Should every suspected cancer referral be assessed …...@GM_Cancer I #GMCC2019 Referral Criteria: Non site-specific referral criteria • Some symptoms point towards a specific cancer

Should every suspected cancer referral be assessed in a Rapid Diagnostic Centre?

Dr Sarah Taylor, Sue Sykes, Campbell McNeil

© Copyright Greater Manchester Cancer. All rights reserved.

@GM_Cancer I #GMCC2019

NHSE: The RDC Service Model


NHSE Planning for 2019/20

Sep 2019 Jan 2020 Aug 2019 Jul 2019 Oct 2019

Publication: RDC Vision and Specification

Web-Ex: Q&A on publication of specification

Web-Ex: Top tips for RDC planning

Submission: Alliances submit 2019/20 plans to regions

Assurance: Regions assure 2019/20 plans, then to NHSE

Approval: 2019/20 plans Live service: RDCs

accept referrals for agreed cohorts

NHSE will use the same template and sign-off approach as 2019/20

Cancer Alliance Delivery Plans

Approval: NHSE approve 2019/20 plans

How the Multidisciplinary

Diagnostic Centre (MDC)

informed the

development of a Rapid

Diagnostic Centre (RDC)

in Greater Manchester



Multidisciplinary Diagnostic Centres

• Appointments offered within 14 days

• Navigator key to co-ordination

• One-stop clinic model

• Diagnostic tests CT and gastroscopy

• Hot reporting

• Most patients will receive the results on the same day

• If cancer is confirmed, patients

supported in the clinic by a Clinical Nurse

Specialist and referred on to the

appropriate MDT for further investigations

and management.

• If cancer is excluded, patients will

receive appropriate safety netting advice

and be offered strategies to reduce their

primary cancer risk.

• If cancer cannot be excluded in a

single appointment, patients will be

booked for further investigations until a

cancer diagnosis is either confirmed or

ruled out.


Referral Criteria: Non site-specific referral criteria

• Some symptoms point towards a specific cancer. These should be investigated or referred in accordance

with the NICE NG12 guidelines and not considered for non-site specific pathway

Exclusion Criteria: Possible site-specific referral criteria

Example symptoms to investigate through this route (non-exhaustive list)

Decreased appetite Non-specific abdominal pain Persistent pain

Nausea Lymphadenopathy Unexplained DVT

Non-specific iron deficiency

anaemia

Hepatomegaly Continued patient or family

concern

Fatigue Splenomegaly GP Concern

Weight loss Bloating

Example symptoms to not investigate through this route

Post-menopausal bleeding Melaena Shortness of breath

Abnormal vaginal bleeding Dysphagia Cough

Rectal bleeding Haematemesis Haemoptysis

Altered Bowel habits Haematuria


Primary Care Urgent Investigations

In addition to a full clinical assessment and examination, the GP is asked to

arrange the following mandatory tests and review their results before

referring the patient:

• Urgent CXR: within 1 working day of the GP appointment.

• Urinalysis: same-day.

• Urgent blood test: including FBC, U&E, LFT, Bone profile, TFT, LDH,

PV/CRP, Ferritin, Glucose, HbA1c, Mononucleosis test, Coeliac screen.

Also PSA (male only), beta-HCG (male only), CA125 (female only).

Sending a referral without these mandatory tests is likely to result in

unnecessary delay.


Presenting Symptoms


MDC Summary – Cancer Groups up to 31st January 2019

Tumour Group (ICD 10 Codes) Royal Oldham Wythenshawe GM Total

Brain / CNS (C47, C69-C72) 0 0 0

Breast (C50, D05) 1 1 2

Gynaecological (C51-C58) 0 0 0

Haematology (C81-86, C88, C90-C96) 4 1 5

Head and Neck (C00-C14, C30-C32, C73, C77) 0 1 1

Lower GI (C17-C21, C26) 3 0 3

Lung (C33-C34, C37-C39, C45) 6 4 10

Other (C74-C76, C78-C80, C97) 1 2 3

Sarcoma (C40-C41, C79, C48-C49) 0 0 0

Skin (C43-C44) 1 0 1

Upper GI (C15-C49, C22-C25) 8 2 10

Urological (C60-C68) 4 2 6


Results

Wythenshawe Oldham

Total number of patients seen in MDC 250 260

Number of cancers diagnosed 13 29

Cancer conversion rates 5.2% 11.2%

Median wait from referral to first appointment (14 days) 10 days 9 days

Median wait from referral to diagnosis of cancer communicated

(28 days)

11 days 10 days

Number of patients with cancer diagnosis communicated within

28 days

91.9% 94.9%


Conclusion of MDC Pilot

In summary an MDC approach for patients with non specific but concerning

symptoms:

• Provides a clear pathway for this group of patients.

• Has demonstrated that over 90% of patients receive a Yes / No to cancer on

the same day.

• Onward referral / appropriate treatment for patients where cancer is excluded.

• Provides high rates of patient and staff satisfaction.

PROOF OF CONCEPT


Should every suspected cancer referral be

assessed in a Rapid Diagnostic Centre?

Is the RDC a concept {Rapid Diagnostic Service) or a physical centre?

Are some services (eg breast) already offering a Rapid Diagnostic Service?

Which patients should be seen in the RDC?

• Vague Symptoms

• Simple red flag

• Complex red flag

• Co-morbidities

Do all patients want to be assessed in an RDC?


How should the RDC be organised?

• Should there be one suspected cancer referral form?

• Who can refer to the RDC? GPs? Acute physicians? ED doctors? Patients?

• Who should triage the patient to the correct appointment / investigation

• Who should assess the patient in the RDC?

• How many RDCs are needed in Greater Manchester?

• How often should they run?


How does the Multi-disciplinary Diagnostic Centre

(MDC)

inform the development of a

Rapid Diagnostic Centre (RDC)?

Q1 2019 – Consultation Framework

developed with PPV forum

Q3 2019 – Coproduction

events at 4 ACE Wave 2 sites

plus other events

Q3 2019 – Thematic

Analysis of the conversations

completed with PPV forum

Q3/4 2020 – QMs generated and tested with

the Cancer Alliances

Q4 - 2020 – QM document published

• What does a good experience look like at the point of referral from a GP

to an RDC?

• What does a good experience look like at the RDC? (physical and virtual

process)

• What does a good experience look like at the point of discharge from

the RDC process?

Rapid Diagnosis Centres – Quality Marker Creation

Q&A

© Copyright Greater Manchester Cancer. All rights reserved.

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Should every suspected cancer referral be assessed …...@GM_Cancer I #GMCC2019 Referral Criteria: Non site-specific referral criteria • Some symptoms point towards a specific cancer