cough: a workshop highlighting two new gp guidelines on the investigation of symptoms of lung cancer...
TRANSCRIPT
Cough: A workshop highlighting two new GP guidelines on the Investigation of symptoms of
lung cancer and Chronic Obstructive Pulmonary Disease
Gold Coast Arts Centre21 May 2014
Dr Siva P Sivakumaran & Dr Bajee Krishna Sriram
Investigating symptoms of lung cancer: a guide for GPs
General practitioner workshop
Dr Siva P SivakumaranMBBS, MRCP (UK), FRACP, FCCP
Medical Director, Respiratory Medicine Gold Coast University Hospital
Learning objectives
Demonstrate knowledge of: Best practice assessment of patients who may have lung
cancer Risk factors for lung cancer and symptoms that may indicate
lung cancer Early and rapid referral into the cancer care pathway and
why it is important for patient outcomes The importance and role of multidisciplinary teams
Lung cancer – context
More deaths than breast, prostate and ovarian cancers combined
5-year relative survival is only 14% but this is higher for early stages of lung cancer
Variation in survival in early stages may be due to variation in referral and treatment offered
http://www.uscreates.com/
Diagnosis
Stage Description Treatment options
Localised Only one lobe of the lung is affected. Surgery and/or radiotherapy
Regional The tumour has spread through the wall to surrounding organs and tissues
and/or to nearby lymph nodes.
Surgery & radiotherapy (+/- adjuvant chemotherapy)
increases survival
Distant metastases
The cancer cells have spread to distant parts of the body, such as the bones or
liver.
Palliative radiotherapy to improve quality of life and increase survival
Unknown Insufficient evidence to assign a stage.
Adapted from: 1. Cancer Council Vic. Diagnosing lung cancer. 2013 and 2. Cancer Council. Clinical practice guidelines for the treatment of lung cancer (2013) Cancer Australia, 3. Australian Institute of Health and Welfare & Cancer Australia 2011. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. Canberra: AIHW.
Treatment opportunities
All patients with lung cancer should be seen by a lung cancer specialist to discuss options for treatment, palliation or surveillance.
Options include:– Surgery – usually a lobectomy or pneumonectomy– Chemotherapy– Radiotherapy– Targeted treatment – EGFR mutation– Supportive care
Clinical practice guidelines for the treatment of lung cancer – Cancer Council Australia and Cancer Australia (released Nov 2012) – Recommendations for Stage 1 to 4
http://wiki.cancer.org.au/australia/Guidelines:Lung_cancer
Ref: Peter Mac. Lung cancer treatments. www.petermac.org/LungCancerTreatments
Survival at diagnosis
New South Wales 1999-2003
Stage at diagnosis* Number of cases
% of staged cases Relative survival (%)
Localised 3,272 31.6 29.8
Regional 2,582 24.9 18.7
Distant 4,504 43.5 3.1
Unknown 3,266 31.6 9.3
Total 13,624 100.0 14.0
Reference: 1 Australian Institute of Health and Welfare & Cancer Australia 2011. Lung cancer in Australia: an overview. Cancer series no. 64. Cat. no. CAN 58. Canberra: AIHW.
Five year relative survival by stage at diagnosis, New South Wales 1999-20031
One-Year Relative Survival (%) by Stage, Adults 15-99
Prepared by Cancer Research UK
Original data source:The National Cancer Registration Service, Eastern Office. Personal communication.
http://ecric.org.uk/
Survival by stage
Five -Year Relative Survival (%) by Stage, Adults 15-99
Stage IV survival could not be calculated at five years due to the small number of people surviving more than two years.
Prepared by Cancer Research UK Original data source:
The National Cancer Registration Service, Eastern Office. Personal communication. http://ecric.org.uk/
Survival by stage
Lung cancer in General Practice
Patients with symptoms of lung cancer may present with symptoms to GPs first
Symptoms often present as part of routine primary care or during the management of other diseases e.g. COPD, chronic heart failure and coronary heart disease
Symptoms are often non-specific The average full time GP may see only one lung
cancer patient every 1-2 years
The GP Guide
Questions addressed: Symptoms & signs of lung cancer: What are the
symptoms or combinations of symptoms & signs that are likely to indicate lung cancer?
Investigations: Which investigations are effective in diagnosing a patient with suspected lung cancer?
Referral: Effective investigation and referral of suspected lung cancer – red flags, referral pathways.
Development of the Guide Development of the Guide was overseen by an Expert
Advisory Panel ADAPTE process for guideline adaptation Recommendations adapted from:
– Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. New Zealand Guidelines Group 2009
– The diagnosis and treatment of lung cancer. National Institute of Clinical Excellence (NICE) 2011
– Diagnosis and management of lung cancer. American College of Chest Physicians 2007
The GP Guide
An evidence report supports the 2 page summary
http://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/evidence-relevant-guide-investigation-symptoms
The Guide
Lung cancer in Australia Lung cancer is the fourth most commonly diagnosed
invasive cancer in Australia Lung cancer is the leading cause of cancer death in Australia Lung cancer incidence is strongly related to age Tobacco smoking is the largest single cause of lung cancer Aboriginal and Torres Strait Islander people are 1.7 times as
likely to be diagnosed with lung cancer as non-indigenous people
Risk factors
lifestyle factors: tobacco smoking,
former tobacco smoking
environmental factors passive smoking radon in homes occupational exposure, e.g.
previous exposure to asbestos, diesel exhaust
air pollution
personal factors age family history of lung cancer
smoking-related chronic
obstructive pulmonary disease
previous lung diseases history of cancer, especially
head and neck cancer
16
The GuideRecommendations to facilitate referral and patient support
Ensure referrals are timely & provide relevant / detailed information to the specialist
Provide the patient with information that clearly describes:– where they are being referred– who they will see– what they can expect from the specialty service– the expected timeframes
Advise patient to carry all previous imaging Advise patient to stop smoking and offer therapies to assist Ensure the patient’s need for continuing support is addressed Share appropriate information between healthcare professionals
Symptoms and signs of lung cancer
Symptoms Signs
Unexplained haemoptysis Abnormal chest signs
New or changed cough Finger clubbing
Chest and/or shoulder pain Cervical &/or supraclavicular lymphadenopathy
Shortness of breath Features suggestive of metastasis from a lung cancer
Hoarseness Signs of pleural effusion
Weight loss/loss of appetite
Unresolved chest infection
Any of the following unexplained, persistent symptoms and signs lasting more than 3 weeks (or less in people with known risk factors):
Case study 1
Case study 2
Case study 2
Consolidation consistent with the clinical pictureImage to be included here
Case study 3
Case study 3
Case study 3
Case study 3
Referral pathwaysRecommendation: Refer a patient to a specialist linked to a lung cancer multidisciplinary team (MDT)
Multidisciplinary care is the best practice approach to providing evidence-based cancer care
It involves a team approach to cancer care, improving survival and quality of life
MDTs exist across Australia and provide the mechanism to improve patient care, outcomes and address variations in care
Aboriginal Health Workers provide a critical link for Aboriginal and Torres Strait Islander people, in providing information, support and service co-ordination
Referral pathwaysRecommendation: Refer a patient to a specialist linked to a lung cancer multidisciplinary team (MDT)
Functions of a lung cancer MDT:– diagnoses and staging– selecting and carrying out
optimal treatments– managing symptoms and
side effects– providing support to
manage patient wellbeing or other concerns
A lung cancer MDT may include: – surgeons– GPs– respiratory physicians– oncologists– pathologists – radiologists– specialist nurses– psychological services– allied health and palliative care
services
Engaging with multidisciplinary teams
What happens before and after the meeting?
GP refers their patient to a specialist who is a member of a multidisciplinary team
the GP is invited to attend the meeting (options for tele-link are often available)
if a GP cannot attend the meeting, a summary of discussions is sent to the GP, or can be requested after the meeting
Tasmania http://directory.cancersupportcentre.org.au
Queensland https://qccat.health.qld.gov.au/DOCS#
GP Barriers to implementationDoubt that earlier intervention makes a difference
“Please give us data about earlier diagnosis and survival…not just diagnosing 6 months
earlier so they appear to live for 6 months longer”
Infrequency of lung cancer in practice
“It is a real challenge to expect the existence of a guideline to be
remembered…about a condition that the average GP will diagnose…based on
reasonable evidence, only once every two years.”
GP Barriers to implementation
General comments from GPs about guidelines for lung cancerDoubt that there is a need to re X-ray adults with pneumonia
“I never understood the rationale for exposing all post-pneumonia patients
to more radiation after they have already
recovered.”
Medical Procedure DoseProcedure Dose (millirem)
X-Rays-single exposure
Pelvis 70
Abdomen 60
Chest 10
Dental 1.5
Hand/Foot 0.5
Mammogram (2 views) 72
Nuclear Medicine 400
CT Scan
Full body 1,000
Chest 700
Head 200
US Nuclear regulatory commissionhttp://www.nrc.gov/about-nrc/radiation/around-us/doses-daily-lives.html
The GP Guide – Key take home messages
Be aware of lung cancer risk factors in your patients and community
Early recognition of symptoms and signs is critical 3 week window for unexplained persistent symptoms X-ray is the first line of investigation Chest CT is the second line of investigation Referral to a lung cancer multidisciplinary team (MDT)
Other sources of information about the GP guide
Investigating the symptoms of lung cancer – a Qstream course for GPs– Category 2 points with RACGP– 30 planned reflective development points with ACCRMhttp://cl-wedg.qstream.com/wedgcollaboration/courses/3373-Investigating-the-symptoms-of-lung-cancer-A-Qstream-course-for-GPs
Investigating the symptoms of lung cancer – an Active Learning Module with RACGP– 6 Category 2 points with RACGP– Soon to be released on the gplearning RACGP website
www.canceraustralia.gov.au