Qcancer : symptom based approach to cancer risk assessment

+

Qcancer: symptom based approach to cancer risk assessmentJulia Hippisley-Cox, GP, Professor Epidemiology & Director ClinRisk Ltd3rd cancer Care Congress26 Sept 2012

+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

http://creativecommons.org/choose/www.qcancer.org

http://creativecommons.org/licenses/by-sa/3.0/deed.en_GB






+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


http://www.qresearch.org/








+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









+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









+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









+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.









+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









+‘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









+Qcancer now predicts risk all major cancers including

PancreasLung Kidney Ovary

Colorectal Gastro Testis

Breast Prostate Blood

Cervix

Uterus









+Results – the algorithms/predictorsOutcom

eRisk factors Symptoms

Lung Age, sex, smoking, deprivation, COPD, prior cancers

Haemoptysis, appetite loss, weight loss, cough, anaemia

Gastro-oeso

Age, sex, smoking status

Haematemsis, appetite loss, weight loss, abdo pain, dysphagia

Colorectal

Age, sex, alcohol, family history

Rectal bleeding, appetite loss, weight loss, abdo pain, change bowel habit, anaemia

Pancreas Age, sex, type 2, chronic pancreatitis

dysphagia, appetite loss, weight loss, abdo pain, abdo distension, constipation

Ovarian Age, family history Rectal bleeding, appetite loss, weight loss, abdo pain, abdo distension, PMB, anaemia

Renal Age, sex, smoking status, prior cancer

Haematuria, appetite loss, weight loss, abdo pain, anaemia









+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









+Using QCancer in practice – v similar to QRISK2

Standalone tools a. Web calculator

www.qcancer.org/2013/female/php www.qcancer.org/2013/male/php

b. Windows desk top calculatorc. Iphone – simple calculator

Integrated into clinical systema. Within consultation: GP with patients with symptoms b. Batch: Run in batch mode to risk stratify entire

practice or PCT population


http://www.qcancer.org/2013/female/php

http://www.qcancer.org/2013/male/php








+QCancer – women http://qcancer.org/2013/female/index.php

PROFILE64yr old woman, Moderate smokerLoss appetiteAbdo painAbdo swelling72% risk of no cancer28% risk any cancer - ovarian = 20% - colorectal = 1.5% - pancreas =.16%- Other 3.4%









+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%









+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.









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

+

Thank you for listening

Questions & Discussion









+Comparison other cancer risk tools 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

QCancer The “RAT”









Qcancer : symptom based approach to cancer risk assessment

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