Realising the Potential in Primary Care - Otago
24
Realising the Potential in Primary Care Dr John McMenamin GP Whanganui #CancerCrossroads
Transcript of Realising the Potential in Primary Care - Otago
Realising the Potential in Primary Care
Dr John McMenaminGP Whanganui
CancerCrossroads
What are the expectations for Primary Care about Cancer
Prevention and early detection More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent information resources
Diagnosis and treatment Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Follow-up care More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general physicians primary care providers senior
nurses)
Integrated palliative care services will be available
Cancer care expectations 2015-2018 Primary Care contributions
Prevention and early
detection
More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent
information resources
Fewer people smoking but marked ethnic disparities
Pathways with more streamlined referral processes
New resources eg prostate cancer information tool (Kupe) (Need FH tool )
Need alcohol on this agenda 4 cancer deaths attributed to alcohol
Diagnosis and
treatment
Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of
cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Palliative care aligned not integrated Data improving ndash need personalised feedback
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
What are the expectations for Primary Care about Cancer
Prevention and early detection More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent information resources
Diagnosis and treatment Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Follow-up care More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general physicians primary care providers senior
nurses)
Integrated palliative care services will be available
Cancer care expectations 2015-2018 Primary Care contributions
Prevention and early
detection
More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent
information resources
Fewer people smoking but marked ethnic disparities
Pathways with more streamlined referral processes
New resources eg prostate cancer information tool (Kupe) (Need FH tool )
Need alcohol on this agenda 4 cancer deaths attributed to alcohol
Diagnosis and
treatment
Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of
cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Palliative care aligned not integrated Data improving ndash need personalised feedback
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Prevention and early detection More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent information resources
Diagnosis and treatment Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Follow-up care More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general physicians primary care providers senior
nurses)
Integrated palliative care services will be available
Cancer care expectations 2015-2018 Primary Care contributions
Prevention and early
detection
More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent
information resources
Fewer people smoking but marked ethnic disparities
Pathways with more streamlined referral processes
New resources eg prostate cancer information tool (Kupe) (Need FH tool )
Need alcohol on this agenda 4 cancer deaths attributed to alcohol
Diagnosis and
treatment
Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of
cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Palliative care aligned not integrated Data improving ndash need personalised feedback
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Prevention and early
detection
More people will be making healthy food and activity choices and sustaining healthy weights
More people will be aware of cancer risks and will be doing something about them
Fewer people will be smoking
More people across all population groups will be screened for bowel breast and cervical cancer
Referral processes will be streamlined
More people will have access to easily understood and nationally consistent
information resources
Fewer people smoking but marked ethnic disparities
Pathways with more streamlined referral processes
New resources eg prostate cancer information tool (Kupe) (Need FH tool )
Need alcohol on this agenda 4 cancer deaths attributed to alcohol
Diagnosis and
treatment
Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of
cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Palliative care aligned not integrated Data improving ndash need personalised feedback
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Diagnosis and
treatment
Patients will receive first cancer treatment within 62 days of urgent referral with a high suspicion of
cancer
Diagnostic and treatment processes will be streamlined faster and more standardised
Patients will be prioritised and their care discussed at MDMs
Tumour standards will be reviewed and service changes implemented
A cancer nurse coordinator workforce will have been established
People will be better informed and more confident about their treatment
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Integrated palliative care services will be available
Available facilities and equipment will meet population need
There will be timely access to comprehensive accurate patient-level data
Cancer information will be consolidated
Cancer workforce will have grown and be working at the top of their scope
Palliative care aligned not integrated Data improving ndash need personalised feedback
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Follow-up care
More people will be accessing psychological and social support they need
People will have access to easily understood and nationally consistent information resources
Patients will receive consistent follow-up and surveillance from all clinicians (eg general
physicians primary care providers senior nurses)
Integrated palliative care services will be available
Follow up and surveillance include in Primary Care co-morbidity management
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Most cancers present in general practice
A GP sees a common cancer every 1-2 years rarer cancers every 5-10 years
80 referred after 1 ndash 2 consultations
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
For the 20 requiring 3 or more consultations do delays affect cancer outcomes
Yes though varies by cancer longer delays for multiple myeloma and shortest for melanoma and breast cancer
Systematic Review Reducing delays in diagnosis probably has benefits for patients in terms of improved survival
o earlier-stage diagnosiso improved quality of life especially for breast colorectal head and
neck testicular and melanoma
Br J Cancer 2015 Mar 31112 Suppl 1S92-107 doi 101038bjc201548Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes Systematic reviewNeal RD1 Tharmanathan P2 France B1 Din NU1 Cotton S3 Fallon-Ferguson J4 Hamilton W5 Hendry A1 Hendry M1 Lewis R2 Macleod U6 Mitchell ED7 Pickett M3 Rai T8 Shaw K4 Stuart N9 Toslashrring ML10 Wilkinson C1 Williams B4 Williams N11 Emery J12
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
If a cancer is present is it likely to be diagnosed
Some will present with easily recognised high risk symptoms
dysphagia (5 likelihood of cancer if age gt55 years) postmenopausal bleeding (4 likelihood if age gt55 years) haemoptysis (2 likelihood if age gt40 years)
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
But most will have vague or non-specific symptoms such as cough fatigue or abdominal pain
The likelihood of cancer is low (mostly under 05)
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
If a cancer is present is it likely to be diagnosed
Delayed Diagnosis of Cancer in Primary Care Complaints to the Health and Disability Commissioner 2004ndash2013
An HDC report analyses data from complaints about 228 GPs and delayed diagnoses of cancer 2004-2013
Just over half non-specific symptoms
Just under half potential reduction in delay
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Longitudinal review of colorectal cancer presentations to ED
approximately a fifth of emergency presenters hadlsquoalarm symptoms (bleeding diarrhoea anaemia abd pain) within last year
16 had 3 or more consultations with relevant symptoms suggesting possible opportunities for earlier diagnosis
Consultation rates increased significantly in the last months before diagnosis independently of the diagnostic route
Implication repeat attenders may have cancer
C Renzi G Lyratzopoulos T Card T P C Chu U Macleod B RachetDo colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms A longitudinal data-linkage study in EnglandBr J Cancer 2016 Sep 27 115(7) 866ndash875 Published online 2016 Aug 18 doi 101038bjc2016250
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
What can primary care do to understand this better
Cancer Significant Event Analysis
Peer review
Knowledge and skills updates from cancer specialists
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
A systematic review of Interventions to reduce primary care delay in cancer referral
Limited evidence for complex interventions including
audit and feedback
specific skills training
Br J Gen Pract 2011 Dec 61(593) e821ndashe835
Published online 2011 Nov 28 doi 103399bjgp11X613160
PMCID PMC3223780
PMID 22137419
Interventions to reduce primary care delay in cancer referral a systematic review
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Significant event analyses of delayed cancer diagnosesin general practice
Delayed diagnoses usually result from
complexity often associated co-morbidities negative investigation
E D Mitchell G Rubin L Merriman and U MacleodThe role of primary care in cancer diagnosis via emergency presentation qualitative synthesis of significant event reports British Journal of Cancer 2015 Mar 31 112(Suppl1) S50ndashS56
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
RNZCGP Policy brief recommendations for GPs
undertake clinically indicated examinations consider a lsquowatch and reviewrsquo strategy hold a suspicion of cancer despite comorbidities be aware of the limitations of diagnostic testing change the management plan in response to new or persistent symptoms provide patients with safety-netting advice use robust follow-up systems
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Whatrsquos going on for the patients
Patient delays talking with close people
Most patients delayed because
Acceptable explanation for symptoms Waiting for symptoms to resolve without intervention
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort
Most pts with bowel cancer are not thinking about cancer
Of the patients with bowel cancer ony 17 suspected bowel cancer as cause of symptoms for which they sought GP advice ndash majority had classical symptoms
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Adressing cancer literacy in Primary Care
On average New Zealanders have poor health literacy skills
Up to 80 of Maori men and 75 of Maori women have poor health literacy skills and are at risk of adverse outcomes
Zoe Windner Sue Crengle Brandon de Graaf Ari Samaranayaka Sarah Derrett New Zealandersrsquo experiences and pathways to a diagnosis of bowel cancer a cross-sectional descriptive study of a younger cohort NZ Med J 5 October 2018 Vol 131 No 1483 ISSN 1175-8716
Lung cancer stage-shift following a symptom awareness campaign Kennedy MPT et al Thorax 2018731128ndash36
lsquoGot a cough Get a checkrsquo a cancer awareness campaign in UK
80 increase in chest x-ray referrals Diagnosis of 6000 lung cancers 10 reduction in late-stage diagnoses 8 stage shift towards earlier stage lung cancer
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
System delays
HDC report Delayed diagnosis of
skin cancer significantly associated with the patient not reporting their symptoms
prostate cancer strongly associated with failure to follow-up results
Primary Care needs robust systems
Management of test results Follow up of patients Referral pathway
Funding and organisation of care
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Some helpful ldquoadvicerdquo in literaturerdquo
Clinical alertness -gt specifically ask cancer questions
Monitor symptoms Safety netting
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Does primary care contribute to inequity
From the PIPER Study
Disparities in survival following CRC
ldquodifferences in late-stage presentation will largely reflect inequity in access to andor from primary carerdquo
The New Zealand PIPER Project colorectal cancer survival according to rurality ethnicity and socioeconomic deprivationmdashresults from a retrospective cohort study 8th June 2018 Volume 131 Number 1476Katrina Sharples Melissa Firth Victoria Hinder Andrew Hill Mark Jeffery Diana Sarfati Charis Brown Carol Atmore Ross Lawrenson Papaarangi Reid Sarah Derrett Jerome Macapagel John Keating Adrian Secker Charles De Groot Christopher Jackson Michael Findlay
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
What do GPs think
This New Zealand study showed that the participating
GPs generally believed that the continuity of cancer care can be improved
Some patients ldquodisappearrdquo
Improving role clarity would result in better communication between cancer specialists general practitioners other health care professionals and patients
Supporting patient care and managing co-morbidities
19th August 2016 Volume 129 Number 1440Paul Kane Marieke Jasperse Richard Egan Lynn McBain E McKinlay Susan Pullon Patries HerstContinuity of cancer patient care in New Zealand the general practitioner perspectiveNZMJ 19 August 2016 Vol 129 No 1440 ISSN 1175-8716
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
Proposal we need a primary care cancer strategy
Prevention and early detection
Diagnosis and treatment
Follow-up care
Management of Co-morbidities
Quality
Education
Equity
Funding
