Upper GI 2WW referrals & open access endoscopy

Dr Amanda J Hughes

Upper GI 2WW referral forms & open access endoscopy

• Background

• Upper GI cancer

• Challenge

• Case scenarios

• New 2WW & open access forms

• Questions

Background 1) Increased demand for GI services

Increasing referrals but ↓yield

1/4/12 – 31/3/13

• Approx 550 referred FT– 46/month

• 41 cancers ……….represents 25% of total upper GI cancers diagnosed

• 7.5% yield

1/4/13 – 30/11/14

• Approx 1100 referred as FT– 55/month

• 66 cancers …………represents approximately 30% of total upper GI cancers diagnosed

• 6% yield

1/1/15- 31/3/15 = 366 referred FT i.e. 122 / month

• Current open access forms not fit for purpose

– “Group A” encompasses 2 WW symptoms– Out of line with NICE guidance

• Wolverhampton changed their referral process

– Clinical Assessment service• Straight to test• Clinic review • Advice to GP………………anecdotally patients referred WMH

Consequence: Unable to see all the patients referred / perform endoscopy required within timely basis

Oesophago gastric cancers

• 6% all cancers• UK - oesophagus 13th & stomach 15th most common cancer

• 2/3 men

• 92% occur ≥ 55yrs

Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s

British Journal Cancer (2013) 108, 25-31

Pancreatic Cancer

• 11th most common cancer in UK• Rare < 40yrs, > 50% in patients over 75yrs• Risk factors:

– Smoking ( 1:3)– Diabetes– Chronic pancreatitis– Obesity– Sedentary lifestyle– Genetic ( 1:10)

• > 50 % jaundice at 1st presentation

Challenge

Timely diagnosis &management of cancer patients

Avoid overloading system with unnecessary referrals

Cases

• 74 yr female

– 3 months dysphagia• Food lodges distal oesophagus & regurgitates phlegm

– 1 stone weight loss

What do you want to do with her ?

Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s

British Journal Cancer (2013) 108, 25-31

Endoscopy

Diagnosis – SCC oesophagus

71 yr female

– “ New onset dyspepsia”

– Previously seen with dyspepsia by Dr Cox , symptoms difficult to control & required Nexium.

– Changed to Lansoprazole in community –

dyspepsia returned

What’s your management plan ?

Actual Management

– Referred as fast track. - was that appropriate ?

– Key symptom reflux

– Consultant re-instituted Nexium

Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s

British Journal Cancer (2013) 108, 25-31

72yr male, smoker

– 3/52 history of wt loss , nausea & vomiting

– New onset iron deficiency – started on Fe

– CXR – COAD

How would you manage him ?

Actual management

• Referred to respiratory team as 2WW

• Respiratory consultant made clinical diagnosis of gastric outflow obstruction

Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s

British Journal Cancer (2013) 108, 25-31

Investigations

OGD CT

• 45yr old female

– Persistent dyspepsia

– BMI 44

– Referred as fast track – is that truly appropriate ?

Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s

British Journal Cancer (2013) 108, 25-31

• 70 yr old

– Jaundice

– Diabetes diagnosed 1 yr ago

– Weight loss

– Most common causes in this age group ?

73 yr old male

• RUQ pain• Wt loss

• USS – multiple liver mets

• Who do you refer to ?

73 yr old male

• RUQ pain• Wt loss

• USS – multiple liver mets

• Who do you refer to ?

• Depends on history…. Patient known previous colorectal Ca

Actually referred via upper GI pathway

Most common primary sites for liver mets

• Colon

• Stomach

• Pancreas

• Breast

• Lung

New forms……….

New NICE guidance May 2015 referral for suspected cancer.

Fast Track Criteria

Open Access Criteria

Summary

• Upper GI cancer – Common– Symptoms including PPV’s for oesophago gastric cancer

• Challenge – Selecting appropriate patients for onward referral

• Case scenarios

• Reviewed new 2WW & open access forms

Thank You

Any Questions ??