Cancer diagnosis: in the GP’s consulting room€¦ · Georgios Lyratzopoulos , Richard D Neal ,...
Transcript of Cancer diagnosis: in the GP’s consulting room€¦ · Georgios Lyratzopoulos , Richard D Neal ,...
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Cancer diagnosis: in the GP’s consulting room
Olga Kostopoulou Tom Marshall Trish Green
Chairman: Willie Hamilton, MD, BSc, FRCP, FRCGP
Professor of primary care diagnostics London, March 2015
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Let’s go inside – if we can find a parking space
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A quarter of us will die of cancer
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And around half of the problem is ascribed
to delays in diagnosis
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Abdominal pain and diarrhoea = Irritable Bowel
Syndrome
Abdominal pain and diarrhoea =
Colorectal cancer
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90% of cancers present initially to GPs
Hamilton W, British Journal of General Practice 2010;60:121-28
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But what is going on in a GP’s
mind?
Firstly, very few consultations
relate to cancer, even remotely
And even when it’s remotely
possible we may not even think of it
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Does not thinking of cancer exist?
Odds ratios and 95% CIs for three or more general practitioner consultations before hospital referral, by cancer type The information
in this figure is derived from the main effects model.
Georgios Lyratzopoulos , Richard D Neal , Josephine M Barbiere , Gregory P Rubin , Gary A Abel. Variation in number of
general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient
Experience Survey in England. The Lancet Oncology, Volume 13, Issue 4, 2012, 353 - 365
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Myeloma
• What is the commonest symptom?
• We are all taught in medical school to think of rib pain. Yet rib pain was
recorded in only 3% of cases in a recent paper.
• Some of you probably even remember the ‘pepperpot skull’
• But the commonest symptom in myeloma (reported by
28%) is backache.
Who would possibly think of myeloma in backache?
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Breast
• Every GP in the land will think of breast cancer when a
woman presents with a lump
• And (almost) every woman in the land will think of breast
cancer when she finds a lump
• So it is well nigh impossible the subject is omitted from
discussion
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Thinking, but not thinking enough
• Diagnosis is not a linear process
• Several theories abound, and different conditions
probably require different schemas
• Olga Kostopoulou
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Thinking, but not acting
• There are several potential barriers to taking action,
once cancer has been considered as a possibility
• It’s a tricky subject to broach – though we know patients
are keen to have cancer investigated even if the risks
are low.
• We also don’t discuss this with our patients, and even if
we refer we do so in ‘coded’ language.
• We may get investigation ‘refused’ – as national
guidance doesn’t suggest it.
• This can be combatted by ‘legitimising’ referrals.
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What’s the most important bit of this
mousemat that made it popular?
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B/H B/H
05
01
00
150
Num
ber
of R
AT
s c
om
ple
ted p
er
wee
k
March 2011 April 2011 May 2011 June 2011 July 2011
Colon
Lung (non-smokers) Lung (smokers)
Actual total Predicted total
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What’s the most important bit of this
mousemat that made it popular?
13
B/H B/H
05
01
00
150
Num
ber
of R
AT
s c
om
ple
ted p
er
wee
k
March 2011 April 2011 May 2011 June 2011 July 2011
Colon
Lung (non-smokers) Lung (smokers)
Actual total Predicted total
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Where do computers fit in?
• They have three main functions in cancer diagnosis
• As a repository of information (national guidance, risk compilation, etc.)
• As an electronic prompt – popping up whenever current information
summates to a risk above an agreed level.
• As an audit tool, which runs regular searches within the GP’s system to
identify patients above an agreed threshold.
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Computers as an audit tool
• Things get missed (sorry, but they do)
• Computers don’t mind ‘fat file patients’
• Tom Marshall
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Computers as a prompt
• A prompt can pop up at the start of the consultation, alerting the GP to the
possibility of cancer
• It can show the precise risk estimate, and can include several cancers
• Most GPs like and use them (either based on RATs or on QCancer) and
they seem to provoke appropriate diagnostic activity.
• But not all GPs like them
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Computers as a prompt
• A prompt can pop up at the start of the consultation, alerting the GP to the
possibility of cancer
• It can show the precise risk estimate, and can include several cancers
• Most GPs like and use them (either based on RATs or on QCancer) and
they seem to provoke appropriate diagnostic activity.
• But not all GPs like them
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Computers as a prompt
• A prompt can pop up at the start of the consultation, alerting the GP to the
possibility of cancer
• It can show the precise risk estimate, and can include several cancers
• Most GPs like and use them (either based on RATs or on QCancer) and
they seem to provoke appropriate diagnostic activity.
• But not all GPs like them
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And do patients approve?
• But what about patients?
• They are equal partners, of course
• After all "Listen to your patient, he is telling you the
diagnosis.“
• Trish Green