Transcript of Jon Emery Professor of General Practice University of Western Australia Director of PC4.
- Slide 1
- Jon Emery Professor of General Practice University of Western
Australia Director of PC4
- Slide 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.
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- Onctalk.com
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- Cochrane review of Hemoccult screening on colorectal cancer
mortality
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- 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
- Slide 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.
- Slide 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
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- 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)
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- Can some of the variations in cancer survival be improved by
earlier diagnosis?
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- 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
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- Models of diagnostic delay Walter, Scott, Webster, Emery. JHSRP
2011
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- 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 delayDoctor delay Patient
delayDelay in primary care Delay in secondary care F Olesen BJC
2009
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- 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.
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- Diagnosing cancer in general practice: how well do symptoms
predict cancer? Hamilton BJC 2005
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- 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
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- Improving rural cancer outcomes (IRCO) project Symptom
appraisal (days)GP interval (days) MeanMedian IQR [25 th, 75 th ]
MeanMedian IQR [25 th, 75 th ] Breast2700, 131331, 40
Colorectal13090, 491848748, 139 Lung3690, 1036120, 9
Prostate3091512, 28334210, 263 Significant overall differences
between tumour groups for symptom appraisal and GP diagnostic
intervals* * After log transformation
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- Symptom appraisal and patient beliefs Comparison of symptoms
against personal models of disease Alternative explanations for
symptoms Common misconceptions about cancer symptoms I mean its
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 Ive got a twisted bowel or something.
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- Symptom appraisal and patient beliefs Comparison of symptoms
against personal models of disease Alternative explanations for
symptoms Common misconceptions about cancer symptoms And when youre
walking around in slushy mud and all that your gumboots stick to
them and youve got to... if you keep doing it long enough your hips
get that sore you know?
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- 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
theres a bit of blood there but no pain and you think well if
thered been some pain there youd have definitely said oh shit
theres something wrong here.
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- Symptom appraisal & help-seeking in rural Australia The
rural Australian character And the country men are worse than the
women, by a long shot. Theyre, you know, bush blokes. You know, Im
not going to the doctor. Ill be right, mate.
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- Symptom appraisal & help-seeking in rural Australia Fear in
relation to rural machismo Being a real hero bloke, you know, you
dont go to the doctor about that. Im not going there going where
they wanna go, nup.
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- Symptom appraisal & help-seeking in rural Australia Stoic
response to symptoms Well, I had a bit of diarrhoea And it just
didn't want to seem to go away really Id 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.
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- Improving rural cancer outcomes project Access and Specialist
diagnostic interval (days) Total diagnostic interval (days)
MeanMedian IQR [25 th, 75 th ] MeanMedian IQR [25 th, 75 th ]
Breast226338, 100801510,29 Colorectal55200125, 4213473016,60
Lung234122, 2031231411,30 Prostate99190147, 3463576853,83 Overall
significant differences between tumour groups in*: access to
specialists specialist intervals total diagnostic interval * After
log transformation
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- 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 Randomised Controlled
Trial Outcome: total diagnostic interval
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- Approaches to reducing symptom appraisal and help-seeking
intervals
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- Improving rural cancer outcomes project
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- Tumour markers in general practice? In symptomatic diagnosis
Useful: 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
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- 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 Barretts oesophagus in
primary care population
- Slide 30
- 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
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- Diagnostic aids The Molemate Trial Siascopy vs 7-point
checklist (Best Practice) Major featuresMinor features Change in
sizeLargest diameter 7mm+ Irregular shapeInflammation Irregular
colourOozing Change in sensation
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- The gatekeeper role and early cancer diagnosis Relative 1-year
survival Medianp-value Gatekeeper Yes67.80.004 No 73.4 Primary care
1 st point of call Yes66.30.001 No73.4 Vedsted et al BJGP 2011
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- What is the right balance of gatekeeping for possible cancer?
Emeraldinsight.com ? ? Metro only ?
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- Acknowledgements IRCO team DArcy 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, Frede Olesen,
Peter Vedsted and others