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29/03/2016

 Primary care role in cancer


 NICE Summary
 GP investigations
 What's largely unchanged
 Changes in 2ww criteria
 Symptoms
Dr Karen Sennett Islington GP cancer lead
 Safety netting
 What can GPs do now
 What do commissioners + providers need to do
 Resources
 Questions

 Prevention
 Screening Cervical/Bowel/Breast
 Earlier diagnosis “finding the needle in the haystack” Low fruit &
diagnostics +2ww referral Smoking Overweight
veg intake
 300,000 new cancer diagnoses pa E+W
increasing 2ww referral rates, improving survival,
decreasing stage at diagnosis and decreasing Sun
diagnoses at emergency admissions Alcohol Occupation
 Review after diagnosis exposure
 Pt/family/carer support and genetic advice
 Cancer as Long Term Condition-Post survival support.
>50% >5 years.275/10,000 patients Physical
Infections Red meat
 Palliative care inactivity

 Updates 2005 guidance


 Based on primary care evidence
 Based on patient symptoms not risk factors
 Evidence included if risk of cancer>3%
 Sensitivity>75%, NOT 100%
 Recommendations NOT requirements ie all ref forms need option for
referral when cancer suspected outside criteria
 Offer = do. Consider= is an option in NICE
 Lower threshold used for childhood cancers
 3 parts of guidance
- Symptoms related to individual cancers
- Symptom lists as 1 symptom can be several cancers
- Safety netting for low risk, not no risk patients
 Diagnostics will need commissioning, where not available at present
 New 2ww referral forms - pan London 1.4.2016
 Extra category of GP concern re cancer for all forms

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Criteria for haematological tests and refs


1.Gastroscopy within 2weeks if
-dysphagia or 
-aged 55+ weight loss + any of dyspepsia or reflux
2. CT scan abdomen to detect pancreas cancer within 2w if  Skin 2wk refs still suspected melanoma and
-aged 60+ wt loss and any of
-diarrhoea/vomiting/backpain/abdpain/nausea squamous cell cancer only
/vomiting/new onset dm
3.Consider PSA blood test and rectal examn if
-any lower urinary tract symptoms
BCC routine refs,unless high risk site eg face
-new erectile dysfunction
-visible haematuria
T zone
4. CXR If 40+ one of following if ever smoker or+2 of following if never smoker
Cough/ fatigue/sob/chest pain/ wt loss/ appetite loss
-Dermatoscopy added as option
 Breast cancer
Consider CXR if persistent or recurrent chest infection/ clubbing/raised platelets /LN
5. Dermoscopy if available to consider moles that don’t meet criteria for 2w ref

 Head and neck cancers minor changes only,


6. US and CA125 blood for detecting Ovarian cancer
7. US if suspect soft tissue sarcoma, xray if suspect bone sarcoma

including option to use community dentists


8. MRI brain scan within 2wks or ct scan if mri contraindicated
9.FOB <60 yr - change in bowel habit or iron defic aneamia, part of safety netting lower risk group
NB THIS NOT COMMISSIONED IN LONDON. FOBfit evaluation awaited
where available

:
Abdominal pain & 60y+ Abdominal pain & 40y+
unexplained weight loss unexplained weight loss

Unexplained rectal 50y+


Iron deficiency anaemia 40y+
bleeding
or change in bowel habit
Iron deficiency anaemia 60y+
Unexplained rectal 50y+ or change in bowel habit
bleeding
n.b. patients diagnosed at stage 1+2 have 97% chance
Turn to the person next to you and discuss which age matches
of survival compared to 7% of patients with advanced
which symptom cancer. Treatment cost for stage 3+4 or 2.5 times
greater than if diagnosed at stage 1+2

 Presents to the GP with crampy abdominal pain present for 4 weeks  Presents to the GP with crampy abdominal pain present for 4 weeks

What would you ask? What would you ask?


1. Urinary symptoms – no
2. Change in bowel habit - no
3. PR bleeding – no
4. Vomiting – no
5. Weight loss – yes 3kg in last month

What would you do?

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 Presents to the GP with crampy abdominal pain present for ? weeks


2ww refer for lung cancer if they:
What would you ask?  have chest X-ray findings that suggest lung cancer or
1. Urinary symptoms – no  are aged 40+ with unexplained haemoptysis.

2. Change in bowel habit - no Offer a chest X-ray in people aged 40+ if they have 2 or more of the following
unexplained symptoms, or if they have ever smoked and have 1 or more of the
3. PR bleeding – no following unexplained symptoms:
 cough
4. Vomiting – no
 fatigue
5. Weight loss – yes 3kg in last month  shortness of breath
 chest pain
What would you do?  weight loss
2WW (in the past for >40yrs rectal bleeding & looser stool for  appetite loss.

>3 weeks)
Consider an urgent chest X-ray if aged 40+ with any of the following:
 persistent or recurrent chest infection
 finger clubbing
 supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
 chest signs consistent with lung cancer
 thrombocytosis.

Prostate cancer Symptoms of concern in children and young people


Take into account the insight and knowledge of parents and carers when considering making a referral for suspected
2ww refer men for prostate cancer if their prostate feels
malignant on digital rectal examination. PSA Cut-off Values cancer in a child or young person. Consider referral for children if their parent or carer has persistent concern or
anxiety about the child's symptoms, even if the symptoms are most likely to have a benign cause.
Consider a prostate-specific antigen (PSA) test and digital Leukaemia in children and young people
rectal examination to assess for prostate cancer in men Age PSA Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained
petechiae or hepatosplenomegaly. [new 2015]
with: Offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and young people with any
 any lower urinary tract symptoms, such as nocturia, 40-49 2.7 of the following:
urinary frequency, hesitancy, urgency or retention or  pallor
erectile dysfunction or visible haematuria. 50-59 3.9  persistent fatigue
2ww refer men for prostate cancer if their PSA levels are  unexplained fever
above the age-specific reference range. 60-69 5.0  unexplained persistent infection
 generalised lymphadenopathy
70-75 7.2  persistent or unexplained bone pain
Bladder cancer  unexplained bruising
unexplained bleeding
2ww refer for bladder cancer if aged 45+ and have:

Hodgkin's lymphoma in children and young people
 unexplained visible haematuria without urinary tract infection or visible haematuria Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for Hodgkin's
that persists or recurs after successful treatment of urinary tract infection, or lymphoma in children and young people presenting with unexplained lymphadenopathy. When considering referral,
take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight
 aged 60+ and have unexplained non-visible haematuria and either dysuria or a loss.
raised white cell count on a blood test. Brain tumour/cancers
Consider non-urgent referral for bladder cancer in people aged 60+ with recurrent Consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system
cancer in children and young people with newly abnormal cerebellar or other central neurological function.
or persistent unexplained urinary tract infection.

Soft tissue sarcoma  Upper GI symptoms- gp ordered gastroscopy,within 2w, NOT 2ww ref form
Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue
sarcoma in children and young people with an unexplained lump that is increasing in size.  Pancreatic cancer
Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have -2WW ref if they are aged 40 and over and have non infective jaundice.
ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical
concern persists. -Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent
Bone sarcoma ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young weight loss and any of the following:
people if an X-ray suggests the possibility of bone sarcoma.  diarrhoea
Consider a very urgent direct access X-ray (to be performed within 48 hours) to assess for bone sarcoma in children
and young people with unexplained bone swelling or pain.  back pain
Neuroblastoma  abdominal pain
Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for neuroblastoma
in children with a palpable abdominal mass or unexplained enlarged abdominal organ.  nausea
Retinoblastoma  vomiting
Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in  constipation
children with an absent red reflex.
Wilms' tumour  new-onset diabetes
Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for Wilms' tumour in
children with any of the following:
 Gynae – 2ww ref -PMB if lmp>12mths ago
 a palpable abdominal mass
 an unexplained enlarged abdominal organ -NOT 2ww ref for IMB
 unexplained visible haematuria -CA125 + US if ovarian Ca suspected
(London advise US/CA125 same time)
-Consider US if 55yr+ with new unexplained vaginal discharge

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 Individual symptoms may be from a number  No evidence found for safety netting, but
of cancers see symptom section consensus would support earlier diagnosis
 Appetite +weight loss PPV - 4.3% any cancer,  Some symptoms don’t reach the 3% threshold but
may have cancer
-2.3% lung cancer
 Options
- If clinical concern re cancer , refer even if don’t
 DVT - PPV of 3.49% any cancer, lung 0.9% meet criteria. NICE criteria are recommendations
NOT requirements
- If low concern but not no concern offer either
follow up at fixed time or offer patient to come
back if symptoms not settled or worsened

 Refer to guidance when unsure re symptom or individual tumour  Work with primary care re aiming for earlier diagnosis and treatment and
 Use new NICE criteria, even if your referral forms not yet updated new referral forms
Have capacity for the 2ww appts, including appts on choose and book
 If you suspect cancer, but not quite meeting criteria, do still use 
 Have capacity for all cancer targets
2ww form and state reason
 Increase capacity and timing of diagnostics within 2weeks, when cancer
 2ww forms on choose and book or email. Faxing stopping in suspected
London 1.4.2016 -US for gynae or soft tissue sarcoma
 Do ensure patient available for appts for 2wks and aware that is -Gastroscopy
appt for possible cancer -MRI brain
 Your CCG to commission gp direct access tests for suspected -CT scan abdomen
cancer, CXR, US, MRI Brain, gastroscopy, -Continue CXR-reports with GPs max 1 week, blood tests PSA and CA125
CT scan abdomen ,PSA, CA125, all within 2w -FOB IF commissioned for low risk patients
 Use direct access diagnostics, if you know available within 2w - Consider if dermoscopy and community dental services for suspected
 Gps will need systems for followup of diagnostics, what to do cancer should be commissioned
next if eg gastroscopy normal
>Systems for fasttrack to 2ww appt,as well as gp getting results to ds with
patient, when cancer detected on diagnostic eg CXR/ US/ Gastroscopy/
CAT scan

 Guidelines:
 Suspected cancer: Recognition and Referral
 http://www.nice.org.uk/guidance/ng12
 E-learning:
 BMJ Learning Quick tips: referral for suspected cancer - your summary of the 2015 NICE guideline (10 mins)
 http://learning.bmj.com/learning/module-intro/.html?moduleId=10053492
 Pulse learning Key Questions live: NICE cancer guidelines
 http://pulse-learning.co.uk/clinical-modules/cancer/kq-live-nice-cancer
 Journals:
 Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance
 http://www.bmj.com/content/350/bmj.h3036
 Suspected cancer (part 2—adults): reference tables from updated NICE guidance
 http://www.bmj.com/content/350/bmj.h3044
 Toolkit:
 Macmillan Rapid Referrals Guideline
 http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PCCL/Rapidreferralguidelines.pdf

 National Campaigns:
 eg march/ april 2016 “ Blood in Pee” public campaign
 Referral forms: Your local forms
 Cancer decision support tools:
 Qrisk and RAT mousemats or computer tools

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 karen.sennett@nhs.net