Dr Cathy Burton - Cancer Research UK

Dr Cathy Burton
Associate Director SELCN and
Macmillan GP Adviser
17 December, 2010

Engaging GPs in Improving Early
Diagnosis
Dr Cathy Burton
Associate Director SELCN and
Macmillan GP Adviser
15.12.2010

Subdivision of delay
Patient delay Delay in primary care Delay in secondary care
Doctor delay
System delay
First
symptom
First
contact
with the GP
Initiation of
investigation of
cancer-related
symptoms
Referral to
hospital
First visit
at the
hospital
Referral to
treatment
Treatment
initiation

Rate of 2 week referrals versus conversion
rate by practice in Lambeth 2006
30
2WR per 1000 Patients vs % 2WR with Cancer
25
20
15
10
5
0
13
14
11
29
43
23
26
28
9
44
48
35
18
33
6
15
45
41
31
4
8
20
3
27
32
7
22
46
Practice code
12
40
21
51
42
24
19
36
50
47
10
16
2
1
38
25
37
5
34
39
30
17
49
2WRs per 1000 pts
%2wr with cancer

Aims of the National Cancer
Primary Care Audit
• Identify delays in primary care prior to
diagnosis
• Identify tumour groups or groups of patients
vulnerable to delay

The Data Template
• Uses picking lists to improve accuracy and consistency of data
• Demographic data, communication problems, housebound
status
• Date symptoms first noticed, date patient presented to GP,
date referred, date first seen by specialist
• Main presenting symptom
• Investigations in Primary Care
• Referral route
• Tumour type
• Staging information at diagnosis (confined to organ, local
spread, distant metastases)

Some Early Results of the
National Audit
• 18 Cancer Networks participated
• 18,113 cases reported on
• Quality of data high
• Completeness of data 90%+ in most fields

Stage by tumour type
50%
45%
40%
35%
30%
25%
20%
Organ
Local spread
Distant metastases
Not known
15%
10%
5%
0%
Breast Ovary Cervix Lung CRC

Stage and Communication Difficulties
50%
45%
40%
35%
30%
25%
No communication difficulty
Communication difficulty
20%
15%
10%
5%
0%
Organ Local spread Distant mets Not known

Stage and Housebound Status
50%
45%
40%
35%
30%
25%
Not housebound
Housebound
20%
15%
10%
5%
0%
Organ Local spread Distant mets Not known

Benefits of the Primary Care Audit
• GP Practices engaged with looking at their
cancer cases and reflective learning
• Raised awareness of referral guidelines in
participating practices
• Many practices identified changes to make to
improve systems e.g. Reviewed how abnormal
results are managed

Benefits of the Primary Care Audit
• Has provided a huge body of data of high
quality
• Complements data from other sources
• Allows localities to identify local issues
– E.g. SE London identified problem with reporting
of CXRs in A&E departments (not reviewed by
radiologists some lung cancers missed)
– Access to CT following equivocal CXR

What the cancer audit did not tell us
• Not a good way to identify delays before
presentation to the GP
• Also not a good way to identify how long
between first presentation and referral?
• What about those practices which did not
engage?

The Significant Event Audit Project
• GPs undertook SEAs on 132 lung cancer cases
• Analysed by team working with RCGP
• Presentation of lung cancer is complex
• Important to have safety-netting systems in
place (to follow up, manage and refer nonresolving
symptoms)
• Important to have robust systems for
following up abnormal results

The Significant Event Audit Project
• Important for GPs to be aware of the recent
history of presentations
• It is difficult to distinguish new symptoms in
patients with known chest disease
• Consider lung cancer in the differential
diagnosis of shoulder and neck pain
• Patient education to encourage earlier
presentation for new or ongoing chest
symptoms

The Practice Cancer Profiles Project
• Backed by funding from DH and NCAT
• Aims to
– Increase GP leadership for early diagnosis
– Reach practices not previously engaged
– Demonstrate a measurable change in outcome
from undertaking the audit

The Practice Cancer Profiles Project
• NCIN has collated metrics for every practice in
England including:
– Incidence of cancer
– Screening uptake
– Number of 2 week referrals
• Breast, lung, colorectal and skin identified individually
– Conversion rate
– Cancer emergency admissions
– Cancer emergency presentations

The Practice Cancer Profiles Project
• GP leads identified in each area
• GP leads to disseminate profiles to GP
practices
• GP leads to identify small number outlying
practices in each area for one-to-one work
• Outlying practices implement full audit cycle
using primary care audit tool

Analysis of Lambeth Practice Profile data
50
Rank - 2week referrals (High to low)
Rank (2ww with cancer - high to low)
Rank emergengy admissions
40
30
20
10
0
STREATHAM HIGH PRACTICE (DR ASHBY)
THE SURGERY (DR ALA)
APMS SOLUTIONS LTD (DR MUKADAM)
MAWBEY GROUP PRACTICE (LOGAN)
THE VALE SURGERY (DR RAMANAN)
THE ROSENDALE SURGERY (DR CHABUK)
DR WINTER
DRAKEWOOD ROAD MEDICAL CENTRE …
NORWOOD SURGERY (DR FERNANDES)
EDITH CAVELL NHS PRACTICE 1 (DR BELL)
STREATHAM COMMON GROUP PRACTICE …
DR SHAH
VASSALL MEDICAL CENTRE (DR PATEL)
THE CLAPHAM FAMILY PRACTICE (DR …
THE DEERBROOK SURGERY (DR WRIGHT)
THE TULSE HILL PRACTICE (DR AH-MOYE)
THE STREATHAM HILL GORUP PRACTICE …
WATERLOO HEALTH CENTRE (DR …
THE WATER LANE SURGERY (DR SAIF)
DR ARORA
HETHERINGTON GROUP PRACTICE (DR …
THE GRANTHAM CENTRE (DR …
STREATHAM PLACE (DR AK SINGH)
THIRTY ONE PRENTIS ROAD (DR …
SOUTH LAMBETH ROAD (DR COSTA)
CLAPHAM PARK GROUP PRACTICE (DR …
PAVILION PRACTICE (DR PATEL)
THE GRANTHAM CENTRE (MCGINN)
MYATTS FIELD HEALTH CENTRE (WHITMEY)
VALLEY ROAD SURGERY (DR PECK)
THE SURGERY (DR FERREIRA)
THE IVEAGH HOUSE SURGERY (DR …
SANDMERE PRACTICE (DR GUPTA)
BROCKWELL PARK (DR BRUML)
STOCKWELL GROUP PRACTICE (DR …
HURLEY CLINIC (DR POOLE)
THE SURGERY (DR WHITTET)
BRIXTON HILL GROUP PRACTICE (DR …
HERNE HILL GROUP PRACTICE (DR …
DR MASTERTON
MANOR HEALTH CENTRE (SANTAMARIA)
CROWN DALE MEDICAL CENTRE (DR …
DR ASHTON
THE MANOR HEALTH CENTRE (CURRAN)
SPRINGFIELD PRIMARY CARE CENTRE …
PAXTON GREEN PRACTICE (DR EVANS)
LAMBETH WALK GROUP PRACTICE (DR …
DR HU
THE CORNER SURGERY (DR WICKSTEAD)
DR IRANI
THE EXCHANGE SURGERY (DR ROWLEY-…

Finally
• Lung cancer is the commonest cause of cancer death
in the UK
• Mortality is high, as very few are diagnosed at an
operable stage
• There is an easy test – the chest X-ray - but no
screening test
• Almost all present to GPs with symptoms

The problem: we GPs do a good job as
gatekeepers
• We are justifiably proud of UK general practice
• The gatekeeper role has brought many
benefits to patients, not least by ensuring the
correct specialist is seen
• It has also brought disadvantages, arising from
GPs’ desire to use resources appropriately
• In cancer this means not investigating the lowrisk
symptom – and NICE tells us not to

Thank you
Cathy Burton
calburton@gmail.com