Jon Emery Professor of General Practice University of Western Australia Director of PC4.

Jon Emery Professor of General Practice University of Western Australia Director of PC4

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.

Onctalk.com

Cochrane review of Hemoccult screening on colorectal cancer mortality

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

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.

Variations in cancer survival International variations in cancer survival Australia, Canada and Sweden better than UK and Denmark Differences greatest for 1- year survival

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)

Can some of the variations in cancer survival be improved by earlier diagnosis?

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

Models of diagnostic delay Walter, Scott, Webster, Emery. JHSRP 2011

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

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.

Diagnosing cancer in general practice: how well do symptoms predict cancer? Hamilton BJC 2005

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

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

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.

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?

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.

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.

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.

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.

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

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

Approaches to reducing symptom appraisal and help-seeking intervals

Improving rural cancer outcomes project

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

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

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

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

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

What is the right balance of gatekeeping for possible cancer? Emeraldinsight.com ? ? Metro only ?

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

Jon Emery Professor of General Practice University of Western Australia Director of PC4.

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