GP Clinical Update and Referral Management Training

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Upper GI TWR referrals Can they be controlled?. Lead for Upper GI Cancer SASH. Oesophago-Gastric Cancer. 5th most common cancer ~12000 cases nationally5 year survival

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GP Clinical Update and Referral Management Training

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1. GP Clinical Update and Referral Management Training A G E N D A Apologies: Proposed Agenda (2 Hours 12:30 to 2:30) Introduction and preparation (15 minutes) Consultant Presentation (45 minutes) Current Patient Pathway Speciality Best Practice and Innovation Referrals Primary Care Management Appropriate Referrals Inappropriate Referrals GP Referral Content Advice only Communication Q&A / Discussion (15 minutes) Referral Volumes by Practice in Chosen Specialty (15 Minutes) Review of Previous Month’s Training (15 minutes) Close and Next Steps (5 minutes) (10 minutes for slippage)

2. Upper GI TWR referrals Can they be controlled? Lead for Upper GI Cancer SASH

3. Oesophago-Gastric Cancer 5th most common cancer ~12000 cases nationally 5 year survival – all referrals Oesophagus 7% Gastric 13% 5 year survival- curative treatment ~30%

4. TWR pathway

5. Case History -potted 70 yr old lady TWR referral with weight loss/CIB Direct to OGD+colonoscopy Inflamed ileum- IBD. Taken of pathway Treated for IBD Deteriorated Admitted Different team, no notes etc CT repeat endoscopy etc Died On hindsight…

6. Case history Asian lady with weight loss, fevers and change in bowels. Possible granuloma on ileal biopsies ==Small bowel TB

7. TWR pathway- future

8. Current Practice

9. National Audit (AUGIS)2007-2009 ~12000 patients ~ 2000 operations ~2000 palliative oncology ~1600 stents

10. Investigations 88% CT scan 58% EUS 48% laparoscopy

11. Outcomes 35% curative resections (25-40%) Median age 67 (6% >80) 3% 30 day mortality 30% “failed” neoadjuvant chem 20% “failed” adjuvant chemo

12. Data

13. Age

14. Age 2

16. Time to referral

17. Referral patterns

18. Referrals

19. Recommendations AUGIS 2009 1. O-G cancer services should strive to improve awareness of the disease among their population, local GPs and hospital clinicians. National initiatives such as the recent O-G cancer awareness week should be supported by all trusts and networks. 2. Cancer Networks should examine their referral guidelines and pathways, in order to reduce the proportion of referrals after emergency admission and attempt to reduce the delays experienced by patients referred nonurgently. 3. O-G cancer services should ensure that all patients undergo a CT-scan plus an EUS (if oesophageal / upper junctional tumour) or a staging laparoscopy (if gastric / lower junctional tumour) before undergoing curative treatment and should improve the monitoring of their use. 4. All patients should be discussed with the specialist MDT to reduce the observed variation in the proportion of patients selected for curative treatment and palliative oncology. 5. All patients with stage II or III adenocarcinoma who are physiologically ?t enough should be offered neoadjuvant chemotherapy or entered into appropriate national trials of such treatment, irrespective of tumour site. 6. Surgeons should monitor their pathology outcomes in order to ensure an adequate lymph node yield is obtained in every patient. 7. Minimally invasive surgery should continue to be introduced cautiously following the guidance published by the Association of Upper Gastro-Intestinal Surgeons 7. Early indications are that this approach is safe and may reduce the incidence of postoperative respiratory complications. 8. Cancer Networks should improve access to brachytherapy, because it improves symptom control in patients with a prognosis longer than three months 9. Dilatation alone should not be performed as it is ineffective in controlling symptoms and much better alternatives are available. 10. NHS trusts should concentrate on improving the data completeness of their submissions, in particular those data items essential for examining treatment processes (such as staging investigations) and outcomes (such as resection margin status).

20. But

21. Is endoscopy a necessary investigation of dyspepsia? My answer to that question is NO… I don’t believe that an OGD is a necessary investigation of dyspepsia. I have to say that this is not the best audience or venue to argue this point but I hope that, although I am unlikely to sway many of you, I may sow the seed that will make some of you re-examine the indications for an OGD. Before I start I would to like thank 2 people. The first is Paul Moayyedi, who has allowed me to use some of his slides. And John Galloway who will be sitting outside with the engine running if things start getting ugly!My answer to that question is NO… I don’t believe that an OGD is a necessary investigation of dyspepsia. I have to say that this is not the best audience or venue to argue this point but I hope that, although I am unlikely to sway many of you, I may sow the seed that will make some of you re-examine the indications for an OGD. Before I start I would to like thank 2 people. The first is Paul Moayyedi, who has allowed me to use some of his slides. And John Galloway who will be sitting outside with the engine running if things start getting ugly!

23. Aims of NICE panel Particularly discourage OGD in young patients Avoid “automatic” OGD in older patients Early OGD for those with alarm symptoms To free resources for national bowel cancer screening program? Further aims of the panel were to… Discourage OGD in younger patients Avoid automatic OGD in older patients But encourage OGD for those with alarm symptomsFurther aims of the panel were to… Discourage OGD in younger patients Avoid automatic OGD in older patients But encourage OGD for those with alarm symptoms

24. NICE core group members J Asgar Pharmacist J Dalrymple GP B Delaney Technical support & GP K MacDermott GP J Mason Methodologist & Tech support P Moayyedi Technical support and gastroenterologist A Ragunathan GP Malcom Thomas GP and Group Leader R Walt Gastroenterologist S Wright GP M Sanderson Patient representative To that end the panel was composed of: 6 GPs (1 Technical lead and Guideline group leader) 2 Consultant Physicians (1 Technical support) 1 Pharmacist 1 Patient representative 1 Health Economist (Methodologist) Other colleges were invited to send representatives but they didn’t. We declined an offer for representation from the Royal College of Radiologists, as we did not envisage the issue of X-ray imaging would be relevant. The guidelines were agreed and approved by all members of the groupTo that end the panel was composed of: 6 GPs (1 Technical lead and Guideline group leader) 2 Consultant Physicians (1 Technical support) 1 Pharmacist 1 Patient representative 1 Health Economist (Methodologist) Other colleges were invited to send representatives but they didn’t. We declined an offer for representation from the Royal College of Radiologists, as we did not envisage the issue of X-ray imaging would be relevant. The guidelines were agreed and approved by all members of the group

25. Reasons for endoscopy Diagnose cancer early Diagnose Barrett’s oesophagus Reassure the doctor Reassure the patient So why do we scope patients? We want to diagnose cancer early We want to diagnose Barrett’s We want to reassure the doctor And we want to reassure the patientSo why do we scope patients? We want to diagnose cancer early We want to diagnose Barrett’s We want to reassure the doctor And we want to reassure the patient

26. The Leeds data re-interpreted (Sue-Ling et al. Gut 1992; 33:1318-22) 46 EGC detected 42 EGC with epigastric pain or ‘dyspepsia’ but no ‘alarm’ symptoms Median age was 69y 16 (36%) died at operation or due to complications 40,000 endoscopies 1 EGC/900 endoscopies Over £300,000 per cancer detected 46 EGCs were detected. 42 had epigastric pain or ‘dyspepsia’ but no ‘alarm’ symptoms. Although pain, I think, is an alarm symptom. The median age was 69y and there was a 36% mortality at or after operation BUT 40,000 endoscopies were performed during the same time period. Which means that at today’s costs it would cost over £300,000 per cancer detected.46 EGCs were detected. 42 had epigastric pain or ‘dyspepsia’ but no ‘alarm’ symptoms. Although pain, I think, is an alarm symptom. The median age was 69y and there was a 36% mortality at or after operation BUT 40,000 endoscopies were performed during the same time period. Which means that at today’s costs it would cost over £300,000 per cancer detected.

27. Reasons for endoscopy Reassure the doctor The third reason we do endoscopies is to reassure the doctor. This is the flip side of the coin. Are the dyspeptic symptoms of the patient in front you actually denoting cancer? Furthermore, we all remember the cautions in the BNF dating from the early days of H2RAs, that..The third reason we do endoscopies is to reassure the doctor. This is the flip side of the coin. Are the dyspeptic symptoms of the patient in front you actually denoting cancer? Furthermore, we all remember the cautions in the BNF dating from the early days of H2RAs, that..

28. Three retrospective studies of patients with upper GI cancers: Cancer was rare in patients under the age of 55 years without alarm symptoms Malignancy in patients < 55 years without alarm symptoms is 1/million population /year. The incidence of resectable cancer in patients under 45 years with simple dyspepsia < 1/1800. 2 studies, one in Gloucester and the other in Glasgow found that cancer was rarely detected in patients under the age of 55 years without alarm symptoms, … cancer was usually inoperable. Furthermore, the Glasgow study estimated that the rate of presentation of malignancy in patients less than 55 years without alarm symptoms at 1 per million population per year. In a Canadian study of endoscopic findings in 7004 patients under the age of 45 years identified 3634 (52%) patients investigated without alarm features: 3 cancers were found and of which 2 were resectable. This gave an incidence of resectable cancer in patients under 45 years with simple dyspepsia of less than one per 1800. Two studies in primary care populations provide more applicable evidence... 2 studies, one in Gloucester and the other in Glasgow found that cancer was rarely detected in patients under the age of 55 years without alarm symptoms, … cancer was usually inoperable. Furthermore, the Glasgow study estimated that the rate of presentation of malignancy in patients less than 55 years without alarm symptoms at 1 per million population per year. In a Canadian study of endoscopic findings in 7004 patients under the age of 45 years identified 3634 (52%) patients investigated without alarm features: 3 cancers were found and of which 2 were resectable. This gave an incidence of resectable cancer in patients under 45 years with simple dyspepsia of less than one per 1800. Two studies in primary care populations provide more applicable evidence...

29. Age Augis Audit “the median age of patients at diagnosis was 72 years, though 10 per cent were aged under 55, and 1 per cent were under 40 years. The majority of patients were referred by general practitioners (GP). However, approximately 18 per cent of patients were referred by another hospital consultant. All clinicians need to be alert to the disease, in middle-aged as well as older patients”

30. Dutch prospective study (Numans ME at al How useful is selection based on alarm symptoms in requesting gastroscopy? Scan J gast 2001; 36:437-443) Logistic regression showed that the only independent factors increasing the likelihood of malignancy were weight loss (OR: 4.4), dysphagia (OR: 6.1), male sex (OR: 1.4) smoking (OR: 2.6) In a Dutch study, a prospective referral guide was used to select patients for endoscopy on the basis of persistent symptoms or alarm symptoms. A scoring system was used to evaluate the predictive value of symptoms for malignancy in 861 referred patients. Logistic regression showed that the presence of weight loss dysphagia male sex and smoking were the only independent factors increasing the likelihood of malignancy. In a Dutch study, a prospective referral guide was used to select patients for endoscopy on the basis of persistent symptoms or alarm symptoms. A scoring system was used to evaluate the predictive value of symptoms for malignancy in 861 referred patients. Logistic regression showed that the presence of weight loss dysphagia male sex and smoking were the only independent factors increasing the likelihood of malignancy.

31. Prospective UK study (Kapoor N et al. Predictive value of alarm features in patients referred to a rapid access upper gastrointestinal cancer service. Gastroenterology 2003; 124 S1; A1247) A decision rule of dysphagia or significant weight loss at any age plus age greater than 55 with alarm symptoms would have detected 99.8% of the cancers found in the cohort. A decision rule of dysphagia or significant weight loss at any age plus age greater than 55 with alarm symptoms would have detected 99.8% of the cancers found in the cohort. A decision rule of dysphagia or significant weight loss at any age plus age greater than 55 with alarm symptoms would have detected 99.8% of the cancers found in the cohort.

32. Reasons for endoscopy Reassure the patient The final reason one might wish to scope a patient is to reassure the patient. A study published in the BMJ by a clinical psychologist who interviewed patients before and after an OGD, showed that… The final reason one might wish to scope a patient is to reassure the patient. A study published in the BMJ by a clinical psychologist who interviewed patients before and after an OGD, showed that…

33. Reassurance of OGD (Lucock MP et al. BMJ 1997; 315: 572-5) Patients who have had gastroscopy showing no serious illness experience an immediate reduction in concern after reassurance Some patients with high levels of anxiety about their health (measured by the health anxiety questionnaire) experience a resurgence of their health concerns within 24 hours of reassurance and may still be concerned a year later Patients who have had gastroscopy showing no serious illness experience an immediate reduction in concern after reassurance Some patients with high levels of anxiety about their health (measured by the health anxiety questionnaire) experience a resurgence of their health concerns within 24 hours of reassurance and may still be concerned a year later

36. Basic Principles

38. Am J Gastroenterol 2009. 1033 volunteers (51% male; mean age 59 years) – OGD +UBT Endoscopic findings, present in 240 participants (23.2%), included esophagitis in 11.8%, peptic ulcer in 5.9%, gastroduodenal erosions in 5.3%, Barrett's esophagus in 1.3%, and gastric neoplasia in 1.1%. 552 of 1033 were asymptomatic, including 97 (40.4%) who had positive endoscopies. Approximately one third of individuals with peptic ulcer (22 of 61) and Barrett's esophagus (4 of 13), and about a quarter of those with gastric neoplasia (3 of 11), had no symptoms. 77 subjects had alarm symptoms (dysphagia and/or odynophagia) or signs (recurrent vomiting, unexplained weight loss and/or signs of upper gastrointestinal bleeding). In this group, 27 (35.1%) had endoscopic findings, i.e., esophagitis in 11, peptic ulcer in 6, gastroduodenal erosions in 5, and neoplasia in 7. Positive results were found in only 78 (27.4%) of 285 dyspeptic individuals without alarm symptoms or signs. Oesophagitis was present in 36 (12.6%), peptic ulcer in 26 (9.1%), and gastric neoplasia in 1 (0.4%).

39. Primary care management

40. TWR referrals SASH 2009 633 seen 49 cancers Nurse specialist data- Shelley Gravatt 304 referrals 153 new cancer diagnosis (~1/2 HBP) 63 deaths

43. Appropriate referrals

45. Appropriate referrals Dysphagia Is there a role for barium studies?

46. Appropriate referrals Dysphagia Is there a role for barium studies? Iron deficiency anaemia Definition blurred

47. Appropriate referrals Dysphagia Is there a role for barium studies? Iron deficiency anaemia Definition blurred Dyspepsia

48. Appropriate referrals Dysphagia Is there a role for barium studies? Iron deficiency anaemia Definition blurred Dyspepsia Weight loss Why me?!?

49. Appropriate referrals Dysphagia Is there a role for barium studies? Iron deficiency anaemia Definition blurred Dyspepsia Weight loss Why me?!? Masses and jaundice more likely to be HBP Refer Dr Leigh or Dr Stenner

50. Appropriate referrals Do you suspect cancer or you can’t exclude it?

52. Inappropriate referrals Dysphagia- never inappropriate Unless known pathology to explain symptoms “swallowing problem”

53. Inappropriate referrals Iron deficiency anaemia Limits set on Hb Should have a low ferritin

54. Inappropriate referrals Dyspepsia Level of suspicion Have symptoms really changed?

55. Inappropriate referrals Weight loss Is it related to intake? Is it reported or confirmed? Are known medical conditions managed adequately?

56. Inappropriate referrals Jaundice Alcoholic hepatitis Masses Known non GI malignancy

57. Inappropriate referrals Does the patient know reason for referral? Does the patient want to know if they have cancer? If not competent can investigation be justified? ECN?

58. Referral Content Symptoms Previous investigations- where and when. Warfarin/ insulin Ferritin Are you just looking for a diagnosis and patient would not want treatment?

59. Remember Waiting time for routine OGD/ clinic 4-6 weeks.

60. Summary Oesophageal cancer is increasing Very low threshold for referral for dysphagia Dyspepsia management is “unclear” Balance age and symptoms The TWR pathway is a train running down a track – make sure it is the right one! Consider contacting Dr Leigh/Dr Stenner directly re jaundiced patients.

61. Thank you Dr Jonathan Stenner [email protected] 01737 231777 (sec)

62. ‘…particular care is required to exclude a gastric malignancy before treatment…’ ‘…particular care is required to exclude a gastric malignancy before treatment…’ Intuitively this seemed to be the right thing to do. But what is the chance that a patient with dyspepsia will actually have a cancer. Well for the guidelines we considered 3 types of studies…‘…particular care is required to exclude a gastric malignancy before treatment…’ Intuitively this seemed to be the right thing to do. But what is the chance that a patient with dyspepsia will actually have a cancer. Well for the guidelines we considered 3 types of studies…

63. Endoscopies in England and Wales As you can see endoscopy activity reached a peak in 2000 since then the number have fallen… but this might be a ‘blip’.As you can see endoscopy activity reached a peak in 2000 since then the number have fallen… but this might be a ‘blip’.

64. It also showed that a lower-than-average likelihood of malignancy when there was nocturnal dyspepsia (OR: 0.3), daytime heartburn (OR: 0.2) a history of dyspepsia longer than a year (OR: 0.4) Interestingly, nocturnal dyspepsia daytime heartburn and a history of dyspepsia longer than a year featured a lower-than-average likelihood of malignancy. Interestingly, nocturnal dyspepsia daytime heartburn and a history of dyspepsia longer than a year featured a lower-than-average likelihood of malignancy.

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