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Upper GI 2WW referrals & open access endoscopy
Dr Amanda J Hughes
Upper GI 2WW referral forms & open access endoscopy
• Background
• Upper GI cancer
• Challenge
• Case scenarios
• New 2WW & open access forms
• Questions
Background 1) Increased demand for GI services
Increasing referrals but ↓yield
1/4/12 – 31/3/13
• Approx 550 referred FT– 46/month
• 41 cancers ……….represents 25% of total upper GI cancers diagnosed
• 7.5% yield
1/4/13 – 30/11/14
• Approx 1100 referred as FT– 55/month
• 66 cancers …………represents approximately 30% of total upper GI cancers diagnosed
• 6% yield
1/1/15- 31/3/15 = 366 referred FT i.e. 122 / month
• Current open access forms not fit for purpose
– “Group A” encompasses 2 WW symptoms– Out of line with NICE guidance
• Wolverhampton changed their referral process
– Clinical Assessment service• Straight to test• Clinic review • Advice to GP………………anecdotally patients referred WMH
Consequence: Unable to see all the patients referred / perform endoscopy required within timely basis
Oesophago gastric cancers
• 6% all cancers• UK - oesophagus 13th & stomach 15th most common cancer
• 2/3 men
• 92% occur ≥ 55yrs
Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s
British Journal Cancer (2013) 108, 25-31
Pancreatic Cancer
• 11th most common cancer in UK• Rare < 40yrs, > 50% in patients over 75yrs• Risk factors:
– Smoking ( 1:3)– Diabetes– Chronic pancreatitis– Obesity– Sedentary lifestyle– Genetic ( 1:10)
• > 50 % jaundice at 1st presentation
Challenge
Timely diagnosis &management of cancer patients
Avoid overloading system with unnecessary referrals
Cases
• 74 yr female
– 3 months dysphagia• Food lodges distal oesophagus & regurgitates phlegm
– 1 stone weight loss
What do you want to do with her ?
Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s
British Journal Cancer (2013) 108, 25-31
Endoscopy
Diagnosis – SCC oesophagus
71 yr female
– “ New onset dyspepsia”
– Previously seen with dyspepsia by Dr Cox , symptoms difficult to control & required Nexium.
– Changed to Lansoprazole in community –
dyspepsia returned
What’s your management plan ?
Actual Management
– Referred as fast track. - was that appropriate ?
– Key symptom reflux
– Consultant re-instituted Nexium
Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s
British Journal Cancer (2013) 108, 25-31
72yr male, smoker
– 3/52 history of wt loss , nausea & vomiting
– New onset iron deficiency – started on Fe
– CXR – COAD
How would you manage him ?
Actual management
• Referred to respiratory team as 2WW
• Respiratory consultant made clinical diagnosis of gastric outflow obstruction
Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s
British Journal Cancer (2013) 108, 25-31
Investigations
OGD CT
• 45yr old female
– Persistent dyspepsia
– BMI 44
– Referred as fast track – is that truly appropriate ?
Positive predictive value of symptoms in patients > 40 yrs presenting to GP’s
British Journal Cancer (2013) 108, 25-31
• 70 yr old
– Jaundice
– Diabetes diagnosed 1 yr ago
– Weight loss
– Most common causes in this age group ?
73 yr old male
• RUQ pain• Wt loss
• USS – multiple liver mets
• Who do you refer to ?
73 yr old male
• RUQ pain• Wt loss
• USS – multiple liver mets
• Who do you refer to ?
• Depends on history…. Patient known previous colorectal Ca
Actually referred via upper GI pathway
Most common primary sites for liver mets
• Colon
• Stomach
• Pancreas
• Breast
• Lung
New forms……….
New NICE guidance May 2015 referral for suspected cancer.
Fast Track Criteria
Open Access Criteria
Summary
• Upper GI cancer – Common– Symptoms including PPV’s for oesophago gastric cancer
• Challenge – Selecting appropriate patients for onward referral
• Case scenarios
• Reviewed new 2WW & open access forms
Thank You
Any Questions ??