Discussion Dr Katie Elliott GP Lead for Cancer Northern England - - PowerPoint PPT Presentation

NICE NG12 Suspected Cancer Discussion

Dr Katie Elliott GP Lead for Cancer Northern England Strategic Clinical Network

Aims

 Discuss the changes in the NICE guidance.  Agree any changes required to the 2ww referral criteria.  Discuss/ agree a standard referral form for urgent 2ww referrals for suspected cancer.  Discuss any amendments to local guidelines.

 Issued in June 2015  Identify more cancer at an earlier stage  Symptoms based  Increased emphasis on early referral/ direct to test in primary care  PPV 3%  Implications for referral pathways  Impact on diagnostic services  Cost  62 Day Cancer target  Cancer Strategy

New NICE Guidance NG12

 Benefits

• One form for all practices to all trusts
• Up to date criteria. Only one form to change if guidance changes
• Standard formatting to link with GP IT system
• Move away from hand written forms/ fax
• Concentrate on clinical narrative and criteria for referral
• Reduce risk of delay due to wrong form/ wrong information

 Disadvantages

• How to accommodate local variation in services
• Local advice telephone contact numbers
• Will the forms get changed anyway?

Opportunity to develop a standard, region wide referral form for suspected Upper GI cancer

Update from HPB NSSG

 No direct access to the tertiary care HPB MDT  All suspected pancreatic/ liver/ gallbladder cancer will still go via the local Upper GI team.  Do not recommend USS in primary care for investigating suspected pancreatic cancer.  Consider a pathway from abnormal CT direct appointment with upper GI team.  Refer to clinic

The North of England NSSG for UGI OG cancers has adopted in their entirety the comprehensive national guidelines for UGI oesophago-gastric cancers; these are to be used in collaboration with NICE 2005 referral guidance. To support local implementation of these, each section included below provides the clinician with information on referral pathways and clinical team. GP referrals This flow chart illustrates the referral mechanism for GPs to use for patients with dyspepsia. Note that iron deficiency anaemia is <110g/l (men) and <100g/l (post-menopausal women). The presence of low ferritin and/or low MCV without anaemia does not warrant endoscopy.  Dyspepsia: Epigastric pain, Heartburn, Bloating, Nausea With:  Alarm Symptoms: Dysphagia/ Unintentional weight loss/ Epigastric Mass/ Recent Onset >55/ Persistent vomiting/ Iron Deficiency Anaemia  >>>>2ww referral

OG Cancer Clinical Guidelines OG NSSG on behalf of NESCN June 2015

 Refer urgently for endoscopy, or to a specialist  patients of any age with dyspepsia and any of  the following  chronic gastrointestinal bleeding  dysphagia  progressive unintentional weight loss  persistent vomiting  Iron deficiency anaemia  epigastric mass  suspicious barium meal result  Refer urgently for endoscopy  patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone.

Old CG27 Guideline 2005

 Refer urgently patients presenting with:  dysphagia  unexplained upper abdominal pain and  weight loss, with or without back pain  upper abdominal mass without  dyspepsia 

• bstructive jaundice (depending on clinical

 state) – consider urgent ultrasound if  available.  Consider urgent referral for patients presenting with:  persistent vomiting and weight loss in the  absence of dyspepsia  unexplained weight loss or iron deficiency  anaemia in the absence of dyspepsia  unexplained worsening of dyspepsia and: 

• Barrett’s oesophagus



• known dysplasia, atrophic gastritis or

 intestinal metaplasia  peptic ulcer surgery over 20 years ago

Old CG27 guideline 2005

 Consider a suspected cancer pathway referral ( to be seen within 2 weeks) for an upper abdominal mass consistent with stomach cancer. [new 2015]  Offer urgent direct access UGIE (to be performed within 2 weeks) for assessment for oesophageal or gastric cancer in people:  With dysphagia  Aged 55 and over with weight loss AND any of the following  Upper abdominal pain  Reflux 

• Dyspepsia. [new2015]

 Consider non-urgent direct access UGIE to assess for oesophageal or gastric cancer in people with haematemesis. [new 2015]  Consider non-urgent direct access UGIE to assess for oesophageal or gastric cancer in people aged 55 or over with:  Treatment-resistant dyspepsia OR  Upper abdominal pain with low HB levels OR  Raised platelet count with any of the following:  Nausea  Vomiting  Weight loss  Reflux  Dyspepsia  Upper abdominal pain OR  Nausea or vomiting with any of the following:  Weight loss  Reflux  Dyspepsia  Upper abdominal pain. [new 2015]

NICE NG12 Assessment for Oesophageal/Gastric Cancer

 Pancreatic  Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice.  Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:  Diarrhoea back pain abdominal pain  Nausea vomiting constipation new-onset diabetes.  Gallbladder  Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder.  Liver cancer  Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver.

NICE NG12 Assessment for Pancreatic/ gallbladder/ liver cancer

 Previous guidance used a disparate range of percentage risks of cancer in their recommendations.  Few corresponded with a PPV of lower than 5%.  The GDG felt that, in order to improve diagnosis of cancer, a PPV threshold lower than 5% was preferable.  The GDG aspired to broaden recommendations to try and improve the timeliness and quality of cancer diagnosis. The lower the threshold could reasonably be set, the more patients with cancer would have expedited diagnoses, with accompanying improvements in mortality and morbidity.  GDG considered costs vs benefits and decided on PPV of 3%.  Same criteria for referral and urgent direct access investigations except where access to direct investigation would replace referral to a specialist.

How the NICE Guideline Development Group (GDG) decided the PPV

 These recommendations are recommendations, not requirements.  They do not override clinical judgement. This guidance  seeks to assist primary care clinicians in selection of patients, and seeks to help patients in expediting their diagnosis when they may have cancer.  It also helps secondary care in understanding what services to provide.  Exceptions will occur, however, and clinicians should trust their clinical experience where there are particular reasons that this guidance does not pertain to the specific presentation of the patient.

What these recommendations are and what they are not

Suspected Pancreatic Cancer Pathway

(subset of UGI pathway 15/11/13) Clinical Presentation suggests pancreatic cancer Review against NICE criteria and Hamilton Risk Assessment Tool Patient fulfils NICE criteria Patient >40 yrs doesn’t fulfil NICE criteria, but has a RAT score of 2 or above with 4/52 history Patient doesn’t fulfil NICE criteria or have a RAT score of 2 or above

Two week wait referral

Consider abdominal USS

Direct to CT scan of thoraxabdomen / pelvis

Consultant review

Symptoms resolved Symptoms persisting No further action Routine referral

Meets Direct to CT test criteria Has one of following:

• Upper abdominal pain and weight

loss

• Obstructive jaundice
• Upper abdominal mass

USS abnormal USS normal Clinical responsibility transfers to secondary care

Clinical responsibility within secondary care Red outline indicates urgent pathway

Pancreatic Cancer Risk Assessment Tool

Back pain New

• nset

diabetes Diarrhoea Constipation Malaise Nausea

• r

vomiting Abdominal pain Loss

• f

weight Jaundice

0.1 (0.1, 0.1) 0.2 (0.2, 0.2) 0.2 (0.2, 0.2) 0.2 (0.2, 0.2) 0.2 (0.2, 0.3) 0.3 (0.3, 0.4) 0.3 (0.3, 0.4) 0.8 (0.7, 1.0) 21.6 (14,52)

PPV as a single symptom

0.3 (0.2, 0.4) 0.2 (0.1, 0.3) 0.3 (0.2, 0.4) 0.3 (0.2, 0.6) 0.3 (0.2, 0.5) 0.4 (0.3, 0.5) 2.0 (1.0, 4.3) 8.9

• Back pain

0.4 (0.3, 0.5) 0.4 (0.3, 0.6) 0.5 (0.3, 0.9) 0.7 (0.5, 1.0) 0.9 (0.7, 1.1) 1.6 (1.0, 2.9) 22.3

• New
• nset

diabetes

0.2 (0.1, 0.3) 0.3 (0.1, 0.5) 0.2 (0.2, 0.3) 0.4 (0.3, 0.5) 2.7

• >10
• Diarrhoea

0.3 (0.2, 0.5) 0.6 (0.4, 0.8) 0.5 (0.4, 0.7) 1.5 (0.8, 3.0) >10

• Constipation

0.5 (0.3, 0.8) 0.6 (0.4, 0.8) 0.9 (0.4, 2.1) >10

• Malaise

0.9 (0.7, 1.2) 2.2 (1.1, 4.6) 14.6

• Nausea
• r

vomiting

2.5 (1.5, 4.4) 15.0

• Abdominal

pain

>10

• Loss of weight

32.3

• Jaundice

1. What will be the changes to the referral criteria on the 2ww forms?

• 2. If it is a non-urgent UGIE referral, what is the time

scale?

• 3. What happens if GP orders an urgent 2ww CT/USS

and it it is reported consistent with cancer?

• 4. What happens if a non-urgent UGIE is abnormal?
• 5. What happens if an urgent 2ww UGIE is normal but

symptoms are suspicious?

• 6. Should we continue to recommend urgent 2ww USS

What should we advise GPs ?

 Reference point using new NICE guidance  Formatting for demographics and practice details already agreed.  Clinical information to be agreed  Any additional info required?  What about direct to CT option for areas without access to urgent CT?  Any need for a separate suspected HPB cancer form ?

Sample form

Weight loss Upper abdominal pain Reflux Dyspepsia Low HB Nausea/ Vomiting Raised platelets Weight loss 2ww UGIE 2ww UGIE 2ww UGIE IDA in over 60 2ww LGIE Non-urgent UGIE Non-urgent UGIE Upper abdominal pain 2ww UGIE Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Reflux 2ww UGIE Treatment resistant reflux Non-urgent UGIE (BSG) Non-urgent UGIE Non-urgent UGIE Dyspepsia 2ww UGIE Treatment resistant dyspepsia Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Low HB IDA in over 60 2ww LGIE Non-urgent UGIE Assess for active bleeding Nausea/ vomiting Non- urgent UGIE Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Raised Platelets Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Non-urgent UGIE Assess for active bleeding Non-urgent UGIE

Any actions required?

Thank you

Cancer strategy recommendations relevant to diagnostic pathways

 Recommendations:  16 Implementation of NICE NG12  17 NHS should mandate GP direct access to investigations for suspected cancer : blood tests, CXR, CT, MRI, endoscopy – by end 2015  21 Pilot 5 Multi-diciplinary diagnostic centres.  22 Pilot patient self referral via nurse triage if they have a red- flag symptom that would always result in a test.  24 95% patients referred for testing to have either cancer diagnosis confirmed or excluded and communicated to the patient within 4 weeks by 2020. 50% within 2 weeks

 62 Day Cancer target event  Reduce lead time - <14 days  Work with primary care  Work with secondary care

 Diagnostics  MDT  Capacity – diagnosis/ clinic/ treatment  Process mapping for diagnostics agreed for:

 Colorectal - Sunderland  OG - South Tees  HPB - Newcastle  Lung – North Tees  Urology – North Cumbria

Additional supporting work from the SCN and NSSGs