QCancer qcancer Professor Julia Hippisley-Cox

1. QCancerwww.qcancer.orgProfessor Julia Hippisley-Cox Professor of Clinical Epidemiology & General Practice Professorial Fellow St Annes, Oxford GP Woodstock Director QResearch (non-profit collaboration with EMIS Health) Director ClinRisk Ltd (software company)

2. QResearch database founded in 2003 Collaboration with EMIS Health One of the largest databases of linked electronic health records internationally Anonymised data from > 1500 practices Individual data > 30 million patients Historical Data > 25 years World beating resource for innovative medical research Many tools integrated into EMIS Web Generating new knowledge to improve patient care

3. Generating new knowledge to improve patient care

4. Risk Prediction Tools • Developed, validated and implemented suite of novel risk prediction tools • Prognostic models - Risk of future disease • Diagnostic models - Risk of current disease • 1sttime national GP data used to develop risk tools • Enables informed consent - improved risk communication • Enables risk stratification – targeting resources to highest risk & those most likely to benefit from interventions • Screening & prevention • Early diagnosis • Independent, external and international validations undertaken • Recommended in NICE guidelines & implemented into NHS computer systems Generating new knowledge to improve patient care

5. QTools-absolute risk of major outcomes • QRISK3 • QStroke • QDiabetes • QFrailty & QMortality • QAdmissions • QBleed • QDiabetes • QKidney QCancer - 3 aspect • risk of current cancer • 10 year risk of cancer • prognosis for patients with cancer Generating new knowledge to improve patient care

6. Early diagnosis of cancer: The problem • 300,000 new cancers each year • UK has relatively poor track record when compared with other European countries • Partly due to late diagnosis with estimated 7,500+ lives lost annually • Later diagnosis due to mixture of • late presentation by patient (lack awareness) • Late recognition by GP • Delays in secondary care • Earlier diagnosis cancer improves chances of survival www.qcancer.org

7. NICE guidance on suspected cancer (2015) • Symptom based approach • Lower threshold for intervention to 3% PPV of individual cancers • More investigation and referral • Didn’t make explicit reference to use of risk assessment tools • Used research underpinning QCancer to develop guidance • Qcancer provides practical way to identify patients at risk to improve early diagnosis • QCancer now in EMIS Web www.qcancer.org

8. Why symptoms based approach? Many patients present with symptoms GPs need to decide which patients to investigate and refer Decision support tool must mirror setting where decisions made Symptoms based approach needed (rather than cancer based) Must account for multiple symptoms Must have face clinical validity eg adjust for age, sex, smoking, Family history Need to be able to update to meet changing requirements, populations, recorded data www.qcancer.org

9. QCancer– what it needs to do • Accurately predict individual level of risk of multiple cancers for based on multiple risk factors and multiple symptoms • Discriminate between patients with and without cancer • Help guide decision on who to investigate or refer and degree of urgency. • Educational tool for sharing information with patient. Sometimes will be reassurance. • QCancer combined model published BJGP January 2013 • Cancer in women • Cancer in men www.qcancer.org

10. Methods – development algorithm Representative cohort from QResearch 2.5 million men & women aged 25-89 years cancer outcome - all new diagnoses on GP record or linked record in 2 years Identify key risk factors Identify key symptoms Established methods to develop risk prediction algorithm Measure of absolute risk of any cancer as well as by cancer type www.qcancer.org

11. QCancer predicts global cancer risk & risk12 types cancers Lung Pancreas Renal tract Ovary • These accounts for 85% cancers • Plan to extend to rarer cancers when sufficient data Colorectal Testis Gastro Cervix Breast Prostate Blood Uterus www.qcancer.org

12. Key Risk Factors in QCancer Demographics life style Co-morbidities Age Sex Smoking status Alcohol use Deprivation score Family history of cancer COPD Endometrial hyperplasia/polyp Chronic pancreatitis Type 2 diabetes Anaemia (HB < 11g/DL) Venous thromboembolism www.qcancer.org

13. Key symptoms in model general Bleeding • Loss of appetite • Unintentional weight loss • Indigestion +/- heart burn • Dysphagia • Abdominal pain or swelling • Constipation • Night sweats • Cough • Neck lump Haemoptysis Haematemesis Haematuria Rectal bleeding Haematuria Unexplained bruising Men women • Genito-Urinary symptoms (men) • Retention • Nocturia • Frequency • Impotence • Testicular lump Vaginal Bleeding Breast lump Breast pain Nipple changes www.qcancer.org

14. Validation of QCancer • Essential to demonstrate the tools work and identify right people in an efficient manner • Tested performance • separate sample of QResearch practices • external dataset (Vision practices) • Good at identifying those who do and don’t have cancer • Good at estimating level of risk • Real world testing 2013-14 with Macmillan and CRUK to evaluate its use in > 250 practices across the UK. • Currently used in the NHS England ACE program Don’t forget QCancer works out cancer risk NOT diagnosis www.qcancer.org

15. Using QCancer in practice • Standalone web calculator • www.qcancer.org • Integrated into clinical system • Within consultation: GP with patients with symptoms • Within consultation QOF style alert • Run in batch mode to risk stratify populations www.qcancer.org

16. QCancer Protocol Alert • Alert on all sites now (version 5.5) • Deployed in INACTIVE form • Practices need to activate it: • https://www.emisnug.org.uk/activating-qcancer-alerts • Alert will appear if codes added during consultation on fly e.g. if add haematuria, it will pop up • Click on score will take you to template

17. QCancer symptom checker template Template to capture relevant symptoms & risk factors https://qcancer.org/female/

18. QCancer site specific scores

19. QCancer follow up template

20. QCancer Batch Add Similar to QRISK2 which is in 95% of GP practices– automatic calculation of risk for all patients in practice based on existing data. Safety netting - Identify patients with symptoms/adverse risk profile without follow up/diagnosis Enables systematic recall or further investigation Systematic approach - prioritise by level of risk. https://www.emisnug.org.uk/batch-add-cancer-risk-score www.qcancer.org

21. Thank you for listening & any questions