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RESEARCH & EVIDENCE: DRIVING IMPROVEMENTS IN EARLY DIAGNOSIS

EARLY DIAGNOSIS RESEARCH

CONFERENCE, 23 FEB 2017

Harpal Kumar

CEO

CANCER RESEARCH UK

THE IMPORTANCE OF EARLY DIAGNOSIS

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LATE DIAGNOSIS = POORER OUTCOME

2014

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HOW CAN WE IMPROVE EARLY DIAGNOSIS?

Hiom et al. (2015) Diagnosing cancer earlier: reviewing the evidence for improving cancer survival. BJC (1) Robb et al, 2009; Waller et al, 2009; Quaife et al, 2014; Keeble et al, 2014; (2) Lyratzopoulos et al, 2012, 2013; (3) Von Wagner et al, 2011; Lo et al, 2014; (4) Shawihdi et al, 2014; (5) Elliss-Brookes et al, 2012; Mitchell et al, personal communication; (6) Cancer Waiting Times; NHS England, 2015; (7) Maringe et al, 2012, 2013; Walters et al, 2013a, b; National Cancer Intelligence Network (2015); (8) McPhail et al, 2013; (9) De Angelis et al, 2014; Allemani et al, 2014; Coleman et al, 2011; and (10) Abdel-Rahman et al, 2009.

HOW WE’RE WORKING TO IMPROVE EARLY DIAGNOSIS

First

pre-

cancerou

s

indicato

r

First

development

of cancer

First

symptom

First

presentati

on/

clinical

appearance

Investigat

ion of

related

symptoms

Referral

to

secondary

care

First

special

ist

visit

Diagnosi

s/

referral

to

treatmen

t

Start of

treatmen

t

Potential screening interval Primary care interval Secondary care interval

Early

biomarke

rs

Screening Symptomatic Treatment

Early

biomarke

rs

Treatment

CanTest Catalyst award

EDAG Early

Diagnosis Advisory

Group

Lung Matrix

Cytosponge

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UPTAKE OF BOWEL CANCER SCREENING IS POOR

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– Bowel screening (gFOBT) is about 10 years old

now, but uptake remains lower than other

national screening programmes

– Bowel cancer mortality is 25% lower in those

who’ve taken part in bowel screening (gFOBT)

– There are significant inequalities in uptake

related to:

• Deprivation

• Sex (lower in men)

• Age

0%

20%

40%

60%

80%

100%

Uptake of National Screening Programmes (England)

Bowel (FOBT) Breast (50-70) Cervical (25-64)

BOWEL CANCER SCREENING

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– Bowel screening uptake looks set to improve through:

• Implementation of FIT in England and Scotland

• Bowel scope roll-out in England

– We’re supporting these changes through:

• Publication of GP good practice guide

• Be Clear On Cancer: Bowel screening regional pilot

(Jan – March 2017)

Advertising: Jan – Mar 17

Bowel Cancer Screening Regional Pilot NORTH WEST ENGLAND: JAN – MAR 17

Direct mail: Feb – Mar 17

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CERVICAL CANCER SCREENING

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– Testing for HPV as a first test in cervical screening is more

effective than current cytology-only screening

• England, Scotland and Wales have committed to introducing

this test.

– Women who test HPV-negative would need to be screened

less often

• 5 year screening interval

• Cost-saving to NHS

LOCAL STAGING DATA COMPLETENESS IS IMPROVING

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Percentage of cases, of known stage, diagnosed at stage I and II, for patients diagnosed between 2012 and 2014.

Based on Public Health England data.

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REGIONAL VARIATION IN STAGE AT DIAGNOSIS

SOCIOECONOMIC FACTORS

AGE

GENDER

ETHNICITY

ADDITIONAL

DRIVERS OF

VARIATION

UNADJUSTED ADJUSTED FOR

CANCER TYPE

WE KNOW MORE ABOUT THE DIFFERENT ROUTES TO DIAGNOSIS

ALL CANCERS BOWEL CANCER

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WE KNOW MORE ABOUT THE DIFFERENT ROUTES TO DIAGNOSIS

0

25,000

50,000

75,000

100,000

125,000

150,000

Oct

-09

Jan

-10

Ap

r-10

Jul-

10

Oct

-10

Jan

-11

Ap

r-11

Jul-

11

Oct

-11

Jan

-12

Ap

r-12

Jul-

12

Oct

-12

Jan

-13

Ap

r-13

Jul-

13

Oct

-13

Jan

-14

Ap

r-14

Jul-

14

Oct

-14

Jan

-15

Ap

r-15

Jul-

15

Oct

-15

Jan

-16

Ap

r-16

Jul-

16

Oct

-16

GP Urgent Referrals (from Waiting time data)

GP Urgent Referrals Patients beginning treatment following GP Urgent Referral2009 2016

WE’RE NOT MEETING WAITING TIME TARGETS

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75%

80%

85%

90%

95%

100%

Oct

-09

Jan

-10

Apr

-10

Jul-

10

Oct

-10

Jan

-11

Apr

-11

Jul-

11

Oct

-11

Jan

-12

Apr

-12

Jul-

12

Oct

-12

Jan

-13

Apr

-13

Jul-

13

Oct

-13

Jan

-14

Apr

-14

Jul-

14

Oct

-14

Jan

-15

Apr

-15

Jul-

15

Oct

-15

Jan

-16

Apr

-16

Jul-

16

Oct

-16

Performance against 62 day standard from GP Urgent Referral to First Treatment

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Oct

-09

Jan

-10

Apr

-10

Jul-

10

Oct

-10

Jan

-11

Apr

-11

Jul-

11

Oct

-11

Jan

-12

Apr

-12

Jul-

12

Oct

-12

Jan

-13

Apr

-13

Jul-

13

Oct

-13

Jan

-14

Apr

-14

Jul-

14

Oct

-14

Jan

-15

Apr

-15

Jul-

15

Oct

-15

Jan

-16

Apr

-16

Jul-

16

Oct

-16

Percent of patients waiting more than 6 weeks for a diagnostic test

Combined endoscopies (Colon-, Flexi sig-, Cyto-, Gastro-) % 6+ Week

High volume Imaging (MRI, CT, US) % 6+ Week

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PATIENTS WAITING MORE THAN SIX WEEKS FOR

PATHOLOGY DIAGNOSTICS AT QUARTER END

PATIENTS WAITING >12 WEEKS FOR PATHOLOGY

DIAGNOSTICS AT QUARTER END

WAITING TIMES FOR PATHOLOGY SERVICES ARE INCREASING

WE KNOW WE HAVE LESS IMAGING EQUIPMENT AND FEWER

TRAINED STAFF IN THE UK

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CRUK COMMISSIONED WORK ON ENDOSCOPY,

IMAGING AND PATHOLOGY SERVICES

KEY RECOMMENDATIONS

INCREASE INVESTMENT IN DIAGNOSTIC

SERVICES

RECRUIT AND TRAIN MORE STAFF

INCREASE NUMBER OF IMAGING MACHINES IN

A WIDER RANGE OF LOCATIONS

CONTINUE CONSOLIDATION OF NETWORKING

FUTUREPROOFING

WE NEED GREATER DIAGNOSTIC CAPACITY

Endoscopy report: University of Birmingham and the Strategy Unit at NHS Midlands and Lancashire

commissioning support unit

Imaging report: 2020 delivery

Pathology report: 2020 delivery

A FASTER DIAGNOSIS STANDARD HAS BEEN SET

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THE ACE PROGRAMME

• A programme to

accelerate,

coordinate and

evaluate (ACE)

innovation and

streamline diagnostic

pathways to achieve

earlier diagnosis of

cancer.

• ACE 2 is piloting six

projects trialling a

new diagnostic

pathway for patients

with vague symptoms –

an approach

incorporating a

Multidisciplinary

Diagnostic Centre as

in Denmark.

THE INTERNATIONAL CANCER BENCHMARKING PARTNERSHIP

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19 jurisdictions in 6 countries

8 cancers

PHASE 2

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LOOKING TO THE FUTURE

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New research directions:

- Biomarkers of disease:

- Pre-cursors

- Early cancers

- New imaging modalities

- Distinguishing lethal cancers that need treating from non-lethal ones which don’t

- Use of AI/machine learning:

- Radiology and pathology – capacity (and accuracy?)

- Investigation or presentation patterns

LOOKING TO THE FUTURE

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– Screening: diagnose bowel cancer earlier through screening

– UK wide implementation of FIT

– Evaluating ACE: ensure appropriate recognition, management and referral of

patients in primary care

– Implementing good practice

– Diagnostics: ensure swift access to, and reporting of, appropriate diagnostic tests

– Greater diagnostic capacity

– Improved diagnostic efficiency

– Improved skills mix in workforce and networking of specialists

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RESEARCH & EVIDENCE: DRIVING IMPROVEMENTS IN EARLY DIAGNOSIS

EARLY DIAGNOSIS RESEARCH

CONFERENCE, 23 FEB 2017

Harpal Kumar

CEO

CANCER RESEARCH UK