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Qcancer : symptom based approach to cancer risk assessment. Julia Hippisley-Cox, GP, Professor Epidemiology & Director ClinRisk Ltd 3 rd cancer Care Congress 2 6 Sept 2012. A cknowledgements. Co-authors QResearch database EMIS & contributing practices & User Group

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qcancer symptom based approach to cancer risk assessment

Qcancer: symptom based approach to cancer risk assessment

Julia Hippisley-Cox,

GP, Professor Epidemiology & Director ClinRisk Ltd

3rd cancer Care Congress

26 Sept 2012

a cknowledgements
Acknowledgements
  • Co-authors
  • QResearch database
  • EMIS & contributing practices & User Group
  • University of Nottingham
  • ClinRisk (software)
  • Oxford University (independent validation)

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qresearch database www qresearch org
QResearch Database www.qresearch.org
  • Over 700 general practices across the UK, 14 million patients
  • Joint venture between EMIS and University of Nottingham
  • Patient level pseudonymised database for research
  • Available for peer reviewed academic research where outputs made publically available
  • Data linkage – deaths, deprivation, cancer, HES

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qscores new family of r isk p rediction tools
QScores – new family of Risk Prediction tools
  • Individual assessment
    • Who is most at risk of preventable disease?
    • Who is likely to benefit from interventions?
    • What is the balance of risks and benefits for my patient?
    • Enable informed consent and shared decisions
  • Population level
    • Risk stratification
    • Identification of rank ordered list of patients for recall or reassurance
  • GP systems integration
    • Allow updates tool over time, audit of impact on services and outcomes

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

early diagnosis of cancer the problem
Early diagnosis of cancer: The problem
  • 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 (alack awareness)
    • Late recognition by GP
    • Delays in secondary care

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

symptoms based approach
Symptoms based approach
  • 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, FH
  • updated to meet changing requirements, populations, recorded data

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qcancer scores what they need to do
QCancer scores – what they need to do
  • Accurately predict level of risk for individual based on 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.

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

methods development algorithm
Methods – development algorithm
  • Huge representative sample from QResearch aged 30-84
  • Identify new alarm symptoms (eg rectal bleeding, haemoptysis) and other risk factors (eg age, COPD, smoking, family history)
  • Identify cancer outcome - all new diagnoses either on GP record or linked ONS deaths record in next 2 years
  • Established methods to develop risk prediction algorithm
  • Identify independent factors adjusted for other factors
  • Measure of absolute risk of cancer. Eg 5% risk of colorectal cancer

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

red flag or alarm symptoms identified from studies including nice guidelines 2005
‘Red’ flag or alarm symptoms (identified from studies including NICE guidelines 2005)
  • Haemoptysis
  • Haematemesis
  • Dysphagia
  • Rectal bleeding
  • Vaginal bleeding
  • Haematuria
  • dysphagia
  • Constipation, cough
  • Loss of appetite
  • Weight loss
  • Indigestion +/- heart burn
  • Abdominal pain
  • Abdominal swelling
  • Family history
  • Anaemia
  • Breast lump, pain, skin tethering

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qcancer now predicts risk all major cancers including
Qcancer now predicts risk all major cancers including

Lung

Pancreas

Kidney

Ovary

Colorectal

Testis

Gastro

Cervix

Breast

Prostate

Blood

Uterus

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

results the algorithms predictors
Results – the algorithms/predictors

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

methods validation is crucial
Methods - validation is crucial
  • 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) at Oxford University
  • Measures of discrimination - identifying those who do and don’t have cancer
  • Measures of calibration - closeness of predicted risk to observed risk
  • Measure performance – Positive predictive value, sensitivity

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

using qcancer in practice v similar to qrisk2
Using QCancer in practice – v similar to QRISK2
  • Standalone tools
      • Web calculator

www.qcancer.org/2013/female/php

www.qcancer.org/2013/male/php

      • Windows desk top calculator
      • Iphone – simple calculator
  • Integrated into clinical system
      • Within consultation: GP with patients with symptoms
      • Batch: Run in batch mode to risk stratify entire practice or PCT population

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qcancer women http qcancer org 2013 female index php
QCancer – women http://qcancer.org/2013/female/index.php

PROFILE

64yr old woman, Moderate smoker

Loss appetite

Abdo pain

Abdo swelling

72% risk of no cancer

28% risk any cancer

- ovarian = 20%

- colorectal = 1.5%

- pancreas =.16%

- Other 3.4%

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

qcancer men http qcancer org 2013 male index php
QCancer – men http://qcancer.org/2013/male/index.php
  • PROFILE
  • 64yr old man,
  • Heavy smoker
  • FH GI cancer
  • Loss appetite
  • Recent VTE
  • Weight loss
  • Indigestion
  • RESULTS
  • 71% risk of no cancer
  • 29% risk any cancer
    • Lung = 9%
    • Pancreas =6%
    • Prostate =2%
    • Other =5%

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

gp systems integration batch processing
GP systems integrationBatch processing
  • Similar to QRISK which is in 95% of GP practices– automatic daily calculation of risk for all patients in practice based on existing data.
  • Identify patients with symptoms/adverse risk profile without follow up/diagnosis
  • Enables systematic recall or further investigation
  • Systematic approach - prioritise by level of risk.

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

thank you for listening questions discussion
Thank you for listeningQuestions & Discussion

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

comparison other cancer risk tools
Comparison other cancer risk tools

QCancer

The “RAT”

  • Large UK sample with data until 2012
  • Symptoms based approach
  • Takes account of risk factors including age, sex, smoking, FH
  • Independent external validation by Oxford University
  • Can be updated and integrated into computer systems into workflow
  • 20-40 Exeter practices; paper records from 10 years ago
  • Focused on single symptoms and pairs where enough data
  • No adjustment for age although cancer risk changes with age
  • Not validated
  • Distributed as a mouse mat for each cancer

This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License