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Cancer Cascade Workshop
The Studio, Glasgow
1st December 2016
Dr Richard RoopeRCGP and Cancer Research UK Cancer Clinical Champion
Senior Clinical Advisor Cancer Research UK
Cancer Cascade Workshop
What’s new?
Cancer Cascade Workshop
What’s new?• Breast cancer presentation• Very brief intervention• Colorectal paper • E-cigarettes• New CRUK Stats/infographics• Dismantling Scottish QOF• Formation of GP Clusters
Cancer Cascade Workshop
What’s new?• BBC News 08.11.16 (NIHR Conference)• Breast cancer presentation
Cancer Cascade Workshop
http://www.bbc.co.uk/news/health-37894360
Cancer Cascade Workshop
What’s new?UCL Researchers:1 in 6 cases of breast cancer begin with non-lump symptoms
Cancer Cascade WorkshopNICE NG12 2015
2 week breast referral pathway:• aged 30 and over and have an unexplained breast lump• aged 50 and over with any of the following symptoms in one
nipple only: • discharge • retraction • other changes of concern. [new 2015] • skin changes that suggest breast cancer• aged 30 and over with an unexplained lump in the axilla.
[new 2015]• Consider non-urgent referral in people aged under 30
with an unexplained breast lump with or without pain. See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice. [new 2015]
Cancer Cascade Workshop
What’s new?Very brief advice
Cancer Cascade Workshop
What’s new?Very brief advice
http://www.bbc.co.uk/news/health-37717594
Cancer Cascade Workshop
What’s new?Very brief advice: 12 months later average weight loss:• Advice alone: 1.0kg • Advice with Tier 2 referral: 2.4 kg
• 1 in 4 lost 5% body weight• 1 in 10 lost 10% body weight
Cancer Cascade Workshop
What’s new?"The impact is pretty substantial given the effort - 30 seconds - that went into it.
"If we were year-on-year to knock 2.4kg off the heaviest people in society then that would have a very big effect in health terms.“ Prof Paul Aveyard
Cancer Cascade Workshop
What’s new?No such thing as “heavy bones”
Cancer Cascade Workshop
What’s new?No such thing as “heavy bones”
https://www.google.co.uk/search?q=heavy+bones+mri&biw=1440&bih=770&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjB_f6SgZnQAhUJDMAKHQoFBusQ_AUIBigB#imgdii=fhmxHroHSCs8KM%3A%3BfhmxHroHSCs8KM%3A%3B6LKV_QYXM9BJiM%3A&imgrc=fhmxHroHSCs8KM%3A
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer?
Colorectal cancer – when to refer?
• When did we refer? Variably
Colorectal cancer – when to refer?
• When did we refer? Variably across CCGs
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
Colorectal cancer – when to refer?
• When did we refer? Variably (across time)
Colorectal cancer – when to refer?
• When did we refer? Variably (across time) – improving!
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
Colorectal cancer – when to refer?
• When did we refer? Variably (across time) – improving!
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
Colorectal cancer – when to refer?
• 1 year survival
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-
type/bowel-cancer/survival#heading-Two Last accessed 28.9.16
• When did we refer? Variably (across time) – improving!
• When did we refer? Variably (across time) – improving!
Colorectal cancer – when to refer?
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-
type/bowel-cancer/survival#heading-Two Last accessed 28.9.16
0.0
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CRC cancer rates per 100,000
Incidence Mortality
Colorectal cancer – when to refer?
• When did we refer? Variably – why is this important?
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
Colorectal cancer – when to refer?
• When did we refer? Variably – why is this important?
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All routes Screening Two Week Wait GP referral Other OutpatientInpatient Elective Emergency… Unknown
Relative survival estimates by presentation route and survival time, Colorectal, 2006-2013
1-month
3-month
6-month
9-month
12-month
24-month
36-month
Colorectal cancer – when to refer?
• When did we refer? Variably – why is this important?
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All routes Screening Two Week Wait GP referral Other OutpatientInpatient Elective Emergency… Unknown
Relative survival estimates by presentation route and survival time, Colorectal, 2006-2013
1-month
3-month
6-month
9-month
12-month
24-month
36-month
Colorectal cancer – when to refer?
• When did we refer? Variably – why is this important?
http://www.ncin.org.uk/publications/routes_to_diagnosis (accessed 2.10.16)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All routes Screening Two Week Wait GP referral Other OutpatientInpatient Elective Emergency… Unknown
Relative survival estimates by presentation route and survival time, Colorectal, 2006-2013
1-month
3-month
6-month
9-month
12-month
24-month
36-month
Colorectal cancer – when to refer?
• What are the “key” symptoms?
Colorectal cancer – when to refer?
• What are the “key” symptoms for colon cancer?
• Rank order for symptoms reported or findings in 30 days prior to diagnosis:
Option A1. Rectal bleeding2. Change in bowel habit3. Weight loss4. Abdominal pain5. Anaemia
Option B1. Abdominal pain2. Anaemia3. Rectal bleeding4. Change in bowel habit5. Weight loss
Option C1. Abdominal pain2. Weight loss3. Rectal bleeding4. Change in bowel habit5. Anaemia
Option D1. Rectal bleeding2. Anaemia3. Change in bowel habit4. Abdominal pain5. Weight loss
Colorectal cancer – when to refer?
• What are the “key” symptoms for colon cancer?
• Rank order for symptoms reported or findings in 30 days prior to diagnosis:
Option A1. Rectal bleeding2. Change in bowel habit3. Weight loss4. Abdominal pain5. Anaemia
Option B1. Abdominal pain2. Anaemia3. Rectal bleeding4. Change in bowel habit5. Weight loss
Option C1. Abdominal pain2. Weight loss3. Rectal bleeding4. Change in bowel habit5. Anaemia
Option D1. Rectal bleeding2. Anaemia3. Change in bowel habit4. Abdominal pain5. Weight loss
Discuss and choose which is correct ranking.
Colorectal cancer – when to refer?
Option A1. Rectal bleeding2. Change in bowel habit3. Weight loss4. Abdominal pain5. Anaemia
Option B1. Rectal bleeding2. Anaemia3. Change in bowel habit4. Abdominal pain5. Weight loss
Option C1. Abdominal pain2. Weight loss3. Rectal bleeding4. Change in bowel habit5. Anaemia
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
Option D1. Rectal bleeding2. Anaemia3. Change in bowel habit4. Abdominal pain5. Weight loss
• What are the “key” symptoms for colon cancer?
• Rank order for symptoms reported or findings in 30 days prior to diagnosis:
Option B1. Abdominal pain 15.7%2. Anaemia 6.2%3. Rectal bleeding 4.4%4. Change in bowel habit 2.5%5. Weight loss 1.8%
Colorectal cancer – when to refer?
30 days pre-Δ 12 months - 30 days pre-Δ1. Abdominal pain 15.7% 25.1%2. Anaemia 6.2% 19.2%3. Rectal bleeding 4.4% 9.4%4. Change in bowel habit 2.5% 5.5%5. Weight loss 1.8% 3.1%
• What are the “key” symptoms for colon cancer?
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
Colorectal cancer – when to refer?
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
1.Abdominalpain
2.Anaemia 3.Rectalbleeding
4.Change inbowel habit
5.Weight loss
Frequency of symptoms in colon cancer
30 days pre-Δ 12 months - 30 days pre-Δ
• What are the “key” symptoms?
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
Colorectal cancer – when to refer?
• What are the “key” symptoms?
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
1.Abdominalpain
2.Anaemia 3.Rectalbleeding
4.Change inbowel habit
5.Weight loss
Frequency of symptoms 30 days pre-diagnosis in colon cancer
Non-EP EP
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
1.Abdominalpain
2.Anaemia 3.Rectalbleeding
4.Change inbowel habit
5.Weight loss
Frequency of symptoms in rectal cancer
30 days pre-Δ 12 months - 30 days pre-Δ
Colorectal cancer – when to refer?
• What are the “key” symptoms?
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
1.Abdominalpain
2.Anaemia 3.Rectalbleeding
4.Change inbowel habit
5.Weight loss
Frequency of symptoms 30 days pre-diagnosis in rectal cancer
Non-EP EP
Colorectal cancer – when to refer?
• What are the “key” symptoms?
http://www.nature.com/bjc/journal/v115/n7/pdf/bjc2016250a.pdf
Cancer Cascade WorkshopE-cigarettes
Cancer Cascade WorkshopE-cigarettes – RCGP November Clinical News
Cancer Cascade Workshop
E-cigarettesToxicity:• Smoking tobacco: >7000 chemicals1
• Vaping: 42 chemicals2 – though will vary
1. http://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/chemicals_smoke/2. http://www.gaspforair.org/gasp/gedc/pdf/E-CigSmoke.pdf
Cancer Cascade Workshop
E-cigarettesToxicity:
Eur Addict Res 2014;20:218-225
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?2. Safety?3. Is it effective in cessation?4. Is passive vaping of concern?5. Should we wait for more research?
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?
• Use in children is rare – of those who do, most are ex-smokers
• Youth smoking: 1996 13% 2014 3%1
1. Smoking drinking and drug use among young people in England 2014, HSCIC, www.hscic.gov.uk/pubs/sdd14
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?2. Safety?
• Long term safety profile not yet known –but much safer than cigarettes1
• PHE report 95% safer than cigarettes2
1. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010216. DOI:
2. www.gov.uk/government/uploads/system/uploads/attachment_data/file/454517/Ecigarettes_a_firm_foundation_for_evidence_based_policy_and_practice.pdf
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?2. Safety?3. Is it effective in cessation?
• Since 2013 ECs are England’s most successful quitting aid1
1. Smoking Toolkit Study www.smokinginengland.info
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?2. Safety?3. Is it effective in cessation?4. Is passive vaping of concern?
• No identified hazards to bystanders1
1. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010216. DOI:
Cancer Cascade Workshop
E-cigarettesConcerns:1. Entry into smoking?2. Safety?3. Is it effective in cessation?4. Is passive vaping of concern?5. Should we wait for more research?
• No – the benefits are so larger, there are lives to be saved…
Cancer Cascade Workshop
E-cigarettesPosition statement now adopted
Cancer Cascade Workshop
Cigarette smoking prevalence
0.0
5.0
10.0
15.0
20.0
25.0
30.0
% smoking
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/541959/Local_tobacco_control_profiles_indicators_at_a_glance_August_2016.pdf accessed 6.10.16http://www.smokinginengland.info/latest-statistics/ Accessed 6.10.16
Cancer Cascade Workshop
% of smokers trying to stop
www.smokinginengland.info/latest-statistics
Cancer Cascade Workshop
Cigarette smoking prevalence
Cancer Cascade Workshop
What’s new?• New CRUK Stats/infographics
http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/how-to-stop-smoking last accessed 26.11.16
Cancer Cascade Workshop
New CRUK Stats/infographics
Cancer Cascade Workshop
New CRUK Stats/infographics
http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/diet-and-cancer/how-healthy-eating-prevents-cancer last accessed 8.10.16
Cancer Cascade Workshop
New CRUK Stats/infographics
http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/physical-activity-and-cancer/how-physical-activity-prevents-cancer last accessed 8.10.16
Cancer Cascade Workshop
New CRUK Stats/infographics
https://pbs.twimg.com/media/B2uE_6vCQAAB_pK.png last accessed 8.10.16
Cancer Cascade Workshop
New CRUK Stats/infographics
http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@cah/@gen/documents/image/cr_123923.png last accessed 8.10.16
Cancer Cascade Workshop
New CRUK Stats/infographics
http://publications.cancerresearchuk.org/downloads/Product/prostate_screening_info.pdf last accessed 8.10.16
Cancer Cascade Workshop
• Dismantling Scottish QOF• Formation of GP Clusters
Cancer Cascade Workshop
• Dismantling Scottish QOF• Formation of GP ClustersRCGP Publication:Setting the strategy for Quality in Scotland’s General Practices
Cancer Cascade Workshop
RCGP Publication:Setting the strategy for Quality in Scotland’s General Practices
file:///D:/Users/The%20Roopes/Downloads/Setting%20the%20Strategy%20for%20Quality%20for%20Scotlands%20general%20practices%20%20Final.pdf
Cancer Cascade Workshop
RCGP Publication:Setting the strategy for Quality in Scotland’s General Practices
RCGP Scotland is committed to building QI activities into the role of all members of the primary health care team and to the inclusion of the patient/public voice in designing QI activities at all levels from individual practices to national organisations.
Cancer Cascade Workshop
What’s new?• Breast cancer presentation• Very brief intervention• Colorectal paper • E-cigarettes• New CRUK Stats/infographics• Dismantling Scottish QOF• Formation of GP Clusters
Cancer Cascade Workshop
What’s new?• LOTS…!!!
Cancer Cascade Workshop
What’s new?• LOTS…!!!
KEEPCALM
EXCITINGTIMES AHEAD
!!