Qcancer : symptom based approach to cancer risk assessment

1. Qcancer: symptom based approach to cancer risk assessment Julia Hippisley-Cox, GP, Professor Epidemiology & Director ClinRisk Ltd 3rd cancer Care Congress 26 Sept 2012

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. ‘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

10. 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

11. Results – the algorithms/predictors This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

12. 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

13. 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

14. 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

15. 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

16. 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

17. Next steps - pilot work in clinical practice supported by Macmillan& DH

18. Thank you for listeningQuestions & Discussion This work by Julia Hippisley-Cox is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License

19. 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