Factorsinfluencingtimetodiagnosis of
childhoodcancersfromaPrimaryCare
Perspective
DRFATIMAKAGALWALA
Outline
§ Childhoodcancerisrare- 1,550outof11millionchildrenunder14
years
§ 82%survivalfor≥5years
§ Nationally,23percentofcancers(childrenandadults)are
diagnosedviatheemergencyroute.
StudyDesign
§ Multi-practicequestionnairestudy
§ Jan2012toFeb2015
§ Allpaediatriccancersincluded
§ FirststudyencompassingGPsviewsonserviceimprovement
Figure2:FlowdiagramforGPEnrolment
PatientsidentifiedbyCDRas
referredtoGOSHoncologyfromJan
2012toJan2015
n=1239
Eligible for Inclusion
n=992
Exclusioncriterian=247
Notcancer
OutsideGOSHcatchmentarea
Referredforsecondopinion
Referredforsurgicalinput
E-mail not sent n=447
- GP retired
- Locum GP
- e-mail address not
obtainable
- Random exclusion
52 patients had same GP
E-mail sent
n=493
Age
9%
14%
22%
<1yr
1-5yrs
5-10yr
55%
10+yrs
Table3:DistributionofDiagnosisamongstthe96
Responses:
Leukemia33
•ALL26
•AML2
•Lymphoma5
Braintumours29
•Astrocytoma11
•ATRT4
•Ependymoma4
•Medulloblastoma7
•Retinoblastoma2
•EmbryonaltumourNOS1
Solidtumours34
•Neuroblastoma11
•Rhabdomyosarcoma10
•Wilm's4
•LCH2
•Others7*
HospitalbasedPaediatricTraining
NoPaediatricTraining
TrainingduringGP
rotation(6months)
Trainingduring FY
rotation (4months)
More
Paediatric training
(>6months)
17%
61%
8%
14%
Cancersuspicionrates
38%ofthosewithhospitalbasedpaediatrictraining
suspectedcanceronreferralcomparedto31%withoutthis
experience
Size of Practice List and the percentage of children referred into secondary care within 3 visits
SizeofPracticeList
Numberoffamilies registered
%ofchildrenreferredwithinfirst
3visits
<5,000
17
64%
5,000to10,000
34
52%
10,000to20,000
44
45%
Duration of registration with a surgery (in years) and GPs cancer suspicion at time of referral.
NumberofGPvisitspriortoreferral
TheaveragenumberofvisitstoGPforanychildwithacancer
diagnosiswas3.5withtherangebeing1to13visits.
Numberofattendances toGPwithin thevariousdiagnostic groups
Overallopiniononreferralguidelines
WeretheguidelinesPracticalanduseful?
Easy?
Yes
Yes
17
No
3
Notsure
6
GrandTotal
26
No
1
1
Notsure
GrandTotal
1
18
2
6
8
14
11
38
Referralmodedepending oncancersuspicion
Guidelineawareness
§ 60%notawareofanyguideline
§ Other40%namedvarietyoflocalguidelines
§ 11%GPs(11outof96)namedtheNICEguidelines
ServiceImprovement
§ Diagnosticfacilities:54%
§ Rapidaccessforadvice/clinic
§ ConsultationtimeandLanguagedifficulties:54%
§ Knowledgeandcomplexityofsymptoms:Significantbarrier,twothirdsfelt
thatimprovedreferralpathwayessential
§ Primary-secondarycareinterface
Outcome
§ 17%GPsdidnothaveanyhospitalbasedpaediatrictrainingduringtheir
trainingyears
§ 53%childrenwithcancerwerereferredforassessmentwithsomeother
differentialdiagnosis
§ TheaveragenumberofpresentationstoGPinthe12monthspriorto
referralwas3.5forallcancergroups,with10%having>6attendances
§ Only11%GPsusedtheNICE2005cancerreferralguidelines
§ Improvedknowledgeandsuspicionofcancerimprovesspeedofreferral
(67%vs21%)