Understanding the Single Cancer Pathway – Part 3

In the last blog of our series on the single cancer pathway we will look at just some of the ways in which research can help drive the continued performance of the new pathway.

Broadly speaking, the single cancer pathway can be divided up into a consecutive series of discrete but sometimes overlapping intervals.  These may be defined as the patient interval, the primary care interval, and the secondary care interval. Overshadowing these are the diagnostic interval which bridge both primary and secondary care (since a cancer diagnosis may be made in either a GP surgery, an intermediate rapid diagnostic centre, or in hospital) and the treatment interval which is usually restricted to the hospital setting. Research has the potential to better define these intervals and optimise how each one operates.

 


A schematic of how the new single cancer pathway may look – (Reproduced with kind permission from the Wales Cancer Network)

 

Let’s Think Cancer – A Focus on the Patient and Primary Care Interval

The major performance measure of the new single cancer pathway will the 62 day waiting time – by which point all patients must have started treatment.  The stop watch for this new target will start when a medical professional, usually a GP, first suspects cancer – and not when a cancer is finally diagnosed, as has previously been the case. However, if cancer survival rates are to truly improve as a result of quicker referral, diagnosis, and treatment, then the ability of GPs to recognise and act upon symptoms with greater impetus will be equally important.

In the past, research has shown that Welsh GPs are less likely to refer patients, and although recent evidence suggests this is changing, great variation is still thought to exist between practices across the nation. Educating or facilitating GPs to improve decision making and increase referrals of suspected cancer without causing undue worry will be key, but will not be without its challenges.

In several other countries research is underway to better understand and synthesise the current cancer knowledge of GPs and other allied health professionals working in primary care, all of which will help identify the barriers to timely referral.  Notably, the countries leading this research are Australia and Denmark, both which of have demonstrably shorter time to diagnosis compared to the UK.

An ongoing Cancer Research Wales funded study at The North Wales Primary Care Research Centre, Wrexham, is looking at ways to improve the quality of GPs cancer knowledge, attitudes and general beliefs about cancer matters as they occur in Wales.  It is hoped by the end of the study, an interventional tool kit and educational package that addresses some of the modifiable primary care issues can be introduced to help improve informed decisions with regard to suspected cancer and patient referral within GP surgeries.

As mentioned in the first blog of this series, a better understanding of how the public act upon symptoms and other factors that influence people’s decision to visit a GP, will also prove informative. Further research will help refine how and where awareness campaigns should be directed, and by what means hard to reach communities can be better accessed, and how the general public can be empowered and helped to lead healthier lifestyles.

New Cancer Tests for Primary Care – Hastening the Diagnostic Interval

A great difficulty faced by GPs is that a lot of red-flag symptoms won’t be cancer, and a not so insignificant number of vague symptoms, normally associated with other conditions, will found to be cancer-related.  There is a drive within research to develop better point of care tests that GPs can use to help diagnose cancers with more accuracy than previously available.

The two tests currently used in primary care for investigation of possible cancer are PSA for prostate cancer, and CA-125 for ovarian cancer. While these tests have their uses, they also have their limitations. Both PSA and CA-125 are useful for monitoring treatment response and disease progression when cancer is confirmed but their precision for the unequivocal diagnosis of cancer is below that required for a specific cancer test. Unfortunately, since their introduction over 25 years ago, there have been no new tests that a GP can utilise to help diagnose cancer with increased confidence.

With the introduction of the right tests there is a real opportunity to transform GP surgeries into hubs of diagnostic excellence for cancer. New highly specific cancer tests that are more precise at detecting cancer in symptomatic patients, however vague the symptoms, will lead to a more efficient and streamlined single cancer pathway. In a perfect setting this will see only those patients with cancer receive the required down-stream investigations in a timelier manner, while those without cancer can avoid having to undergo unnecessary procedures that are often unpleasant and invasive in nature.

Cancer Research Wales is proud to be leading the way in the UK with this type of research with the development of two blood-based tests for the early detection of bowel, pancreatic and oesophageal cancer. These diagnostic tests are set to be piloted in primary care, the two Rapid Diagnostic Centres, as well as some hospitals across South Wales during 2019. It is hoped the tests will give GPs the ability to detect cancer at an earlier stage when they easier to treat, manage and cure. It is anticipated their use will be extended across Wales, and assessed alongside other more conventional methods such as faecal occult blood test currently used in the national bowel cancer screening programme.

Medical Imaging, Genomics and All Things Science – Optimising the Treatment Interval

The multi-disciplinary teams or MDT’s as they are affectionately known, represent a vital convergence point at which the two cancer pathways (urgent and non-urgent) currently meet. The MDT’s are composed of many different health-care specialists and include surgeons, oncologists, pharmacists, general medical clinicians, dieticians, and physiotherapists.  Each one will meet with the patient in turn, before the team collectively decides the best treatment plan and supportive care.MDT’s will still remain a crucial feature of the single cancer pathway but as research continues to deliver a better understanding of disease processes and as a result improved treatments, we may yet see other disciplines introduced into the MDT setting. Medical genetics and medical physics are just two examples of specialties that have bridged the research gap and revolutionised the detection and treatment of some cancers within the clinic.

As new classes of cancer drugs, for example, the molecular targeted therapies which target the underlying molecular drivers of disease continue to step out from the research setting and into clinical practice, and as the complexity of medical imaging and radiotherapy treatment plans increase, the expertise of their protagonists will very much compliment any MDT.

In the field of cancer research, there is great interest in understanding how the varying genetic landscape of the human genome may leave some people more prone to developing certain cancers than others, and once a tumour has become established, how the genetic instability continues to drive the evolution of the disease, which forever erect new barriers to successful treatment. As more is learned we may see future screening programmes further refined to include some of these research findings, similar to the recent incorporation of HPV testing in the national cervical screening programme.

Cancer genetics and a better appreciation of the dynamic interaction that growing tumours have with the whole body systems such as the immune system and the microbiome will lead to the discovery and development of new drugs and treatment strategies.  While the use of molecular targeted therapies as single agents have yet to deliver the promise of personalised cancer medicine – their correct scheduling in treatment plans and their use when combined with other treatment modalities may yet see their full potential realised. Only research will be able to answer these ponderables.

The setup of an Imaging Academy in Wales affords a real opportunity to link research with clinical practice at the very coal face of cancer care. With the wealth of expertise that the Imaging Academy will propagate – all trained using the latest technology, in addition to the masses of data that will be generated and stored – there exists an exciting prospect of the best clinicians and medial physicists in Wales working together to develop new intelligent systems that are able to determine characteristics of disease, possible treatments and prediction of response – just from routine scans.

As radiotherapy machines and imaging modalities increase in complexity, research has the scope to further improve the planning of radiotherapy protocols which will hopefully lead to better disease control and increased cure rates. Also the recent introduction of proton therapy facilities in Wales offers unlimited possibility with regard to the radiotherapy research and the development of combined therapies, all of which will serve to optimise the treatment interval of the single cancer pathway.

 

Horizon Scanning and International Comparisons – Improving the Whole Pathway

Research and service delivery are two forever evolving disciplines that perfectly align, complement, and cross pollinate one another within a health system. As we unceasingly strive to provide better care, lessons can be learnt from other countries following a careful examination of the processes already in place that have led to better outcomes. One such study is the International Cancer Benchmarking Project that looks to compare countries with similar health care systems.

Further research will allow the identification of best practice and provide the critical evidence base by which better systems can be incorporated into the single cancer pathway in Wales. The Rapid Diagnostic Centres recently launched in Neath-Port Talbot and Cynon Taf is only one example of how learning from other countries can help improve matters here.  First created in Denmark, these centres soon made a lasting impression that has stood the test of time, as Denmark is now one of the top performing countries with respect to early cancer diagnosis.

 

Patient Involvement – For the People Who Matter Most

In addition to reducing waiting times and detecting cancers earlier another major goal of the single patient pathway is to ensure patients have as good an experience as possible during their cancer journey. The regular patient experience surveys that take place in Wales have proven invaluable for identifying areas where improvement is needed as well as providing examples of best practice for others to follow.

Research that focuses on the patient experience, and research that involves patients in the decision making processes, either through the avenue of patient surveys, direct communication with patient advocacy groups, or representation on steering committees will be indispensable as the operational structures of the single cancer pathway are continually refined and improved following its introduction.

Clinical Trials offer patients access to the very latest therapies in a safe controlled environment. Where appropriate all cancer patients should be offered advice on the possibility of taking part in clinical trials, as todays research is tomorrow’s treatment. Wales has already shown what it can achieve as it recruited more patients than any other country for the international, multi-centre, STAMPEDE trial for prostate cancer. Elements of this research has now become standard treatment for advanced prostate cancer in many countries.  Cancer Research Wales will aim to play its part in enabling Welsh clinicians to establish and host more clinical trials in their respective organisations and Health Boards.

 

Out With the Old and in With the New

Last year we celebrated 70 years of the NHS, an institution that started in Wales and went on to become the envy of the world.  As we enter 2019, there is a great opportunity for Wales to once again show the world that it can lead the way in health care. While the potential of a new single cancer pathway is unlimited, we need to be reminded that the challenges will also be great. It will require involvement, cooperation and full commitment from patients, Primary Care Practitioners, Health Boards and their respective cancer centres, Welsh Government, and Third Sector.

Patience will be needed, as the single cancer pathway as a finished product, is unlikely to happen overnight – as seldom is anything that has stood the test of time and refinement in the crucible of fire. Following its launch, the single pathway will continually evolve and sharpen in its delivery of cancer care as lessons are learned and best practices implemented.   Empowered leadership will also be required as these type of leaders do more than control the direction in which people travel, they ignite the passion in others and see the whole journey before the adventure has even started.

Cancer Research Wales wishes all those at the Wales Cancer Network much success in 2019 and as a Charity we will strive to play our part, however small or large, in helping deliver a cancer service that the people of Wales so readily deserve.

 

Blog written by Dr Lee Campbell