Awareness & Early Diagnosis Clinical Advisory Group (CAG) FINAL MEETING Output from Workshop Discussions on Implementing the Cancer Strategy.

1. Emergency cancer diagnosis
audit
Discussion of the final report prepared by Ashford & St Peter’s
Hospitals and North West Surrey CCG
Dr Cat Hodges
Macmillan GP
NWS CCG
Dr Madeleine Hewish
Consultant Medical Oncologist
SLCC/ASPH

2. Background
 21% of new cancers are diagnosed during an emergency
admission
 National findings indicate emergency presentation of cancer
is associated with inferior survival compared to other routes
 ASPH Acute Oncology database Audit in 2015
 Review of patients referred with a suspected cancer during
acute admission over a 6 month period
 Concluded cancer diagnosis during an emergency
admission associated with:
 advanced stage of disease
 prolonged inpatient stay
 no active treatment

3. Aims
 Capture journey of patients diagnosed with cancer
following an emergency admission through primary and
secondary care
 Reflect upon patient journey
 Identify strengths and lessons to be learned
 Recommendations for improvements

4. Structure of audit
 Split into 4 phases:
Phase 1: AOS
database audit of
patients
diagnosed
following an
emergency
admission
COMPLETED
Phase 2: Primary
care audit of
Phase 1 patients
to identify contact
with health
services
Phase 3:
collection of
secondary care
demographics
and detailed
analysis of notes
via RCRR
Phase 4:
reflective
exercise
involving specific
tumour groups
67 30 30 17

5. Phase 2
 GP practices identified as having patients in Phase 1
contacted
 Asked to complete audit and undertake SEA to look at
opportunities to refer at an earlier stage
 Full review of notes:
 Time between onset of symptoms and date of diagnosis
 Common presenting symptoms
 Number of contacts with primary care prior to diagnosis
 Investigations undertaken
 Reason for emergency presentation

6. Phase 3
 Only completed for cases where phase 2 audit received
 RCRR which included:
 Emergency presentation event
 Patients’ previous activity in secondary care
 Reflective exercise (MDT lead AO team +/- others)
 Selected minimum 1 case per tumour type
Phase 4

7. Results
 30 patients over 15 practices in NWS CCG
 57% aged over 70yo:
Age Number of patients
50-60 4
60-70 9
70-80 10
80-90 7
Total 30

8. Patient Demographics
 93% White British
 23% were housebound
 14% stated to have communication problems
 27% lived alone
 50% were either current or ex-smokers
 80% not alive at time of audit

9. Tumour Type
0
2
4
6
8
10
12
Number in primary care
Number in secondary care

10. Staging
0
5
10
15
20
25
30
0
I
IIA
IIB
IIC
IIIA
IIIB
IIIC
IV
notabletostage
notknown
notstated
Comparison of stage given in primary and secondary care
Primary care Secondary care

11. Performance Status
0
5
10
15
0 1 2 3 4 not recorded
Comparison of performance status in primary care and at time of
emergency presentation in secondary care
Primary care Secondary care

12. Timescales
36
0
50
100
150
200
250
Days from first primary care presentation to cancer diagnosis
Individual patients Median
Median: 36

13. 7
0
5
10
15
20
25
30
35
Days from emergency presentation to cancer diagnosis
Individual patients Median
Timescales
Median: 7

14. Tests carried out in secondary
care
0
5
10
15
20
25
30
CT
Ultrasound
Biopsy
MRI
Endoscopy
Bronchoscopy
Interventional
radiology
PETCT
Laporascopy
Tests carried out in secondary care - number of cases requesting
each type of test

15. Number of tests that each patient
received

16. Tests confirming cancer
diagnosis
 In almost half of cases, diagnosis of cancer confirmed
by histopathology or cytology
 In remainder cancer diagnosis was suggested by
radiological investigations:

17. Management following
diagnosis
Treatment intent Number of
patients
Curative
2
Palliative therapy
(chemotherapy/radiation)
13
Supportive care
15

18. Previous contacts with primary
care
 25 GP audits reported the number of primary care
consultations in the previous 12 months
 Range from 0 – 39, median 6
 Number of different primary care professions seen in
previous 12 months ranged from 0 – 3, median 3

19. Presenting symptoms to primary
care in 12 months prior to
presentation
 Top 5 presenting symptoms in primary care before EP
were:
 Weight loss
 Loss of appetite
 Cough
 Deterioration/unwell
 Lethargy/tiredness

20. Reported symptoms at
emergency presentation

21. Details of GP appointment where
symptoms 1st discussed
 In 21 audits reported that had presented in primary
care with relevant symptoms
 At initial consultation:
 All examined by a GP
 6 referred for XR
 4 referred for USS
 15 sent for bloods
 12 referred into secondary care

22. Details of secondary care
referrals

23. Limitations
 Tight timescales and Christmas period led to delayed receipt
of many proformas from primary care; only 30/67 eventually
received; possible bias in terms of which practices returned
proformas
 Secondary care analysis undertaken under time constraints
 Not possible to include all cases in an in depth analysis and
reflective exercise
 Quality of information in GP audits variable and some
appeared to have gaps in information provided – unclear if
information simply not available or GPs misread question.

24. Recommendations from
primary care
1. The need for a vague symptoms or rapid referral clinic
2. The need for public health information or education to encourage patients
to present sooner with symptoms
3. The need for improved public awareness and education to reduce smoking
rates
4. The need for improved services for patients living alone or housebound
5. The need for more direct access diagnostic tests to be available to primary
care
6. Better sharing and accessing of local shared electronic patient records
between primary, secondary, community health care services and nursing
homes to facilitate improvement in direct patient care
7. More comprehensive safety-netting by GPs

25. Recommendations from
secondary care
1. Roles of AOS team: diagnostic and therapeutic expertise, support,
coordination, futility
2. Communication with primary care (what, how, when): Discharge
summaries/MDT outcomes. Cancer specific fields on discharge summaries
within medicine/surgery/ICE tools. Safety netting on discharge
3. Communication within secondary care: Early referral to site-specific team/
diagnostics/AOS/palliative care. Communication skills, documentation, more
widespread use of HNA to identify patients with complex needs
4. MDT workflow: review of pathway for patients with no clear primary, or
investigations suggest alternative primary: Tracking systems, MDT-MDT
communication, use of patient advocates, change to default of MUO MDT for
complex presentations.
5. Commissioning new services: Vague symptoms clinic, suspicious radiology
clinic, anaemia pathways, MUO slots on discharge from hospital

26. Danish cancer pathway
Ingeman et al., BMC Cancer 2015

27. Danish cancer pathway
Ingeman et al., BMC Cancer 2015

28. Danish cancer pathway
Vedsted and Olesen BJC 2015

29. Danish 3 legged cancer
model
Vedsted and Olesen BJC 2015

30. Danish 3 legged cancer
model
Vedsted and Olesen BJC 2015

31. Any questions?