Jon Emery Professor of General Practice University of Western Australia Director of PC4 Early cancer diagnosis I went to see my oncologist in hospital earlier this week and we talked about this and that and the importance of catching cancer early which I found a bit annoying as they had ID: 568309
Download Presentation The PPT/PDF document "The challenges of early diagnosis of can..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
The challenges of early diagnosis of cancer in primary care
Jon EmeryProfessor of General PracticeUniversity of Western AustraliaDirector of PC4Slide2
Early cancer diagnosis
‘I went to see my oncologist in hospital earlier this week and we talked about this and that, and the importance of catching cancer early, which I found a bit annoying as they had not caught my cancer early, but it turned out he was just filling in time and wanted to talk to me about something different.’Slide3
Onctalk.comSlide4
Cochrane review of Hemoccult
screening on colorectal cancer mortalitySlide5
Symptomatic cancer and early diagnosis
Richards et al Lancet 1999Delays from symptoms to diagnosis of 3-6 months associated with 7% worse 5-year survival from breast cancerEffects not due to lead time bias
Longer delays associated with more advanced diseaseSlide6
Colorectal cancer diagnostic interval and mortality
Torring et al BJC 2010Waiting list paradoxDiagnostic intervals >5 weeks associated with worsening mortality if ‘alarm symptoms’.
Similar U-shaped association for lung, melanoma and prostate cancer. Slide7
Variations in cancer survival
International variations in cancer survivalAustralia, Canada and Sweden better than UK and DenmarkDifferences greatest for 1- year survival Slide8
Variations in cancer survival
Rural cancer outcomes in Australia worseApproximately 20% worse 5- year survival for common cancersDifferences in treatments received (eg
radical prostatectomy Baade 2011)Later stage at presentation (eg colorectal cancer Baade 2011)Slide9
Can some of the variations in cancer survival be improved by earlier diagnosis?Slide10
Potential approaches
Improve uptake of proven screening testsSystematic application of evidence around symptoms as predictors of cancerCommunity symptom awarenessGeneral populationTargeted high risk groups
General practice level interventionsTumour markersDiagnostic aidsSlide11
Models of ‘diagnostic delay’
Walter, Scott, Webster, Emery. JHSRP 2011Slide12
Models of ‘diagnostic delay’
First symptom
First contact with the GP
Referral to hospital
Initiation of investigation of cancer-related symptoms
First visit at the hospital
Referral to treatment
Treatment initiation
System delay
Doctor delay
Patient delay
Delay in primary care
Delay in secondary care
F
Olesen
BJC 2009 Slide13
Diagnosing cancer in general practice: how well do symptoms predict cancer?
Shapley et al BJGP 201025 studies includedRectal bleeding; change in bowel habit; iron deficiency anaemia;
haematuria; malignant DRE; haemoptysis; dysphagia; breast lump; post-menopausal bleeding.Slide14
Diagnosing cancer in general practice: how well do symptoms predict cancer?
Hamilton BJC 2005Slide15
Improving Rural Cancer Outcomes Project
Patients with lung, prostate, breast, colorectal cancer in Goldfields and Great Southern
66 patients
Interview patients
Symptom appraisal and help-seeking
Calendar
landmarking
and diagram to aid recall
Medical notes audit
Mixed methods matrix analysis
PerthSlide16
Improving rural cancer outcomes (IRCO) project
Symptom appraisal (days)
GP
interval
(days)
Mean
Median
IQR
[25
th
, 75
th
]
Mean
Median
IQR
[25
th
, 75
th
]
Breast
27
0
0, 13
13
3
1, 40
Colorectal
130
9
0, 49
184
87
48, 139
Lung
36
9
0, 103
61
2
0, 9
Prostate
309
15
12, 28
33
42
10, 263
Significant overall differences between tumour groups for symptom appraisal and GP diagnostic intervals*
* After log transformationSlide17
Symptom appraisal
and patient beliefs
Comparison of symptoms against personal models of disease
Alternative explanations for symptoms
Common misconceptions about cancer symptoms
I mean it’s like you know a horse ,colic in a horse... it comes on pretty damn quick and ... you know you think well, you know I began to think maybe I’ve got a twisted bowel or something.Slide18
Symptom appraisal
and patient beliefs
Comparison of symptoms against personal models of disease
Alternative explanations for symptoms
Common misconceptions about cancer symptoms
And when you’re walking around in slushy mud and all that your gumboots stick to them and you’ve got to ... if you keep doing it long enough your hips get that sore you know?Slide19
Symptom appraisal
and patient beliefs
Comparison of symptoms against personal models of disease
Alternative explanations for symptoms
Common misconceptions about cancer symptoms
The trouble is with cancer, I think you know it creeps in on you and ... and like there’s a bit of blood there but no pain and you think well if there’d been some pain there you’d have definitely said oh shit there’s something wrong here.Slide20
Symptom appraisal & help-seeking in
rural AustraliaThe rural Australian character
And the country men are worse than the women, by a long shot. They’re, you know, bush blokes. You know, “I’m not going to the doctor. I’ll be right, mate.”Slide21
Symptom appraisal & help-seeking in
rural AustraliaFear in relation to rural machismo
Being a real hero bloke, you know, you don’t go to the doctor about that. I’m not going there … going where they
wanna
go,
nup
.Slide22
Symptom appraisal & help-seeking in
rural AustraliaStoic response to symptoms
Well, I had a bit of diarrhoea… And it just didn't want to seem to go away… really I‘d had it for about three months before I went and seen the doctor… I just put up with it … thought oh it'll go away soon…. then I just got sick of it. Yeah, because I had to - I finished up wearing um … [incontinence] pads and things you know.”Slide23
Improving rural cancer outcomes project
Access and Specialist diagnostic interval (days
)
Total diagnostic interval (days)
Mean
Median
IQR
[25
th
, 75
th
]
Mean
Median
IQR
[25
th
, 75
th
]
Breast
22
63
38, 100
80
15
10,29
Colorectal
55
200
125, 421
347
30
16,60
Lung
23
41
22, 203
123
14
11,30
Prostate
99
190
147, 346
357
68
53,83
Overall significant differences between tumour groups in*:
access to specialists
specialist intervals
total diagnostic interval
* After log transformationSlide24
The IRCO Trial
Community level:
Community campaign to reduce symptom appraisal and help-seeking intervalsPractice level: to reduce diagnostic interval
2 x 2 factorial Randomised
Controlled Trial
Outcome: total diagnostic intervalSlide25
Approaches to reducing symptom appraisal and help-seeking intervalsSlide26Slide27
Improving rural cancer outcomes projectSlide28
Tumour markers in general practice?
In symptomatic diagnosisUseful: α fetoprotein, Bence
Jones protein, HCG, PSAUncertain value: Ca125, Ca-19-9, Of no value: CEA, Ca15-3, thyroglobulinLittle research in primary care populations
Sturgeon et al BMJ 2009Slide29
The BEST Studies
Immunohistochemistry
of trefoil factor 3 (TFF3)
BMJ 2010.
doi:10.1136/bmj.c4372
Sensitivity 90.0%; specificity 93.5% for clinically relevant Barrett’s oesophagus in primary care populationSlide30
Diagnostic aids
Dermoscopy and sequential digital monitoring (Menzies, Emery et al BJD 2009)Doubled sensitivity for diagnosis of melanoma to 97%63.5% reduction in excision of benign lesions
Importance of monitoring strategySlide31
Diagnostic aids
The Molemate TrialSiascopy vs 7-point checklist (Best Practice)
Major features
Minor features
Change in size Largest diameter 7mm+
Irregular shape Inflammation
Irregular colour Oozing
Change in sensationSlide32
The gatekeeper role and early cancer diagnosis
Relative 1-year survival
Median
p-value
Gatekeeper
Yes
67.8
0.004
No
73.4
Primary care 1
st
point of call
Yes
66.3
0.001
No
73.4
Vedsted et al BJGP 2011Slide33
What is the right balance of gatekeeping
for possible cancer?
Emeraldinsight.com
?
? Metro only
?Slide34
Acknowledgements
IRCO teamD’Arcy Holman, Vicky Gray, Emma Croager, Terry Slevin, Christobel Saunders, Fiona Walter and others
Molemate TeamFiona Walter, Helen Morris, Toby Prevost, Ann-Louise Kinmonth, Per Hall and othersDiscovery Team
Willie Hamilton, Fiona Walter, Greg Rubin, Richard Neal and others
Consensus working group on early diagnosis of cancer
David Weller, Greg Rubin, Richard Neal, Fiona Walter, Suzanne Scott, Willie Hamilton,
Frede
Olesen
, Peter Vedsted and others