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The challenges of early diagnosis of cancer in primary care

The challenges of early diagnosis of cancer in primary care. Jon Emery Professor of General Practice University of Western Australia Director of PC4. Early cancer diagnosis.

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The challenges of early diagnosis of cancer in primary care

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  1. The challenges of early diagnosis of cancer in primary care Jon Emery Professor of General Practice University of Western Australia Director of PC4

  2. 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.’

  3. Onctalk.com

  4. Cochrane review of Hemoccult screening on colorectal cancer mortality

  5. Symptomatic cancer and early diagnosis • Richards et al Lancet 1999 • Delays from symptoms to diagnosis of 3-6 months associated with 7% worse 5-year survival from breast cancer • Effects not due to lead time bias • Longer delays associated with more advanced disease

  6. Colorectal cancer diagnostic interval and mortality • Torring et al BJC 2010 • Waiting list paradox • Diagnostic intervals >5 weeks associated with worsening mortality if ‘alarm symptoms’. • Similar U-shaped association for lung, melanoma and prostate cancer.

  7. Variations in cancer survival • International variations in cancer survival • Australia, Canada and Sweden better than UK and Denmark • Differences greatest for 1- year survival

  8. Variations in cancer survival • Rural cancer outcomes in Australia worse • Approximately 20% worse 5- year survival for common cancers • Differences in treatments received (eg radical prostatectomy Baade 2011) • Later stage at presentation (eg colorectal cancer Baade 2011)

  9. Can some of the variations in cancer survival be improved by earlier diagnosis?

  10. Potential approaches • Improve uptake of proven screening tests • Systematic application of evidence around symptoms as predictors of cancer • Community symptom awareness • General population • Targeted high risk groups • General practice level interventions • Tumour markers • Diagnostic aids

  11. Models of ‘diagnostic delay’ Walter, Scott, Webster, Emery. JHSRP 2011

  12. Models of ‘diagnostic delay’ Patient delay Delay in primary care Delay in secondary care Doctor delay System delay Initiation of investigation of cancer-related symptoms First symptom First contact with the GP Referral to hospital First visit at the hospital Referral to treatment Treatment initiation F Olesen BJC 2009

  13. Diagnosing cancer in general practice: how well do symptoms predict cancer? • Shapley et al BJGP 2010 • 25 studies included • Rectal bleeding; change in bowel habit; iron deficiency anaemia; haematuria; malignant DRE; haemoptysis; dysphagia; breast lump; post-menopausal bleeding.

  14. Diagnosing cancer in general practice: how well do symptoms predict cancer? Hamilton BJC 2005

  15. 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 Perth

  16. Improving rural cancer outcomes (IRCO) project Significant overall differences between tumour groups for symptom appraisal and GP diagnostic intervals* * After log transformation

  17. Symptom appraisal and patient beliefs 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. • Comparison of symptoms against personal models of disease • Alternative explanations for symptoms • Common misconceptions about cancer symptoms

  18. Symptom appraisal and patient beliefs 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? • Comparison of symptoms against personal models of disease • Alternative explanations for symptoms • Common misconceptions about cancer symptoms

  19. Symptom appraisal and patient beliefs 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. • Comparison of symptoms against personal models of disease • Alternative explanations for symptoms • Common misconceptions about cancer symptoms

  20. Symptom appraisal & help-seeking in rural Australia • The 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.”

  21. Symptom appraisal & help-seeking in rural Australia 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. • Fear in relation to rural machismo

  22. Symptom appraisal & help-seeking in rural Australia 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.” • Stoic response to symptoms

  23. Improving rural cancer outcomes project Overall significant differences between tumour groups in*: access to specialists specialist intervals total diagnostic interval * After log transformation

  24. The IRCO Trial • Community level: Community campaign to reduce symptom appraisal and help-seeking intervals • Practice level: to reduce diagnostic interval • 2 x 2 factorial RandomisedControlled Trial • Outcome: total diagnostic interval

  25. Approaches to reducing symptom appraisal and help-seeking intervals

  26. Improving rural cancer outcomes project

  27. Tumour markers in general practice? • In symptomatic diagnosis • Useful: α fetoprotein, Bence Jones protein, HCG, PSA • Uncertain value: Ca125, Ca-19-9, • Of no value: CEA, Ca15-3, thyroglobulin • Little research in primary care populations Sturgeon et al BMJ 2009

  28. The BEST Studies Sensitivity 90.0%; specificity 93.5% for clinically relevant Barrett’s oesophagus in primary care population Immunohistochemistry of trefoil factor 3 (TFF3) BMJ 2010. doi:10.1136/bmj.c4372

  29. 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 strategy

  30. Diagnostic aids • The Molemate Trial • Siascopyvs 7-point checklist (Best Practice) Major featuresMinor features Change in size Largest diameter 7mm+ Irregular shape Inflammation Irregular colour Oozing Change in sensation

  31. The gatekeeper role and early cancer diagnosis Vedsted et al BJGP 2011

  32. What is the right balance of gatekeeping for possible cancer? ? ? Metro only ? Emeraldinsight.com

  33. Acknowledgements • IRCO team • D’Arcy Holman, Vicky Gray, Emma Croager, Terry Slevin, Christobel Saunders, Fiona Walter and others • Molemate Team • Fiona Walter, Helen Morris, Toby Prevost, Ann-Louise Kinmonth, Per Hall and others • Discovery 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, FredeOlesen, Peter Vedsted and others

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