optimising symptomatic cancer diagnosis in primary care dr fiona walter the primary care unit...
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Optimising symptomatic cancer diagnosis in primary care
Dr Fiona WalterThe Primary Care Unit
Cambridge Institute AWAY DAY 25th June 2014of Public Health
How has our primary care cancer diagnosis research influenced policy and practice?
NIHR DISCOVERY programme (PG) 2010-5 MelaTools programme (CS) 2013-8
Charities Cancer Research UK/ NAEDI Pancreatic Cancer Action
Team Linda Birt, Angelos Kassianos, Silvia
Mendonca, Katie Mills, Helen Morris, Chantal Smeekens, Juliet Usher-Smith
‘Exemplar of the work of the PCU’
BACKGROUND
1995-99 2000-02 2005-0720
25
30
35
40
45SWE
NOR
DEN
UK
AUS
CAN
Lung Cancer 1yr RS
1995-99 2000-02 2005-0765
70
75
80
85
90 AUS CAN SWE NOR DEN UK
AUS
NOR
DEN
UK
CAN
SWE
Colorectal Cancer 1yr RS
ICBP: Coleman et al, Lancet 2011
The National Awareness and Early Diagnosis Initiative
(NAEDI)
METHODS- Model of Pathways to Treatment
Walter et al, JHSR&P 2012, Scott et al, BJHP 2013
METHODS- Aarhus Statement
Weller et al, BJC 2012
PUBLIC AWARENESS
Factors influencing time to presentation: Appraisal: lack of knowledge Help-seeking: avoidance, fatalism, reluctance to seek help (including
embarrassment, wasting the doctor’s time)
Be Clear on Cancer campaigns- lung, colorectal cancer
Early evidence of effects on: Awareness GP consultations Use of diagnostic tests Urgent referralsPreliminary results suggest: Impact on stage at diagnosis Trigger presentation
PUBLIC AWARENESS- skin cancer
Walter et al. BMJ Open, in press
Be Clear on Cancer campaigns- skin cancer Melanoma interview study
63 adults aged 29 - 93 Interviewed with 10 weeks of diagnosis
Key results Common features: change in
size, shape, colour Unassuming features: ‘just a
little spot’ Subtly different patterns of
features: ‘vertical growth’ Normal explanations: life
changes
PATIENT PATHWAYS- Symptom Study
What symptoms and other patient factors are associated with later presentation or later stage at diagnosis of lung, colorectal, pancreas cancer?
Prospective cohort study: patient questionnaires and nested qualitative in-depth interviews
Setting: East and North East England, patients referred to urgent, routine & investigative clinics
Inclusion criteria: aged ≥40 with symptoms suspicious of colorectal, lung, pancreatic cancer
Recruitment: when referred, mailed SYMPTOM questionnaire
Further data collection: from primary care and hospital records relating to participants’ symptoms and diagnosis
RECRUITMENTTo end May 2014
COLORECTAL 2506
LUNG 996
PANCREAS 334
Inhibiting
Facilitating
“And if I should be out and I get this sort of urge to go to the toilet, I have to go otherwise I’ve pooed myself. .. very embarrassing” (female, 77 years, NC)
“that was probably the thing that put me off going more than anything in the first instance was the embarrassment of that sort of thing. .. I don’t suppose anybody likes, whether it’s a doctor or not, playing around what you consider as your private parts” (Male, 66 years, CRC)
Looking for symptom relief Perceived seriousness and/or
anxiety about cancer Loss of privacy e.g. wind, faecal
incontinence (or fear of) Lack of embarrassment
Prompt help-seeking
Socio-cultural norms Symptom monitoring Embarrassment of investigations
PATIENT VIEWS- ‘private nature of symptoms’me personally, the way I was brought up, one, you don’t talk about downstairs, and two, you don’t look at downstairs. So, when people ask me questions like “Is it in the stool?” or anything like that, I tend not to look, I do now, but I didn’t then” (Female, 54 years, NC)
PATIENT VIEWS- diagnostic tests & referrals
Banks et al. Lancet Onc 2014
PIVOT study- Bristol, Exeter, East of EnglandClinical vignettes presented on a tablet in GP waiting rooms
RISK ASSESSMENT TOOLS for GPs
CAPER studies Main output: risk assessment
tools (RATs) Piloted in 152 practices in
England over a 6-month period, and resulted in: Increase in referrals for
suspected cancer Increase in number of
colonoscopies Increase in number of
colorectal cancers diagnosed
Hamilton et al BJGP 2013
MELANOMA CLINCIAL DECISION SUPPORT
Walter et al, BMJ 2012
DIAGNOSTIC TECHNOLOGIES
Kadri et al, BMJ 2010
PRIMARY CARE CANCER DIAGNOSIS RESEARCH
CURRENT Methodological frameworks Public awareness Patient pathways- symptoms Patient views- diagnostics Risk assessment tools
E-clinical decision support Diagnostic technologies
devices, informatics, biomarkers
NEXT… Other behavioural approaches
e.g. patient self-monitoring New investigative & referral
routes Socio-economic inequalities Diagnostic technologies
devices, informatics, biomarkers
Pre-symptomatic diagnosis
THANK YOU fmw22@medschl.cam.ac.uk
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