Greg Rubin Professor of General Practice and Primary Care Durham University

1. Greg RubinProfessor of General Practice and Primary CareDurham University The Hamilton risk assessment tools – what are they and how can we use them?

2. The problem • The UK has a relatively poor track record when compared with other European countries. • In part this is due to late diagnosis, with an estimated 7,500+ lives lost annually • Later diagnosis can be due to late presentation, non-recognition of cancer as a possibility by us GPs, or delays in secondary care (or a mixture of these).

3. The problem: colon • This is one of the four commonest cancers, and possibly the one with most to benefit from improvements in diagnosis. • Half of patients never have a NICE-qualifying symptom • Only a quarter are diagnosed via 2-week rule clinics • A quarter present as emergencies • Earlier diagnosis may give a stage shift or prevent some of the emergencies

4. The problem: lung • This is the commonest cause of cancer death in the UK. • Mortality is high, as very few are diagnosed at an operable stage. • There is an easy test – the chest X-ray - but no screening test. • Almost all present to GPs with symptoms.

5. West Midlands South Central South East Coast East Midlands East of England London Yorkshire and the Humber South West North East North West SHA

6. The problem: we GPs do a good job as gatekeepers • We are justifiably proud of UK general practice • The gatekeeper role has brought many benefits to patients, not least by ensuring the correct specialist is seen • It has also brought disadvantages, arising from GPs’ desire to use resources appropriately. • In cancer this means not investigating the low-risk symptom – and NICE tells us not to.

7. How do we select patients for cancer investigation? • Some is from hands-on experience • Some from ‘gut feeling’ • Some from advice – like NICE • Some from patient pressure • Some from reading up research

8. Presentation and referral

9. Does delay make a difference to outcome? • Intuitive answer is ‘yes’ • Remarkably difficult to confirm • Differences in definitions, measurement of delay, outcome measures • Failure to account for differences in aggressiveness • Lead time bias • Delays of 3-6m for breast cancer result in 7% lower 5-year survival than delays of <3m (Richards et al Lancet 1999) • Diagnostic delays in cancer do matter, but it is hard to quantify their impact on survival or mortality. (Neal BJC 2009)

10. The waiting time paradoxTorring et al, submitted for publication 2010

11. The research behind this programme • All the cancers in an area in Devon were identified, and generated five controls for each • Identified all symptoms reported to GPs before diagnosis • Identified which symptoms were relevant • Estimated the ‘risk’ of cancer for each symptom in a patient attending their GP

12. Colorectal

14. The effect of smoking

16. Evaluation • Professors Willie Hamilton (Exeter University) and Una Macleod (Hull University) • Steering group includes Kathy Elliott (NCAT) and Greg Rubin (RCGP Cancer Audit Programme) • Claire Morris as project manager • Mixed methods approach

17. Methods • Data on use of RAT: this will be collected using a tear-off pad, so completion for every patient where you consult the RAT is essential! • Some background activity data on the GPs and practices (consultations, use of relevant investigations, 2WW referrals) • Semi-structured telephone interviews with a sample of GP leads, GP users, project managers (n=40 approx) • Framework method of analysis

18. RAT – mouse mat layout • Primary Care Cancer Risk Assessment Tool • NICE guidance implies risks above 3% require urgent referral. These tools help you to decide which patients below this level may benefit from urgent investigation • To be used to supplement NICE guidance • For patients aged 40 and over • To calculate the risk value: • For a single symptom, read the value from the top row • For a single symptom presented more than once, read the value from the cell on the left hand diagonal • For multiple symptoms, read the value from the cell combining the worst 2 symptoms • Amber and red risk values suggests 2WW referral; yellow and white may well be best managed by review within primary care, but use your discretion

19. RAT - desk easel layout RAT tables to go here; 3 pages (one per table). Each page with divider tab at bottom (Lung: non-smoker, Lung: smoker, Colorectal). RAT instructions to go here • Primary Care Cancer Risk Assessment Tool • NICE guidance implies risks above 3% require urgent referral. These tools help you to decide which patients below this level may benefit from urgent investigation • To be used to supplement NICE guidance • For patients aged 40 and over • To calculate the risk value: • For a single symptom, read the value from the top row • For a single symptom presented more than once, read the value from the cell on the left hand diagonal • For multiple symptoms, read the value from the cell combining the worst 2 symptoms • Amber and red risk values suggests 2WW referral; yellow and white may well be best managed by review within primary care, but use your discretion NICE guidance to go on the back of each table

20. RAT – tear off pad layout

21. Aims and objectives of the evaluation • The aim is to describe the use of the Risk Assessment Tool in primary care clinical practice and the consequential utilisation of health care resources. • To describe the GP experience of incorporating the Risk Assessment Tool into their clinical practice • To identify constraints and facilitators at an organisational level to introduction of the RAT in primary care • To characterise the patients in whom the RAT is used and its effect on GP decision making for lung and colorectal cancer • To describe the consequential impact of the RAT on cancer diagnostic services and referral pathways for lung and colorectal cancer