RCGP and Cancer Research UK Workshop Mercure Maidstone ... · RCGP and Cancer Research UK Workshop. Mercure Maidstone, Great Danes Hotel. Maidstone ME17 1RE. 19. th October 2017

RCGP and Cancer Research UK Workshop

Mercure Maidstone, Great Danes HotelMaidstone ME17 1RE

19th October 2017

Dr Richard RoopeRCGP and Cancer Research UK Cancer Clinical Champion

Senior Clinical Advisor Cancer Research UK


Housekeeping


Housekeeping• Fire Exits• Toilets• Mobile phones• Questions• Certificates• Thanks to the team who have set up the day:

• RCGP and Cancer Research UK Team • Mercure Maidstone Great Danes Hotel Staff


The Day:• The expanding role of Primary Care and Cancer Control

• Tea and Coffee

• NICE implementation and early diagnosis within Kent and Medway

• Lunch and networking

• Significant Event Audits – Lessons from two large scale studies

• How best to get your patients to quit smoking

• Evaluation


Primary Care and Cancer Control


Primary Care and Cancer Control

• Cancer: why all the interest?• Why is early diagnosis important?• Past – where were we?• Present – where are we?• Future – where next?• Survivorship• End of life care


Cancer: why all the interest?



21. Cancer2. Other3. Circulatory Disease4. Liver5. Respiratory

41. Cancer2. Circulatory Disease3. Other4. Respiratory5. Liver

Causes of death

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307703/LW4L.pdf (last accessed 17.6.17)



https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307703/LW4L.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307703/LW4L.pdf (last accessed 17.6.17)



37%

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307703/LW4L.pdf


Cancer – why all the interest?

The Future:


The perfect storm:


The Scale of the Challenge:The perfect storm…



Aging population


Aging Population

https://data.worldbank.org/indicator/SP.DYN.LE00.IN?contextual=default&end=2015&locations=GB&start=1960&view=chart (last accessed 12.9.17)

https://data.worldbank.org/indicator/SP.DYN.LE00.IN?contextual=default&end=2015&locations=GB&start=1960&view=chart

RCGP and Cancer Research UK WorkshopAging Population - Centenarians

http://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-data-from-the-period-and-cohort-life-tables/2012-based/info-surviving-to-age-100.html last accessed 17.6.17http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/bulletins/estimatesoftheveryoldincludingcentenarians/2002to2015 last accessed 17.6.17

2013 2062 X

Male 2,242 50,000 22.3

Female 12,328 80,000 6.5

TOTAL 14,750 130,000 8.8

http://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-data-from-the-period-and-cohort-life-tables/2012-based/info-surviving-to-age-100.htmlhttp://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/bulletins/estimatesoftheveryoldincludingcentenarians/2002to2015



Aging population

Lifestyles less healthy: • Smoking• Diet• Alcohol• Exercise• Sun exposure



Aging population

Lifestyles less healthy: • Smoking• Diet• Alcohol• Exercise• Sun exposure Increasing survival


The perfect storm:

2013 2030 % increase

UK 352,000 424,789 20.7%

Global 14.1 million 23.6 million 67.4%

Numbers of cancers

http://globocan.iarc.fr/old/burden.asp?selection_pop=206826&Text-p=United+Kingdom&selection_cancer=290&Text-c=All+cancers+excl.+non-melanoma+skin+cancer&pYear=18&type=0&window=1&submit=%C2%A0Executehttps://publications.cancerresearchuk.org/downloads/product/CS_REPORT_WORLD.pdf


The Scale of the Challenge:

By the end of 2016, there were 1,000 people in the UK being diagnosed with cancer every day

Mistry, M., et al., Cancer incidence in the United Kingdom: projections to the year 2030. Br J Cancer, 2011. 105: p. 17951803.



1 in 2 people will be diagnosed with one or more cancers in their lifetime


Lifetime risk of cancer:

http://www.cancerresearchuk.org/cancer-info/cancerstats/incidence/risk/


Cancer: why all the interest?1 in 2 people will be diagnosed with one or more cancers in their lifetime

10 year survival has improved to reach 50%

www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined#heading-One – last accessed 5.3.17



10 year survival has improved to reach 50%

http://www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined#heading-One



10 year survival has improved to reach 50%, but…

Cancer survival in the UK still lags behind comparable health economies


Hasn’t cancer had its turn?


Hasn’t cancer had its turn?Cancer receives what proportion of NHS spend?

1. 2.4%2. 5.4%3. 8.4%4. 11.4%5. 14.4%

Discuss with your neighbour….


Hasn’t cancer had its turn?Total NHS spend in 2012/3: £125,700,000,000


Hasn’t cancer had its turn?Total NHS spend in 2012/3: £125,700,000,000Total NHS spend in 2012/3: £2008 per head


Hasn’t cancer had its turn?Total NHS spend in 2012/3: £125,700,000,000Total NHS spend in 2012/3: £2008 per headTotal NHS spend cancer care: £109 per head


Hasn’t cancer had its turn?Total NHS spend in 2012/3: £125,700,000,000Total NHS spend in 2012/3: £2008 per headTotal NHS spend cancer care: £109 per head

Just 5.4% of NHS spendhttp://www.nuffieldtrust.org.uk/nhs-numbers-0 last accessed 1.3.17

http://www.nuffieldtrust.org.uk/nhs-numbers-0


Hasn’t cancer had its turn?Cancer receives what proportion of NHS spend?

1. 2.4%2. 5.4%3. 8.4%4. 11.4%5. 14.4%


Why is early diagnosis important?


Why is early diagnosis important?All Cancers

www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined#heading-Two (last accessed 5.3.17)

http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined#heading-Two


Why is early diagnosis important?All Cancers

www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined#heading-Two (last accessed 5.3.17)

Stage Shift

http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/all-cancers-combined#heading-Two

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/388160/fourth_annual_report.pdf (last accessed 9.7.17)


Colorectal 4.00%Ovary 4.00%Breast 3.80%Endometrium 3.70%Prostate 2.40%Melanoma 2.30%Lung 2.00%Kidney 2.00%Bladder 1.30%NHL 0.20%

Minimum increased 5 year survival with 10% increase in stages 1 & 2


Where were we?

Cancer – where have we come from?

January 2011 - Improving Outcomes: A Strategy for Cancer


Where were we?Avoidable deaths pa if survival in England matched the best in EuropeBreast ~2000 Myeloma 250Colorectal ~1700 Endometrial 250Lung ~1300 Leukaemia 240Oesophagogastric 950 Brain 225Kidney ~700 Melanoma 190Ovary ~500 Cervix 180NHL/HD 370 Oral/Larynx 170Bladder 290 Pancreas 75


What did we do?


What did we do?

• Research stream• Primary Care Engagement• Input to Cancer Network and SCNs• RCGP Education Events

– etc


How did we do?


How did we do?

38.0%

40.0%

42.0%

44.0%

46.0%

48.0%

50.0%

52.0%

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Detection Rate

https://fingertips.phe.org.uk/profile/cancerservices


How did we do?

38.0%

40.0%

42.0%

44.0%

46.0%

48.0%

50.0%

52.0%

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Detection Rate

https://fingertips.phe.org.uk/profile/cancerservices (last accessed 21.1.17)

https://fingertips.phe.org.uk/profile/cancerservices

RCGP and Cancer Research UK WorkshopVariation: Kent CCGs

http://lci.cancertoolkit.co.uk/Survival (last accessed 5.3.17)


EnglandionNHS SwaleNHS West Kent

http://lci.cancertoolkit.co.uk/Survival (last accessed 21.1.17)

RCGP and Cancer Research UK WorkshopVariation: South East CCGs

RCGP and Cancer Research UK WorkshopVariation: South East CCGs

https://fingertips.phe.org.uk/profile/cancerservices/data#page/3/gid/1938132830/pat/46/par/E39000035/ati/153/are/E38000199/iid/91356/age/1/sex/4 (accessed 17.10.17)

https://fingertips.phe.org.uk/profile/cancerservices/data#page/3/gid/1938132830/pat/46/par/E39000035/ati/153/are/E38000199/iid/91356/age/1/sex/4


PHE Press release 16.9.15:

“Cancers are being diagnosed earlier in England”

https://www.gov.uk/government/news/cancers-are-being-diagnosed-earlier-in-england(last accessed 21.1.17)

https://www.gov.uk/government/news/cancers-are-being-diagnosed-earlier-in-england

RCGP and Cancer Research UK WorkshopHowever compared to Europe?

http://scienceblog.cancerresearchuk.org/2015/08/05/cancer-survival-in-england-is-improving-but-still-lagging-behind-similar-countries/

RCGP and Cancer Research UK WorkshopHowever compared to Europe?

RCGP and Cancer Research UK WorkshopWhy do we lag behind other Health Systems?

• International Cancer Benchmarking Partnership

• As gatekeepers – the gate needs to be wider• Outcomes closely linked to “readiness to act”• Patients fear wasting GP time


Why do we lag behind other Health Systems?

Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? British Journal of Cancer (2013) 108, 292–300. doi:10.1038/bjc.2012.542 (last accessed 17.6.17)


Gate openers…


• Cancer Strategy 2015-2020 has three core aims:

1. Save thousands more lives2. Transform patient experience and quality of life3. Invest now to save later

www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf (last accessed 21.1.17)

http://www.cancerresearchuk.org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf



1. Save thousands more lives

Cancer Control in Primary Care


1. Save thousands more lives

Under 75 mortality rate for cancer considered preventable www.phoutcomes.info/public-health-outcomes-framework#page/8/gid/1000044/pat/6/par/E12000008/ati/101/are/E06000036/iid/40502/ (last accessed 17.6.17)

http://www.phoutcomes.info/public-health-outcomes-framework#page/8/gid/1000044/pat/6/par/E12000008/ati/101/are/E06000036/iid/40502/



1. Save thousands more lives• Spearhead a radical upgrade in prevention




Ambition:




Ambition:• Fall in age-standardised incidence• Adult smoking rates to fall to 13% (currently

16.9%)

Cancer Control in Primary CareSmoking prevalence in UK

http://www.smokinginengland.info/latest-statistics/ (last accessed 17.10.17)

http://www.smokinginengland.info/latest-statistics/




Smoking cessation:



1.Save thousands more lives• Spearhead a radical upgrade in prevention

Smoking cessation:

£1 investment leads to a return of (including NHS savings and value of health gains)

2 years £ 0.63

5 years £ 1.46

10 years £ 2.82

Lifetime £ 9.35




Weight management:




Weight management:PHE: “Let’s talk about weight”

Cancer Control in Primary CareWeight management:PHE: “Let’s talk about weight”

https://www.gov.uk/government/publications/adult-weight-management-a-guide-to-brief-interventions (last accessed 17.10.17)

https://www.gov.uk/government/publications/adult-weight-management-a-guide-to-brief-interventions



1. Save thousands more lives:• Spearhead a radical upgrade in prevention• Drive a national ambition to achieve earlier

diagnosis, and with it stage shift





Ambition:• Increase 5ys and 10ys – with 57% surviving 10+

years• Increase 1ys to 75% with reduction of variation





• “If the taskforce recommendations are implemented 30,000 cancer deaths a year could be saved by 2020, of these 11,000 will be through early diagnosis”



• Early Diagnosis• Implement NICE Guidance (NG12)• Invest in diagnostic capacity• Direct access to diagnostic capacity• Enhance screening uptake• 28 days to diagnosis (to replace 2WW)• Education – Undergraduate, postgraduate, CPD



1. Save thousands more lives2. Transform patient experience and quality of life



1. Save thousands more lives2. Transform patient experience and quality of life

• Patient experience to be given as high a priority as clinical effectiveness and safety

• Transform approach to support those living with and beyond cancer• Continuous improvement in patient

experience, with reduction in variation• Continuous improvement in long-term

quality of life



1. Save thousands more lives2. Transform patient experience and quality of life3. Invest now to save later

RCGP and Cancer Research UK WorkshopPreventionTobaccoFoodImmunisationsExerciseEnvironment

Early detectionAwarenessHealth care seekingScreeningAccess

DiagnosisInvestigationsAccessTechnologyDecision support

TreatmentSurgery ChemotherapyRadiotherapyComorbidityPsychology

SurvivorshipFollow-upLate effectsRehabilitationHealth promotion

End of lifeBasic palliationSpecialisedSocialBereavement







Primary Care could (should?) have a part to play throughout the cancer pathway, and is well placed to do so…







Primary Care could (should?) have a part to play throughout the cancer pathway, and is well placed to do so…if adequately resourced…


The Lancet Oncology: “The expanding role of Primary Care in Cancer Control”

“For a long time, the role of primary care in cancer was largely seen a peripheral, but as prevention, diagnosis, survivorship, and end-of-life care assume greater importance in cancer policy, the defining characteristics of primary care become more important”

The Lancet Oncology, Vol. 16, No. 12



“The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. ”




“recommendations should be implemented by all stakeholders involved in cancer care…work should start now to ensure that patients get the optimum care to prevent, receive a diagnosis of, and survive cancer, and the best possible care should they die from the disease”



Value in investing in early diagnosis:



• Why? To address our lowly cancer outcomes rank• How? To lower threshold/readiness to refer with

consistency• When? Now



• Results?



• Results?• Better medicine – earlier diagnosis (not just of

cancer)• Fewer consultations• Better outcomes• Less complaints/litigation• Less £££


• Living with and beyond cancer:


• Living with and beyond cancer:

• Rising cancer incidence

• Falling cancer mortality

RCGP and Cancer Research UK Workshop• Living with and beyond cancer:

Projections of cancer prevalence in the United Kingdom, 2010–2040 J Maddams, M Utley and H Møller


• Survivorship:


• Survivorship:Problems faced by cancer survivors:• Physical• Psychological• Social• Financial


• Survivorship:Problems faced by cancer survivors:• Physical

• Consequences of treatment• Immediate (eg radiation proctitis)• Late (eg ↑ x5 incidence of congestive heart failure

after radiotherapy or chemotherapy for NHL) 10+ years after treatment



• Consequences of treatment



• Co-morbidities

Living with other long-term conditions as well as cancer reduces people’s chance of survival and increases their level of support needs. It also increases the cost of treatment1.

1. Macmillan Cancer Support. Routes from Diagnosis research programme. Unpublished data.



• Co-morbidities

Proportion of people with cancer living with one or more other long-term health conditions, by age group


Risk factors common to other long term conditions:



Aging population




Aging population


HypertensionHeart diseaseStrokeDiabetesDementiaMental Health Problems…


Problems faced by cancer survivors:• Physical

• Recurrence



• Recurrence – can be reduced



• Recurrence – can be reduced

• Smoking• Diet• Alcohol• Exercise• Sun exposure


Problems faced by cancer survivors:• Second (and third…) cancers.


Problems faced by cancer survivors:• Second (and third…) cancers.

Of the 1.6 million people expected to be diagnosed with cancer this year in the U.S., about one in six will have already survived a different cancer before being developing this new one, according to statistics from the National Cancer Institute (NCI).

Paraphrased from: http://www.cancertodaymag.org/Spring2013/Pages/Second-Cancers2.aspx


Second (and third…) cancers.

Many preventable (over 40%):

• Smoking• Diet• Alcohol• Exercise• Sun exposure


Problems faced by cancer survivors:• Physical• Psychological

• 21% of patients living beyond cancer had MH problems• Consequences of treatment – 10% develop major

depression1.• Pre-existing

1. Walker, J., et al., Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data. The Lancet Psychiatry, 2014. 1(5): p. 343-350.


Problems faced by cancer survivors:• Physical• Psychological• Social

• Consequences of treatment – impact on family and communities.

• Pre-existing – deprivation gradient


Problems faced by cancer survivors:• Physical• Psychological• Social• Financial

• Consequences of treatment• Loss of job/overtime for patient and carer

RCGP and Cancer Research UK WorkshopSurvivorship - Exercise


Role of cancer rehab:Helps short term:

Fatigue, stress, depression, quality of lifeHelps long term:

Breast cancer patients150 mins of exercise per week 40% cancer mortality

Bowel cancer6 hours of exercise per week 50% cancer mortality

Prostate cancer3 hours of exercise per week 30% cancer mortality

Holmes, MD et al. Physical activity andsurvival after breast cancer diagnosis. JAMA.25 May 2005. 293(20):2479–86.Meyerhardt JA, Giovannucci EL, Holmes MD, Chan AT, Chan JA, Colditz GA, Fuchs CS. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol. 2006. 24:3527–3534.

Kenfield SA, Stampfer MJ, Giovannucci, E, Chan JM. Physical activity and survival after prostate cancer diagnosis in the health professionals follow-upstudy. J Clin Oncol.2011. 29:726–732.


https://www.walkingforhealth.org.uk/ (last accessed 17.10.17)

https://www.walkingforhealth.org.uk/


As survivorship increases:Co-morbiditySecond cancers:

previous history cancer risk other cancer Eg: Melanoma: risk of prostate cancer by 32%

Complications of treatmentEg pelvic radiation


End of Life Care


End of Life Care

Palliative Care

• increasingly seen as “non-curative treatment and support”


End of Life Care


End of Life Care

https://www.eiuperspectives.economist.com/sites/default/files/images/2015%20EIU%20Quality%20of%20Death%20Index%20Oct%2029%20FINAL.pdf (last accessed 21.1.17)

https://www.eiuperspectives.economist.com/sites/default/files/images/2015%20EIU%20Quality%20of%20Death%20Index%20Oct%2029%20FINAL.pdf


End of Life Care

• A third of those diagnosed with cancer will die form their disease

• Most express preference to die at home


Dying at home 2010-12

http://apps.mariecurie.org.uk/marie-curie-atlas/html5/atlas.html (last accessed 21.1.17)

http://apps.mariecurie.org.uk/marie-curie-atlas/html5/atlas.html


What’s new?


What’s new?

Output from the National Cancer Transformation Board • Delivery infrastructure: National Cancer Vanguard and

Cancer Alliances• Faster Diagnosis Standard: 28 days to diagnosis - being

piloted currently • Cancer Dashboard: single, integrated Cancer Dashboard


Alliances and Vanguards:


https://www.cancerdata.nhs.uk/dashboard#?tab=Overview&ccg=99J


“Addressing non-communicable diseases (NCDs) is critical for global public health, but it will also be good for the economy; for the environment; for the global public good in the broadest sense. If we come together to tackle NCDs, we can do more than heal individuals— we can safeguard our very future.”

UN Secretary General Ban Ki-moon


Key to cancer


Education Education Education

Key to cancer


Education – publicEducation – patientsEducation – profession

Key to cancer


Education – publicEducation – patientsEducation – professionEducation – policy makers

Key to cancer


Education – publicEducation – patientsEducation – professionEducation – policy makersEducation – politicians

Key to cancer


Insanity:


Insanity: • doing the same thing over and over again and

expecting different results


Insanity: • doing the same thing over and over again and

expecting different results

Albert Einstein 1879-1955


The ones who are crazy enough to think they can change the world, are the ones who do.


The ones who are crazy enough to think they can change the world, are the ones who do.

Steve Jobs 1955-2001

RCGP and Cancer Research UK WorkshopOur common goal?


We have done amazingly, rising to the challenge of 2011


We have done amazingly, rising to the challenge of 2011We can do even better, individually


We have done amazingly, rising to the challenge of 2011We can do even better, individually

•As a wider health community we could do so much more…if resourced properly:We need to spend money now…

to save money (and misery) later


The Day:• The expanding role of Primary Care and Cancer Control

• Tea and Coffee

• NICE implementation and early diagnosis within Kent and Medway

• Lunch and networking

• Significant Event Audits – Lessons from two large scale studies

• How best to get your patients to quit smoking

• Evaluation


One person can make a difference, and everyone should try.


One person can make a difference, and everyone should try.

John F Kennedy 1917-1963


Thank you


Any questions?

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RCGP and Cancer Research UK Workshop Mercure Maidstone ... · RCGP and Cancer Research UK Workshop. Mercure Maidstone, Great Danes Hotel. Maidstone ME17 1RE. 19. th October 2017