechanisms to ensure hospital letters and abnormal investigations do not slip through the net CADIAS (East of England):

13 Our Project To replicate the SEA methodology used in other areas To use the process obtained to generate learning To use the learning to deliver meaningful change