Why do we need a ‘blood in pee’ campaign?

Presented by Professor Frank Chinegwundoh (Birmingham) and Miss

Jhumur Pati (London) Barts Health NHS Trust

What have the public heard recently about bladder and kidney cancers?

Cancer Awareness Measure 2014: Unpublished data Recall of signs/symptoms (% mentioned)

Q. There are many warning signs and symptoms of cancer. Please name as many as you can think of?

0

0.2

0.2

0.4

0.4

0.8

0.8

1

1.8

4.1

4.1

5.1

6.5

11.8

13.4

14.1

16.7

20.4

22.2

22.9

32.4

33.4

40.3

64.2

Food sticking

Hoarseness

Heartburn

Red/white patch in mouth

Indigestion

Bloating

Looser poo

Difficulty swallowing

Sore

Loss of appetite

Nausea/sickness

General unwell

Breast changes

Tiredness

Blood in poo

Poo (blood in poo/looser poo)

Blood in pee

Weight loss

Mole

Cough/hoarseness

Pain

Bowel/bladder

Bleeding

Lump

How common are bladder and kidney cancers?

• The age-standardised incidence rate of bladder cancer has fallen over the last decade

• The age-standardised incidence rate of kidney cancer has steadily increased over the last decade

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

0

5

10

15

20

25

30

35

40

45

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

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of

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Year

Males - ASR Females - ASR Males - cases Females - cases

0

1,000

2,000

3,000

4,000

5,000

6,000

0

5

10

15

20

25

30

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

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Males - ASR Females - ASR Males - cases Females - cases

Kidney cancer (C64) Bladder cancer (C67)

In England, approximately 7,600 people die from bladder or kidney cancer each year

• The age-standardised mortality rate of bladder cancer has fallen over the last decade

• The age-standardised mortality rate of kidney cancer has not changed

Kidney cancer (C64) Bladder cancer (C67)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

0

2

4

6

8

10

12

14

16

18

20

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

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of

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Year

Males - ASR Females - ASR Males - deaths Females - deaths

0

500

1,000

1,500

2,000

2,500

0

2

4

6

8

10

12

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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Year

Males - ASR Females - ASR Males - deaths Females - deaths

No change in survival from bladder cancer

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Net

su

rviv

al

Year

Males - 1 year Females - 1 year Males - 5 year Females - 5 year

• Despite falling mortality the survival from bladder cancer has not changed since the early 2000s.

• Women have poorer survival, which is unusual for cancer.

Survival from kidney cancer has increased

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Ne

t s

urv

iva

l

Year

Males - 1 year Females - 1 year Males - 5 year Females - 5 year

• Survival from kidney cancer has increased due to increasing incidence and steady mortality

Stage at diagnosis bladder cancer (C67) Year I II III IV Unknown

2011 12% 8% 2% 6% 71%

2012 15% 10% 3% 8% 65%

2013 35% 20% 6% 14% 26%

2011 42% 29% 7% 22%

2012 42% 28% 8% 22%

2013 47% 28% 7% 18%

• Completeness of stage has only been satisfactory for 2013

• Out of those cases staged about 1/5 are diagnosed at the most advanced stage, nearly half are stage I which is non-muscle-invasive

• We expect the proportion of stage IV cases to decrease as completeness increases

Stage at diagnosis kidney cancer (C64) Year I II III IV Unknown

2011 11% 3% 5% 13% 68%

2012 16% 3% 8% 16% 56%

2013 31% 7% 13% 20% 30%

2011 34% 9% 17% 41%

2012 37% 8% 19% 36%

2013 44% 10% 18% 28%

• Completeness of stage has only been satisfactory for 2013.

• Out of those cases staged over 1/4 are diagnosed at the most advanced stage, and over half at stage I/II (which is considered early).

• We expect the proportion of stage IV cases to decrease as completeness increases.

Routes to Diagnosis for bladder cancer (C67)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2006 2007 2008 2009 2010 2011 2012 2013

Male - 2WW Male - GP referral Male - emergency

Female - 2WW Female - GP referral Female - emergency

• There has been a steady increase in 2WW diagnoses.

• Women are more likely to be diagnosed as an emergency.

Routes to Diagnosis for kidney cancer (C64)

0%

5%

10%

15%

20%

25%

30%

35%

2006 2007 2008 2009 2010 2011 2012 2013

Male - 2WW Male - GP referral Male - emergency

Female - 2WW Female - GP referral Female - emergency

• There has been an increase in 2WW diagnoses

• Although emergency diagnoses have fallen they are still high compared to many other cancers (inc. bladder).

It isn’t all about bladder and kidney cancers…

I am a Gynae Oncology Nurse… In a follow up clinic today one of my patients informed me that the reason she sought help for her problematic

symptom of PV bleeding was after watching ' the blood in your pee campaign' on the television. She realised that perhaps having show of

blood was an abnormal sign even if it wasn't in her pee. She has been successfully treated for endometrial cancer and is now

recovering very well post surgery. She asked if I could feed back this to the ‘Be Clear on Cancer Campaign'

Thank you for all your wonderful work.

What happens after referral will vary across the country

• Some areas have one-stop, rapid access haematuria clinics

• The combination of tests will include some, but not all of the following: • Consultation

• Examination

• Urine tests

• Flexible cystoscopy

• Imaging – USS/CT scan

Investigation of two week wait referred haematuria patients in the UK: A national survey Hughes, Drake & Hamm - Liverpool

Journal of Clinical Urology 2015. vol 8(5) 306-314

- 2.6% of population – visible haematuria

131 Trusts 72 responded (55%)

94% - haematuria clinic

but 2/3 a one stop service

96% flexible cystoscopy

Haematuria: national survey cont.

Visible haematuria microscopic

urinalysis 82% 76

Urine culture 64 57

cytology 43 39

FBC 60 59

U&E 75 72

psa 54 51

Ultrasound 75 99

CT-IVU 39 11

Plain xray 20

Haematuria: national survey • ‘Development of an evidence based guideline to

standardise practice across the NHS for haematuria referrals is required to abolish the postcode lottery system’

• Hughes et al 2015

Transurethral resection

OES Pro Resectoscope with PDD TURis

My experience of the last blood in pee campaign…

Who should we be thinking of during this campaign?

Most bladder and kidney cancers are in people over 50 years of age. Other risk factors include:

• Smoking

• Being overweight or obese

• Exposure to or working with certain chemicals

• Some other medical conditions, such as kidney disease or diabetes

What should we be doing to prepare for the campaign?

• Take a look at your hospital data for the 2014 campaign period and use that to help you plan (October 2014 – Jan/Feb 2015)

• Review your clinical pathway – are there any changes that need to be made?

• Are there any opportunities to improve the primary and secondary care interface during the campaign?

In summary…

• We need this campaign to raise awareness of the symptom of ‘blood in pee’

• We know from previous campaigns that it has the potential to change behaviour

• We cant keep ignoring our poor survival and need interventions like this to help improve the outcomes for our patients