Suspected Upper GI cancer 2 WW pathway direct

Suspected Upper GI cancer 2 WW pathway: direct access pilot Dr Nina Lewis Consultant Gastroenterologist and Honorary Assistant Professor

What I think 1. Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way

What I think 1. Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way. 2. Patients presenting with any weight loss, iron def anaemia or diarrhoea need to be assessed in an outpatient clinic so that tests appropriate for the individual patient are organised

What I think 1. Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way 2. Patients presenting with any weight loss, iron def anaemia or diarrhoea need to be assessed in an outpatient clinic so that tests appropriate for the individual patient are organised 3. Many patients do not fit into typical symptomology for a specific cancer but please continue to follow your instinct and refer

Processing of Upper GI 2 WW referrals Cancer Office deliver paper copies of upper GI 2 WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13: 00 Straight to test OGD Gastroenterology clinic

Processing of Upper GI 2 WW referrals Cancer Office deliver paper copies of upper GI 2 WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13: 00 Straight to test OGD • Dysphagia • Dyspepsia (that seems straightforward) Gastroenterology clinic

Oesophageal cancer Most common presenting symptom is dysphagia

Oesophageal cancer Dysphagia is caused by the malignant stricturing

Lung cancer can present with dysphagia

Causes of dyspepsia Cause Proportion of dyspepsia cases Chronic peptic ulcer disease 10 -15% Gastro-oesophageal reflux (with or without oesophagitis) 5 -15% Malignancy Functional (non-ulcer) dyspepsia <2% 60 -65%

Chronic peptic ulcer disease Helicobacter accounts for: • 85% duodenal ulcers • 60% gastric ulcers NSAIDs account for: • 14% duodenal ulcers • 30% gastric ulcers

Gastro-oesophageal reflux • Absence of oesophagitis at endoscopy does not exclude reflux (may require p. H studies) • Common exposures: - young men - abdominal truncal obesity - hiatus hernia - delayed gastric emptying

Functional dyspepsia

Processing of Upper GI 2 WW referrals Cancer Office deliver paper copies of upper GI 2 WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13: 00 Straight to test OGD Gastroenterology clinic • • • Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about

Upper GI 2 WW outpatient assessment for iron def anaemia 1. Test to confirm or refute she has bowel cancer 2. Test to confirm or refute she has UGI cancer 3. Look for other site of malignancy particularly if weight loss is present 4. Imaging +/- cystoscopy to confirm or refute she has urological cancer if haematuria present 5. 6. Small bowel biopsy to exclude coeliac disease Gastric biopsy to exclude helicobacter-associated gastritis whilst on aspirin

Iron def anaemia and bowel cancer ~50% people with incident bowel cancer have evidence of IDA

Upper GI 2 WW outpatient assessment for iron def anaemia 1. Test to confirm or refute she has bowel cancer 2. Test to confirm or refute she has UGI cancer 3. Look for other site of malignancy particularly if weight loss is present 4. Imaging +/- cystoscopy to confirm or refute she has urological cancer if haematuria present 5. 6. Small bowel biopsy to exclude coeliac disease Gastric biopsy to exclude helicobacter-associated gastritis whilst on aspirin

Gastric cancer • Often asymptomatic • Presence of weight loss, post-prandial vomiting, iron def anaemia all reflect advanced disease

Lower GI pathway and diarrhoea

Diarrhoea can be caused by many things

Diarrhoea can be caused by many things

Weight loss is worrying

Processing of Upper GI 2 WW referrals Cancer Office deliver paper copies of upper GI 2 WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13: 00 Straight to test OGD • Dysphagia • Dyspepsia (that seems straightforward) Gastroenterology clinic • • • Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about

Pilot: GP direct access to Upper GI 2 WW OGD or 2 WW clinic GP direct access following 2 WW UGI referral Straight to test OGD • Dysphagia • Dyspepsia (that seems straightforward) Gastroenterology clinic • • • Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about