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