1 / 21

Cancer Mortality reduction: why it needs action in primary care

Cancer Mortality reduction: why it needs action in primary care. Greg Rubin Professor of General Practice and Primary Care University of Durham. How can primary care contribute?. Early diagnosis Care of survivors Screening. The size of the delay problem. Allgar and Neal, BJ Cancer 2005.

caden
Download Presentation

Cancer Mortality reduction: why it needs action in primary care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cancer Mortality reduction: why it needs action in primary care Greg Rubin Professor of General Practice and Primary Care University of Durham

  2. How can primary care contribute? • Early diagnosis • Care of survivors • Screening

  3. The size of the delay problem Allgar and Neal, BJ Cancer 2005

  4. Cancer mortality in relation to time to diagnosis • Secondary analysis of three cohorts: colorectal (349), lung (247) and ovarian (212) • These were part of larger case-control studies • All symptoms reported to their GPs before diagnosis noted from the records • Symptoms associated with cancer identified • The first symptom in the final year noted • Survival identified from cancer registry, and from practicesHamilton et al. In submission

  5. Analyses • Cox proportional hazards analyses, in individual cancer sites and then in the merged dataset • Main explanatory variable - the interval between first symptom in GP records and diagnosis

  6. The cohorts

  7. Results: survival by quartiles Blue: shortest duration, then red, green, and yellow longest

  8. Results: survival by deciles

  9. Interpretation • The excess mortality associated with very early diagnosis is only present for the first two deciles. Only 20% of the cohort suffers this diagnostic paradox. • Mortality is fairly flat up to the 7th decile, so perhaps 30% of the cohort suffers from a delayed diagnosis with a worse prognosis. • The rise for this 30% is quite steep. • The decile bands widen progressively, showing that most patients have a relatively “early” diagnosis.

  10. If we remove the “easy” 20% • The Cox model becomes very simple, with one linear term (p=0.013) • The coefficient for each week of symptoms is 1.0086, equating to an approximate 1% worsening of prognosis for each eight days of symptoms.

  11. The size of the effect • Prognosis worsens by 1% each 8 days of GP “delay”, or 3.8% for a month. • This is a similar size of effect that one sees with adjuvant chemotherapy • It improves the evidence base for the importance of early diagnosis.

  12. Influences on practitioner delay Mitchell et al, BJ Cancer 2008

  13. Detection of relapse • Dewar and Kerr (BMJ 1985) • 546 women with breast cancer, 192 first relapses • >50% were interval events • Grunfeld et al (BMJ 1996) • 296 women with breast cancer randomised to primary or secondary care follow up • 26 relapses • 18/26 were interval events • 7/16 relapses in the 2y care are presented first to their GP

  14. Contribution of co-morbidity to mortality • 2 out 3 patients with cancer have a co-morbidity • A third of these have 2 or more co-morbidities (Ogle et al Cancer 2000)

  15. All cancer survivors (breast, colon and prostate) and controls in the GPRD – Total Charlson score Rose et al, unpublished

  16. Heart failure OR: 1.33 *Adjusted for BMI, smoking Matched to non-cancer survivor controls on the basis of age, sex and practice

  17. Diabetes OR: 1.22 *Adjusted for BMI Matched to non-cancer survivor controls on the basis of age, sex and practice

  18. HbA1c control *good control of HbA1c used as reference category

  19. Interventions to increase use of cancer screening • Effectiveness of intervention components • Organisational change (OR 2.47 to 17.6) • Patient reminder (OR 1.74 to 2.75) • Provider education (OR 3.01) (BCS only) • Effects of the presence of key intervention features • Collaboration and teamwork (OR 1.2 to 9.21) • Learning strategies (OR 1.27 – 5.25)

  20. Primary care: the front line in the war against cancer (Wender 2007) • Having a health care advocate and co-ordinator of care improves outcomes (Starfield Millband Q 2005) • This is likely to be of particular importance for those on the wrong end of health inequalities • Primary care availability is associated with higher rates of early detection for breast, cervical and colorectal cancer (Roetzheim, J Fam Pract 1999)

  21. So what’s the agenda? • Understanding the interval from presentation to diagnosis, and its component parts • Better understanding of its relationship to stage and outcome • Basing service innovation on this evidence • Strategies to address inequalities • New models of follow-up care • Management of co-morbidities • The role of primary care in screening programmes

More Related