Mount Vernon Cancer Network Primary Care Cancer Education Programme

1. Mount Vernon Cancer Network Wednesday 29th February 2012 Novotel, Stevenage 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. Film – Bowel Cancer

8. Colorectal Cancer Incidence within MVCN 2008 (E-Atlas 2011)

9. Colorectal 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.

11. Mount Vernon Cancer Network Ovarian Cancer Marcia Hall Consultant Medical Oncologist Mount Vernon Cancer Centre

12. Mount Vernon Cancer Network Incidence, risk factors, prevention and screening

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

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

15. Mount Vernon Cancer Network 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

16. Mount Vernon Cancer Network Genetic Screening • BRCA mutation families • NICE is vague and discourages referral • Two first degree relatives with one <50 • BRCA neg families with high cancer penetrance • AVOID clinical screening: • without clinical genetics • for single relative

17. Mount Vernon Cancer Network 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

18. Mount Vernon Cancer Network Survival Rates

19. 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.

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

21. Mount Vernon Cancer Network Symptoms & Investigations

22. Mount Vernon Cancer Network Ovarian Cancer Differential • 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

23. Mount Vernon Cancer Network NICE Awareness of symptoms and signs • Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)

24. Mount Vernon Cancer Network It’s Not Irritable Bowel Syndrome! • IBS presenting for the first time in patients over the age of 50 is very unlikely to be the cause for a change in bowel habit

25. Mount Vernon Cancer Network Awareness of symptoms and signs: 2 • Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month - persistent abdominal distension (woman often refer to this as ‘bloating’) - feeling full (early satiety) and/or loss of appetite - pelvic or abdominal pain - increased urinary urgency and/or frequency

26. Mount Vernon Cancer Network Awareness of symptoms and signs: 3 • Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit • Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS) • Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent

27. Mount Vernon Cancer Network First tests in primary care Measure serum CA125 35 IU/ml or greater Less than 35 IU/ml Assess carefully: are other clinical causes of symptoms apparent? Ultrasound of abdomen and pelvis Normal Yes Suggestive of ovarian cancer Repeat CA125 raised No Advise to return to GP if symptoms become more frequent and/or persistent Investigate Refer urgently Consider known causes Take advice gynaeoncol

28. Mount Vernon Cancer Network CA125 Interpretation • Normal CA125 (<35) means little • (10% ovary ca patients have normal CA125) • Moderate rise (say 35-300) • Benign (endometriosis), Borderline, Mucinous Cancer, Early Ca • Massive elevation (high 100s or 1000s) usually peritoneal carcinomatosis (ovarian, breast or bowel) • But I have seen adenomyosis at 1500 and endometriosis at 4500 • IMAGING • PATTERN OF DISEASE

29. Mount Vernon Cancer Network So why bother with CA125? • No good on its own (esp. for population screening) • Marginal rise difficult to interpret • Very useful to add weight to suspicion of ovarian cancer • Urgency of referral • Symptoms or mass • Counselling patient • Always do in postmenopausal patients with suspicious symptoms • Consider very carefully in premenopausal – much less likely to be helpful – and will probably raise more anxieties than help

30. Mount Vernon Cancer Network Postmenopausal Women • Unilocular ovarian cysts (no septations or solid areas) are likely to be benign and can be referred non urgently providing CA125 is not elevated • All other ovarian masses on USS or pelvic masses should be referred under 14 days • New diagnosis of IBS (recent change) is unusual in women over the age of 50

31. Mount Vernon Cancer Network Premenopausal • Raised CA125 is not diagnostic of ovarian cancer and many diagnoses can elevate CA125 through peritoneal inflammation. Causes include cyclical change, endometriosis, haemorrhagic or follicular/luteal cysts and infection. • “Complex” masses are frequently luteal, dermoid or endometrioma

32. Mount Vernon Cancer Network Premenopausal • Women should be referred under 14 days only if the imaging is sufficiently suspicious • Advice from USS reports should be clear stating “Cancer Alert” • “Significant Abnormality” alerts should not automatically be referred under 14 Days

33. Mount Vernon Cancer Network When and how to refer

34. Mount Vernon Cancer Network Referral Sources (NCIN 2010)

35. Mount Vernon Cancer Network Referral Sources (ENHerts) • 14 Day Referral 55% • Other urgent/non-urgent referral 15% • Emergency admission 15% • Colorectal/Gastroenterology 15%

36. Mount Vernon Cancer Network 14 Day Referrals • No evidence that cancer survival in UK improved by 2 week referral • ONLY 8% of 2 week referrals end with cancer diagnosis • Significant use of resource • Delays access of other patients • Raises patient’s anxiety • Referral algorithms need to identify real risk and get right patients to us

37. Mount Vernon Cancer Network Referral Criteria • Palpable postmenopausal mass • Complex postmenopausal mass on USS • Suspicious premenopausal mass • Clinical suspicion by combination of: • GI/abdominal symptoms • Ascites • Family history • CA125

38. Mount Vernon Cancer Network Pathway Overview and Final Take Home Messages

39. Pathway

43. Lung Cancer She Lok Lung NSSG Chair & Consultant Physician East & North Herts Mount Vernon Cancer Network

44. Incidence, risk factors, prevention and screening

45. Epidemiology In 2010 there were more than 39,000 cases of lung cancer in the UK In 2010 more than 35000 deaths from lung cancer. Leading cause of cancer deaths in women. Mount Vernon Cancer Network

46. Lung Cancer Incidence within MVCN 2008 (E-Atlas 2011)

47. Smoking • A study published in December 2011 estimated that over 80% of lung cancers in the UK in 2010 were caused by smoking • Current smokers are 15 times more likely to die from lung cancer than life-long non-smokers • Compared with non-smokers, those who smoke between 1-14 cigarettes a day have eight times the risk of dying from lung cancer and those who smoke 25 or more cigarettes a day have 25 times the risk • Risk of developing lung cancer is affected by level of consumption and duration of smoking • smoking one pack of cigarettes a day for 40 years is more hazardous than smoking two packs a day for 20 years

48. Smoking Cessation A lifelong male smoker has a cumulative risk of 15.9% for dying from lung cancer by age 75. For men who cease smoking at ages 60, 50, 40 and 30 years, their cumulative risk of dying from lung cancer falls to 9.9%, 6.0%, 3.0% and 1.7% respectively

49. Smoking Cessation Refer patients to the smoking cessation service Secondary Care patients are offered this in Out-Patients or if seen as In-Patients. Most GPs have a smoking cessation service in the surgery Mount Vernon Cancer Network

50. Screening No screening program in place at present as studies at the moment have not identified a test with sufficient specificity.