Cancer Care Ontario’s Symptom Management Guide-To-Practice Loss of Appetite
Qcancer : symptom based approach to cancer risk assessment
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Transcript of Qcancer : symptom based approach to cancer risk assessment
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Qcancer: symptom based approach to cancer risk assessmentJulia Hippisley-Cox, GP, Professor Epidemiology & Director ClinRisk Ltd3rd cancer Care Congress26 Sept 2012
+Acknowledgements
Co-authors QResearch database EMIS & contributing practices & User Group University of Nottingham ClinRisk (software) Oxford University (independent validation)
This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License
+QResearch Database www.qresearch.org Over 700 general practices across the UK, 14 million
patients Joint venture between EMIS and University of
Nottingham Patient level pseudonymised database for research Available for peer reviewed academic research where
outputs made publically available Data linkage – deaths, deprivation, cancer, HES
This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License
+QScores – new family of Risk Prediction tools Individual assessment
Who is most at risk of preventable disease? Who is likely to benefit from interventions? What is the balance of risks and benefits for my patient? Enable informed consent and shared decisions
Population level Risk stratification Identification of rank ordered list of patients for recall or
reassurance
GP systems integration Allow updates tool over time, audit of impact on services and
outcomes
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+Early diagnosis of cancer: The problem UK has relatively poor track record when compared
with other European countries Partly due to late diagnosis with estimated 7,500+ lives
lost annually Later diagnosis due to mixture of
late presentation by patient (alack awareness) Late recognition by GP Delays in secondary care
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+Symptoms based approach Patients present with symptoms GPs need to decide which patients to investigate and refer Decision support tool must mirror setting where decisions
made Symptoms based approach needed (rather than cancer
based) Must account for multiple symptoms Must have face clinical validity eg adjust for age, sex,
smoking, FH updated to meet changing requirements, populations,
recorded data
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+QCancer scores – what they need to do Accurately predict level of risk for individual based on
risk factors and multiple symptoms Discriminate between patients with and without cancer Help guide decision on who to investigate or refer and
degree of urgency. Educational tool for sharing information with patient.
Sometimes will be reassurance.
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+Methods – development algorithm Huge representative sample from QResearch aged 30-84 Identify new alarm symptoms (eg rectal bleeding,
haemoptysis) and other risk factors (eg age, COPD, smoking, family history)
Identify cancer outcome - all new diagnoses either on GP record or linked ONS deaths record in next 2 years
Established methods to develop risk prediction algorithm Identify independent factors adjusted for other factors Measure of absolute risk of cancer. Eg 5% risk of
colorectal cancer
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+‘Red’ flag or alarm symptoms (identified from studies including NICE guidelines 2005) Haemoptysis Haematemesis Dysphagia Rectal bleeding Vaginal bleeding Haematuria dysphagia Constipation, cough
Loss of appetite Weight loss Indigestion +/- heart burn Abdominal pain Abdominal swelling Family history Anaemia Breast lump, pain, skin
tethering
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+Qcancer now predicts risk all major cancers including
PancreasLung Kidney Ovary
Colorectal Gastro Testis
Breast Prostate Blood
Cervix
Uterus
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+Results – the algorithms/predictorsOutcom
eRisk factors Symptoms
Lung Age, sex, smoking, deprivation, COPD, prior cancers
Haemoptysis, appetite loss, weight loss, cough, anaemia
Gastro-oeso
Age, sex, smoking status
Haematemsis, appetite loss, weight loss, abdo pain, dysphagia
Colorectal
Age, sex, alcohol, family history
Rectal bleeding, appetite loss, weight loss, abdo pain, change bowel habit, anaemia
Pancreas Age, sex, type 2, chronic pancreatitis
dysphagia, appetite loss, weight loss, abdo pain, abdo distension, constipation
Ovarian Age, family history Rectal bleeding, appetite loss, weight loss, abdo pain, abdo distension, PMB, anaemia
Renal Age, sex, smoking status, prior cancer
Haematuria, appetite loss, weight loss, abdo pain, anaemia
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+Methods - validation is crucial Essential to demonstrate the tools work and identify right
people in an efficient manner Tested performance
separate sample of QResearch practices external dataset (Vision practices) at Oxford University
Measures of discrimination - identifying those who do and don’t have cancer
Measures of calibration - closeness of predicted risk to observed risk
Measure performance – Positive predictive value, sensitivity
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+Using QCancer in practice – v similar to QRISK2
Standalone tools a. Web calculator
www.qcancer.org/2013/female/php www.qcancer.org/2013/male/php
b. Windows desk top calculatorc. Iphone – simple calculator
Integrated into clinical systema. Within consultation: GP with patients with symptoms b. Batch: Run in batch mode to risk stratify entire
practice or PCT population
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+QCancer – women http://qcancer.org/2013/female/index.php
PROFILE64yr old woman, Moderate smokerLoss appetiteAbdo painAbdo swelling72% risk of no cancer28% risk any cancer - ovarian = 20% - colorectal = 1.5% - pancreas =.16%- Other 3.4%
This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License
+QCancer – men http://qcancer.org/2013/male/index.php
PROFILE• 64yr old man, • Heavy smoker• FH GI cancer• Loss appetite• Recent VTE• Weight loss• Indigestion• RESULTS• 71% risk of no
cancer• 29% risk any
cancer• Lung = 9%• Pancreas =6%• Prostate =2%• Other =5%
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+GP systems integrationBatch processing Similar to QRISK which is in 95% of GP practices–
automatic daily calculation of risk for all patients in practice based on existing data.
Identify patients with symptoms/adverse risk profile without follow up/diagnosis
Enables systematic recall or further investigation Systematic approach - prioritise by level of risk.
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+Next steps - pilot work in clinical practice supported by Macmillan& DH
+
Thank you for listening
Questions & Discussion
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+Comparison other cancer risk tools Large UK sample with data
until 2012 Symptoms based approach Takes account of risk factors
including age, sex, smoking, FH
Independent external validation by Oxford University
Can be updated and integrated into computer systems into workflow
20-40 Exeter practices; paper records from 10 years ago
Focused on single symptoms and pairs where enough data
No adjustment for age although cancer risk changes with age
Not validated Distributed as a mouse mat
for each cancer
QCancer The “RAT”
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