School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

William Hamilton, Professor of primary care diagnostics, Peninsula College of Medicine and Dentistry

The Hamilton risk assessment tools – what are they and how

can we use them?

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

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).

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

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

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

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.

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

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.

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

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

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Cambridge, Manchester and Oxford and is part of the National Institute for Health Research.

School for Primary Care Research

The research behind this programme

• We found all the cancers in an area in Devon, 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

Colorectal

Haemoglobin (g/dl)

Age (years)

Annual incidence of

colorectal cancer in this

age group (%)

<9.0 9.0 to 9.9

10.0 to

10.9

11.0 to

11.9

12.0 to

12.9

13.0

30-59 0.026 1.3

0.4, 4.3

1.4

0.2, 10

0.8

0.3, 2.2

0.8

0.2, 2.9

0.2

0.1, 0.3

0.1

0.1, 0.1 60-69 0.19 7.6

3.4, 16

7.2

2.9, 17

2.3

1.1, 4.8

1.4

0.9, 2.3

0.7

0.5, 1.0

0.3

0.3, 0.3 70-79 0.35 8.8

5.4, 14

4.0

2.5, 6.3

3.2

2.2, 4.8

1.5

1.2, 2.0

1.0

0.7, 1.2

0.4

0.3, 0.4

80 0.43 6.8

4.2, 11

6.0

3.4, 10

1.6

1.1, 2.2

1.0

0.8, 1.4

0.6

0.5, 0.8

0.4

0.3, 0.5

Anaemia in men

Anaemia in women

Age (years)

Annual incidence of colorectal

cancer in this age group

(%)

Haemoglobin (g/dl)

<9.0 9.0 to 9.9

10.0 to

10.9

11.0 to

11.9

12.0 to

12.9

13.0

30-59 0.02 0.9

0.3, 2.9

0.3

0.1, 0.6

0.4

0.2, 0.8

0.1

0.1, 0.2

0.0

0.0, 0.1

0.0

0.0, 0.0 60-69 0.11 >5

note

2.7

1.2, 5.9

1.2

0.7, 2.0

0.4

0.3, 0.6

0.2

0.1, 0.2

0.1

0.1, 0.2 70-79 0.21 8.6

5.4, 14

3.6

2.1, 6.0

1.9

1.4, 2.6

0.5

0.4, 0.6

0.3

0.3, 0.4

0.2

0.2, 0.2

80 0.27 7.1

4.5, 11

2.2

1.5, 3.1

1.2

0.9, 1.5

0.6

0.5, 0.8

0.3

0.2, 0.4

0.2

0.2, 0.3

The effect of smoking