Integrated Lower GI Pathway for Improved Cancer Diagnosis

1. South Yorkshire and Bassetlaw , North Derbyshire Integrated Care System Integrated Lower GI Pathway Dr Louise Merriman, Primary Care Cancer Clinical Lead, SY,B&ND Cancer Alliance

2. Background – Case for Change Support patients to have the right test in the right place at the right time • NICE guidance NG12, DG30 • FIT pathway work- Cancer Alliance • FCP pathway work- AHSN • Integration – pathway across SYB equitable • NHS Right Care – identified gastro as area where improvements can be made i.e. spend System Wide Lower GI Pathway Improve early diagnosis of cancer and IBD Efficient utilisation of resources Variation in diagnostic testing – standardising practice

3. Colorectal cancer in UK • >41,000 new cases in 2017 • 4th most common cancer • 2nd most common cause of death • Diagnosed early it has a good prognosis with >90% 5 yr survival at Stage 1 and <10% 5 yr survival when diagnosed at stage 4

4. How and when are people diagnosed? * GPs need a better way to assess “risk” than the current guidance **We need to reduce the number presenting as an emergency

5. NICE Cancer Recognition and Referral guidelines – NG12 • June 2015 • NG12 released, giving new recommendations for recognition and referral of suspected cancer in primary care • Patients with higher risk symptoms recommended for urgent suspected cancer referral (2WW) • Faecal occult blood testing recommended for patients with ‘low risk but not no risk’ signs/symptoms • Varied local implementation of low risk recommendation • July 2017 • Diagnostic guideline (DG) 30 released recommending use of Faecal Immunochemical Test (FIT), a type of faecal occult blood test, in low risk but not no risk patients • DG30 replaced recommended 1.3.4 in NG12

6. Patients recommended for Suspected Cancer Pathway (2WW)-NG12 • Refer on 2WW if: • – ≥40ywithunexplainedweightlossandabdominalpain • – ≥50ywithunexplainedrectalbleeding • – ≥60ywithirondeficiencyanaemia(IDA)or change in bowel habit – Positive faecal occult blood test • • Consider referral on a 2WW if: • – Rectal or abdominal mass • – <50y and rectalbleeding+:abdominal pain,change in bowel habit, weight loss or IDA

7. For the ‘low risk’ but not no risk patients...(DG30) Patients without rectal bleeding who: • – Are aged 50y or over with abdominal pain or weight loss • – Aged <60y and have a change in bowel habit or IDA • – Aged 60y or over and have anaemia, even in the absence of iron deficiency • ......Offer them a FIT

8. Lower GI Symptoms LOW RISK Colorectal Cancer Does not fulfill NICE Guidance (NG12) HIGH RISK Colorectal Cancer Fulfils NICE Guidance (NG12) Perform FIT test along with sending referral ≥50 ≤50 These patients fulfil low risk NICE guidance (DG30) 2WW Perform FCP Fulfils NICE guidance (DG11) Colorectal Cancer Suspected Perform FIT Test FC >100 FC <100 FIT +ve FIT -ve Repeat FCP 2WW Consider FCP NICE Guidance DG11 Primary Care Management and Review FC <100 FC 100-250 FC >250 Routine Gastro Referral Urgent Gastro Referral

9. What is Faecalcalprotectin FC? • It’s a biomarker like D-dimer and troponin • Lacks sensitivity or specificity unless used within a defined protocol/pathway • Targeted use increases it’s predictive value • NICE guidance DG11 – it is an option for adults with recent onset of lower GI symptoms when cancer is not suspected but in whom specialist investigations are being considered • Used to support the diagnosis of IBD and IBS • Normal FCP has a high negative predictive value for IBD of >95% • One third of high tests “normalise” on repeating the test

10. What is FIT? FIT=Faecal immunochemical Test Performed on a single sample of faeces FOBt detects Heme, the iron containing component of Hb and unfortunately false positive associated with quite a lot of foods, supplements and medication FIT uses antibodies to detect human haemaglobin FIT is more specific and sensitive to bleeding in the lower part of the GI tract FIT can be used in both screening and symptomatic patients BUT the level assayed is set differently in the screening group

11. What do we need to remember in practice? • Not all patients with a positive FIT test will have bowel cancer but it will put them into the “target” group and need 2WW referral • FIT has >95% negative predictive value for cancer in the low risk group but it is not yet sufficiently reliable to change management of those with high risk symptoms • Bowel symptoms may be part of bowel specific disease or specifically bowel cancer? • FIT in screening will be the same test but different level assayed and therefore much lower negative predictive value

12. Anticipated roll out? • Engagement with CCGs happening looking at financial considerations and pathology model for FIT – including how a GP receives the result? • FCP already available for requesting on ICE • FIT in Primary Care around January 2019 • FIT in screening December 2018?

13. Lower GI Symptoms LOW RISK Colorectal Cancer Does not fulfill NICE Guidance (NG12) HIGH RISK Colorectal Cancer Fulfils NICE Guidance (NG12) Perform FIT test along with sending referral ≥50 ≤50 These patients fulfil low risk NICE guidance (DG30) 2WW Perform FCP Fulfils NICE guidance (DG11) Colorectal Cancer Suspected Perform FIT Test FC >100 FC <100 FIT +ve FIT -ve Repeat FCP 2WW Consider FCP NICE Guidance DG11 Primary Care Management and Review FC <100 FC 100-250 FC >250 Thank you for listening – Questions? Routine Gastro Referral Urgent Gastro Referral

14. پایگاه پاورپوینت فارسی www.txtzoom.com بانک اطلاعات هوشمند اسلاید پایگاه پاورپوینت فارسی www.txtzoom.com بانک اطلاعات هوشمند اسلاید Click to edit Master subtitle style