Mount Vernon Cancer Network Primary Care Cancer Education Programme

1. Mount Vernon Cancer Network Wednesday 21st March 2012 Niland Centre, Bushey Mount Vernon Cancer NetworkPrimary Care Cancer Education Programme Recognising the Early Signs and Symptoms of Cancers Programme 1: Bowel, Ovarian, Oesophagogastric and Lung Cancers

2. Mount Vernon Cancer Network Mount Vernon Cancer Network • Covers Hertfordshire, Luton and South Bedfordshire – 1.4 m population • West Herts Hospitals Trust • East & North Herts (inc Mount Vernon CC) • Luton & Dunstable FT • Community Trusts and Hospices

3. Mount Vernon Cancer Network Purpose of Network • To implement national guidance (IOGs) • To progress national cancer strategy • To Improve health outcomes • To improve the patient experience • To ensure value for money • Advise/assist commissioners • Advise/assist Trusts on cancer issues • All aspects of Cancer – whole patient pathway

4. Mount Vernon Cancer Network

5. Mount Vernon Cancer Network National Context • New Cancer Strategy – January 2011 Improving Outcomes – A Strategy for Cancer • Aims to save 5,000 lives to get our survival rates up to European standards • Achieving earlier diagnosis, biggest impact • Raising awareness of symptoms in the public • Ensuring GPs diagnose and refer appropriately

7. Mount Vernon Cancer Network Upper Gastrointestinal (GI) Cancer Mark Harrison PhD FRCP FRCR Consultant Oncologist Mount Vernon Cancer Centre

8. Mount Vernon Cancer Network

9. Mount Vernon Cancer Network Staging of oesophageal cancer

10. Upper GI Cancer Incidence within MVCN 2008 (E-Atlas 2011)

11. Mount Vernon Cancer Network National Upper GI cancer statistics 2008 Oesophageal 8173 (5461 male, 2712 female) 7606 deaths 1 yr survival 43.04%, 5 yr survival 13.52% Stomach 7610 (equal sex) 5178 deaths 1 yr survival 43.75%, 5 yr survival 17.69% Pancreas 8085 7781 deaths 1 yr survival 19.21%, 5 yr survival 3.73%

12. Mount Vernon Cancer Network Aetiological Factors • Age • GERD • Smoking • Alcohol • Obesity • H.pylorii • Dietary factors - Food preservation / salting - Refrigeration • Genetics

13. Survival Rates

14. Upper GI Cancer Survival Rates Note: 1, The survival data are relative survival rate from NCIN. 2, Five year rolling data were used. 3, National ranking in quintiles are used. Bottom 20%--Red; Bottom 20%--40%--Pink; 40-60%--Yellow; 60-80%--Light green; above 80%--Green.

15. Mount Vernon Cancer Network Local Context

16. Mount Vernon Cancer Network

17. Symptoms & Investigations

18. Mount Vernon Cancer Network Symptoms • GI tract functions to hold – digest food bolus • Distensible tube with various exocrine glands attached • Vague, few, late features in general

19. Mount Vernon Cancer Network Oesophageal • Dysphagia • Bleeding – occult or haematemesis • Weight loss • Halitosis • Jaundice

20. Mount Vernon Cancer Network Stomach • Not usual to get dysphagia • Even later than oesophageal • Screening by endoscopy in some countries • Pre-existing gastritis?? • H.Pylori associations

21. Mount Vernon Cancer Network Pancreas • Even later • PM diagnosis in many cases • Anatomical and scanning problems • Obstructive jaundice which is painless

22. Mount Vernon Cancer Network Biliary Tree

23. When and how to refer

24. Mount Vernon Cancer Network

25. Mount Vernon Cancer Network

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27. Mount Vernon Cancer Network Therapeutic Modalities • Surgery is the main curative modality • Problems of other local modalities – including radiotherapy • Loco-regional disease – “peek and shriek” • Metastatic disease • Neo-adjuvant therapy

28. Mount Vernon Cancer Network Surgery • Radical resection is the key • Oesophagectomy • Mortality • Functional consequences • Gastric • Japan vs. the rest • Whipples procedure • Major surgical procedure with low cure rates

29. Pathway Overview and Final Take Home Messages

30. Mount Vernon Cancer Network Future challenges • Can we improve early diagnosis ? • Early stage = Better survival • Awareness / Screening / Prevention • Better surgery / cancer treatment / endoscopic techniques

32. Ovarian Cancer Alasdair Drake Gynaecological Oncologist WHerts and ENHerts Lead Clinician Gynaecology Mount Vernon Cancer Network Mount Vernon Cancer Network

33. What we’ll Cover Epidemiology Screening and Prevention Genetic and Familial Risk Symptoms and Signs Initial Investigations and NICE Referral Criteria and Pathway

34. Incidence Risk factors Prevention Screening Mount Vernon Cancer Network

35. Mount Vernon Cancer Network Ovary Cancer Incidence within MVCN 2008 (E-Atlas 2011)

38. Risk Factors Nulliparity/Infertility Western Lifestyle Not much we can influence!

39. Prevention Lifetime risk halved by cocp use for five years Prophylactic oophorectomy Laparoscopic BSO for BRCA Opportunistic salpingo-oophorectomy TAH over 50 or from late 40s Limited ovarian stimulation for fertility Clomiphene 3 months only Careful IVF monitoring Mount Vernon Cancer Network

40. Population Screening for Ovarian Cancer Can we detect curable cancers? Do we do unnecessary interventions? No evidence of benefit Possibly harm: Increased mortality in randomised screening trial in US Emerging evidence: UKCTOCS study CA125 and USS (50000) vs USS (50000) Unscreened control (100000) Completed recruitment: now observational Mount Vernon Cancer Network

41. Who to Refer for Genetic Screening NICE is vague and discourages referral Screening and prophylactic surgery requires recommendation from genetics Two first degree relatives with one <50 Include if patient is one of the two! Benefit to family Benefit to breast/ovarian risk Breast and ovarian primaries in same woman if under 50 Mount Vernon Cancer Network

42. Who to screen clinically • BRCA mutation families • BRCA neg families with high cancer penetrance • AVOID clinical screening: • without clinical genetics • for single relative

43. Genetic risk: Manage the Risk Screening Annual USS and CA125 Start age 45 but see family tree Prophylactic Surgery BRCA: salpingo-oophorectomy MMR/HNPCC: Hysterectomy and salpingo-oophorectomy Mount Vernon Cancer Network

44. Survival Rates Mount Vernon Cancer Network

45. Gynaecology Cancer Survival Rates Mount Vernon Cancer Network Note: 1, The survival data are relative survival rate from NCIN. 2, Five year rolling data were used. 3, National ranking in quintiles are used. Bottom 20%--Red; Bottom 20%--40%--Pink; 40-60%--Yellow; 60-80%--Light green; above 80%--Green.

46. Stage Specific Survival at Five Years Ovary 30-35% all stages 90% stage I Cervix 85% all stages 95% stage I Mount Vernon Cancer Network • Endometrium • 70% all stages • 90% stage I • Vulva • 60% all stages • 80% stage I

47. Symptoms & Investigations Mount Vernon Cancer Network

49. Ovarian Cancer Differential Mount Vernon Cancer Network • Symptoms • Irritable Bowel • Diverticular Disease • UC/Crohns • Imaging • Pelvic Abscess • Borderline Tumour • Benign Masses • Ovarian Torsion • Ascites • Cardiac failure • Liver Failure • Mass • Fibroids • Colorectal Cancer • Inflammatory

50. NICE Awareness of symptoms and signs Urgently refer women with ascites and/or a pelvic or abdominal mass on physical or ultrasound examination Exception is clinically obvious uterine fibroids Mount Vernon Cancer Network