Gold Coast Arts Centre 21 May 2014

1. Cough: A workshop highlighting two new GP guidelines on the Investigation of symptoms of lung cancer and Chronic Obstructive Pulmonary Disease Gold Coast Arts Centre 21 May 2014 Dr Siva P Sivakumaran & Dr Bajee Krishna Sriram  

2. Investigating symptoms of lung cancer: a guide for GPs General practitioner workshop Dr Siva P Sivakumaran MBBS, MRCP (UK), FRACP, FCCP Medical Director, Respiratory Medicine Gold Coast University Hospital

3. Learning objectives Demonstrate knowledge of: Best practice assessment of patients who may have lung cancer Risk factors for lung cancer and symptoms that may indicate lung cancer Early and rapid referral into the cancer care pathway and why it is important for patient outcomes The importance and role of multidisciplinary teams

4. Lung cancer – context More deaths than breast, prostate and ovarian cancers combined 5-year relative survival is only 14% but this is higher for early stages of lung cancer Variation in survival in early stages may be due to variation in referral and treatment offered http://www.uscreates.com/

5. Diagnosis Adapted from: 1. Cancer Council Vic. Diagnosing lung cancer. 2013 and 2. Cancer Council. Clinical practice guidelines for the treatment of lung cancer (2013) Cancer Australia, 3. Australian Institute of Health and Welfare & Cancer Australia 2011. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. Canberra: AIHW.

6. Treatment opportunities All patients with lung cancer should be seen by a lung cancer specialist to discuss options for treatment, palliation or surveillance. Options include: • Surgery – usually a lobectomy or pneumonectomy • Chemotherapy • Radiotherapy • Targeted treatment – EGFR mutation • Supportive care Clinical practice guidelines for the treatment of lung cancer – Cancer Council Australia and Cancer Australia (released Nov 2012) • Recommendations for Stage 1 to 4 http://wiki.cancer.org.au/australia/Guidelines:Lung_cancer Ref: Peter Mac. Lung cancer treatments. www.petermac.org/LungCancerTreatments

7. Survival at diagnosis Five year relative survival by stage at diagnosis, New South Wales 1999-20031 Reference: 1 Australian Institute of Health and Welfare & Cancer Australia 2011. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. Canberra: AIHW.

8. Survival by stage One-Year Relative Survival (%) by Stage, Adults 15-99 Prepared by Cancer Research UK Original data source: The National Cancer Registration Service, Eastern Office. Personal communication. http://ecric.org.uk/

9. Survival by stage Five -Year Relative Survival (%) by Stage, Adults 15-99 Stage IV survival could not be calculated at five years due to the small number of people surviving more than two years. Prepared by Cancer Research UK Original data source: The National Cancer Registration Service, Eastern Office. Personal communication. http://ecric.org.uk/

10. Lung cancer in General Practice Patients with symptoms of lung cancer may present with symptoms to GPs first Symptoms often present as part of routine primary care or during the management of other diseases e.g. COPD, chronic heart failure and coronary heart disease Symptoms are often non-specific The average full time GP may see only one lung cancer patient every 1-2 years

11. The GP Guide Questions addressed: Symptoms & signs of lung cancer: What are the symptoms or combinations of symptoms & signs that are likely to indicate lung cancer? Investigations: Which investigations are effective in diagnosing a patient with suspected lung cancer? Referral: Effective investigation and referral of suspected lung cancer – red flags, referral pathways.

12. Development of the Guide Development of the Guide was overseen by an Expert Advisory Panel ADAPTE process for guideline adaptation Recommendations adapted from: • Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. New Zealand Guidelines Group 2009 • The diagnosis and treatment of lung cancer. National Institute of Clinical Excellence (NICE) 2011 • Diagnosis and management of lung cancer. American College of Chest Physicians 2007

13. The GP Guide An evidence report supports the 2 page summary http://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/evidence-relevant-guide-investigation-symptoms

15. The Guide Lung cancer in Australia Lung cancer is the fourth most commonly diagnosed invasive cancer in Australia Lung cancer is the leading cause of cancer death in Australia Lung cancer incidence is strongly related to age Tobacco smoking is the largest single cause of lung cancer Aboriginal and Torres Strait Islander people are 1.7 times as likely to be diagnosed with lung cancer as non-indigenous people

16. Risk factors lifestyle factors: tobacco smoking, former tobacco smoking environmental factors passive smoking radon in homes occupational exposure, e.g. previous exposure to asbestos, diesel exhaust air pollution personal factors age family history of lung cancer smoking-related chronic obstructive pulmonary disease previous lung diseases history of cancer, especially head and neck cancer 16

17. The Guide Recommendations to facilitate referral and patient support Ensure referrals are timely & provide relevant / detailed information to the specialist Provide the patient with information that clearly describes: • where they are being referred • who they will see • what they can expect from the specialty service • the expected timeframes Advise patient to carry all previous imaging Advise patient to stop smoking and offer therapies to assist Ensure the patient’s need for continuing support is addressed Share appropriate information between healthcare professionals

20. Symptoms and signs of lung cancer Any of the following unexplained, persistent symptoms and signs lasting more than 3 weeks (or less in people with known risk factors):

21. Case study 1

22. Case study 2

23. Case study 2

24. Case study 3 Consolidation consistent with the clinical picture Image to be included here

25. Case study 3

26. Case study 3

27. Case study 3

28. Referral pathways Recommendation: Refer a patient to a specialist linked to a lung cancer multidisciplinary team (MDT) Multidisciplinary care is the best practice approach to providing evidence-based cancer care It involves a team approach to cancer care, improving survival and quality of life MDTs exist across Australia and provide the mechanism to improve patient care, outcomes and address variations in care Aboriginal Health Workers provide a critical link for Aboriginal and Torres Strait Islander people, in providing information, support and service co-ordination

29. Referral pathways Recommendation: Refer a patient to a specialist linked to a lung cancer multidisciplinary team (MDT) Functions of a lung cancer MDT: • diagnoses and staging • selecting and carrying out optimal treatments • managing symptoms and side effects • providing support to manage patient wellbeing or other concerns • A lung cancer MDT may include: • surgeons • GPs • respiratory physicians • oncologists • pathologists • radiologists • specialist nurses • psychological services • allied health and palliative care services

30. Engaging with multidisciplinary teams What happens before and after the meeting? GP refers their patient to a specialist who is a member of a multidisciplinary team the GP is invited to attend the meeting (options for tele-link are often available) if a GP cannot attend the meeting, a summary of discussions is sent to the GP, or can be requested after the meeting

31. Tasmania http://directory.cancersupportcentre.org.au

32. Queensland https://qccat.health.qld.gov.au/DOCS#

33. GP Barriers to implementation Doubt that earlier intervention makes a difference “Please give us data about earlier diagnosis and survival…not just diagnosing 6 months earlier so they appear to live for 6 months longer”

34. Infrequency of lung cancer in practice GP Barriers to implementation “It is a real challenge to expect the existence of a guideline to be remembered…about a condition that the average GP will diagnose…based on reasonable evidence, only once every two years.”

35. General comments from GPs about guidelines for lung cancer Doubt that there is a need to re X-ray adults with pneumonia “I never understood the rationale for exposing all post-pneumonia patients to more radiation after they have already recovered.”

36. Medical Procedure Dose

37. US Nuclear regulatory commission http://www.nrc.gov/about-nrc/radiation/around-us/doses-daily-lives.html

38. The GP Guide – Key take home messages Be aware of lung cancer risk factors in your patients and community Early recognition of symptoms and signs is critical 3 week window for unexplained persistent symptoms X-ray is the first line of investigation Chest CT is the second line of investigation Referral to a lung cancer multidisciplinary team (MDT)

39. Other sources of information about the GP guide Investigating the symptoms of lung cancer – a Qstreamcourse for GPs • Category 2 points with RACGP • 30 planned reflective development points with ACCRM http://cl-wedg.qstream.com/wedgcollaboration/courses/3373-Investigating-the-symptoms-of-lung-cancer-A-Qstream-course-for-GPs Investigating the symptoms of lung cancer – an Active Learning Module with RACGP • 6 Category 2 points with RACGP • Soon to be released on the gplearning RACGP website