How an iPhone attachment is helping streamline cancer referrals

9th January 2025

Dr Chris Coulson, ENT consultant at Queen Elizabeth Hospital Birmingham, UK, and CEO of Endoscope-i, talks to Beth Gault about how a new iPhone-compatible device being piloted in the West Midlands aims to streamline throat cancer referrals.

Beth Gault (BG): What is Endoscope-I and how did you first come up with the idea?

Chris Coulson (CC): Me and another ENT surgeon selfishly tried to solve our problems. We spend a lot of time looking in people’s ears, noses and throats and we generally use an endoscope for that, which you put to your eye to look through and see the area of concern.

About 12 years ago, we recognised we had a decent camera in our pocket, on our phone, and thought why don’t we connect it with the endoscope. So, we did. We created an adapter to align the endoscope with the phone to allow you to take an image or video of the ear, nose or throat, which is what the device is.

We progressed to thinking we could train someone to take a video, which then comes through to me and if the clinician has filled out a history and done a hearing test, then I could just sit down and look at them remotely. So, we put that system together.

ENT is an interesting field in that only 10% of people who see me in clinic need an operation, 90% of people – with appropriate information – can be managed remotely. That’s classically done through a face-to-face consultation, but we wondered how much of that information can I get through other means?

BG: How does the tool work?

CC: You just attach the aligner, which is a bit like a phone case, with the endoscope and the iPhone and then take a video or image and upload it to our cloud system via our referral app. It’s currently only on iPhone, not Android, but the iPhones are included with the service.

BG: The tool is now being used to try and detect and rule out throat cancer – what role can it play in cancer referrals?

CC: The symptoms that are concerning with head and neck cancer are also symptoms that sound like a cold, like a hoarse voice or a sore throat. They are general, non-specific symptoms. Most people with a two-week wait referral for cancer do not have cancer.

The number of people picked up from an urgent cancer referral clinic is tiny – about 3%.  So, the trouble that us head and neck surgeons have is how do we sift through these huge numbers of referrals to get to people who actually have cancer?

Capacity is a huge problem, so the number of referrals go up and up and up and actually the numbers of cancers are not. But you still have to deal with these referrals because you never know who is going to have the cancer.

We set up this referral pathway in Stoke where anyone with low risk for cancer went to a nurse-led clinic. The nurse used the endoscope with our camera system, took a video of their throat and then sent it to the head and neck surgeons. They were able to have a look and say who did not have cancer, and then who needed a further appointment in the clinic.

It’s really quick for us to look and know whether they do not have cancer, because it’s what we do every day. Within seconds you can look at a video and tell, but in a consultation, it takes 20 minutes.

We found through this that we can safely run a service where the nurse sees the vast majority of patients, but the consultant reports on it so it’s a consultant-level answer. 

BG: What funding have you received for this?

CC: We designed and delivered it ourselves without funding. But we then got funding from the Small Business Research Initiative to run an assessment of its delivery. We did this in Dorset County Hospital and Stoke University Hospital for head and neck cancer.

BG: What were the results of the test?

CC: We don’t have impressive numbers that say we’ve caught all these cancers, because our aim is not to find cancer, it’s to deal with the people who don’t have cancer. If you deal with them, you can have more capacity to deal with the cancer patients.

We put 1,800 people through the service and found around six cancers. All of these were low risk, so they’d likely go on to have a late diagnosis if they hadn’t used the service.

BG: If a system was interested, would integrated care boards (ICBs) or Trusts be the one to fund this?

CC: Up to now it’s been Trust funded, because it’s a way of increasing their capacity and saving money. But we do have a couple of ICBs around the country who are looking at it for delivery in their patch. My guess is in a few years we will have a combination of ICBs and hospitals. However, the one thing we won’t have is GPs funding this. The location of delivery could be in primary care, which I think is advantageous to the population, but I don’t think it will be primary care-led funding.

BG: What does it cost?

CC: Around £100,000 upfront for the kit, training and integration and then there’s a monthly license fee for security updates and ongoing support.

BG: How do you see the tool being used in the future in the NHS?

CC: I don’t see GPs using it, it’s one of the core things we’re trying to do is to make things easier for GPs, not delivering something else for them to do. It would work best with someone doing it in high volumes, rather than intermittent users, so it might be that trained staff will go out to practices or any healthcare facility to do it. It would work well in a diagnostic treatment centre as well.

We are also looking at artificial intelligence and if at some stage we can automate some diagnoses or letters, this would further increase efficiency.

BG: How do you think digital tools like this can make a difference to the NHS?

CC: There’s clearly a huge opportunity for digital tech to improve healthcare. But one of the challenges is how can you make sure that your digital tech doesn’t make things worse. We’ve got to be cautious that we don’t make things more complex.

But it’s also got to be clinically led. As soon as there’s tech designed by tech people with tech people in mind, most of us struggle to get on with it. It needs to solve a clinical problem.

This article was originally published by our sister publication Healthcare Leader.

Research digest: The impact of cancer diagnosis on heart failure medical therapy use

6th September 2024

Following a cancer diagnosis, patients with heart failure with reduced ejection fraction (HFrEF) are less likely to continue or maintain the use of guideline-directed medical therapies (GDMTs), according to a new longitudinal study.

Researchers from University College London Hospitals NHS Foundation Trust analysed data from patients with heart failure in UK Clinical Practice Research Datalink between 2005 and 2021. Based on diagnostic and prescription records, patients with probable HFrEF were selected, and trends in the use and dosing of GDMTs before and after receiving a new cancer diagnosis were analysed.

The researchers matched 4,890 HFrEF patients with incident cancer to controls without cancer. The majority of the participants were male (73.9%), and the mean age was 75.7 years.

Patients with cancer were found to be 51% more likely to have poor adherence to renin-angiotensin-system inhibitors (RASIs), 22% more likely to have poor adherence to beta-blockers and 31% more likely to have poor adherence to mineralocorticoid receptor antagonists (MRAs) compared to non-cancer controls (RASIs: OR = 1.51, 95% CI = 1.35–1.68; beta-blockers: OR = 1.22, 95% CI = 1.08–1.37; MRAs: OR = 1.31, 95% CI = 1.08–1.59).

Cancer patients are also less likely to continue taking the GDMTs over time, with 104% more likely to stop taking RASIs, 35% more likely to stop taking beta-blockers and 49% more likely to stop taking MRAs than non-cancer controls.

Titration doses for RASIs and beta-blockers were more likely to be reduced after a cancer diagnosis (OR = 1.69, 95% CI = 1.40–2.04 and OR = 1.31, 95% CI = 1.05–1.62, respectively). None of the patients started new heart medications or had their medication doses increased after a cancer diagnosis, the researchers noted.

The reduction, interruption or cessation of heart failure treatments has a potentially negative impact on cardiovascular outcomes, the researchers said, adding that ‘this issue is even more concerning if the [heart failure] patient eventually needs cardiotoxic cancer treatments’.

Since heart failure leads to increased hospitalisation, and mortality is higher in patients with poor adherence or persistence to GDMTs, the researchers have called for better medical management of heart failure after a cancer diagnosis.

They also highlighted the need for further research, including targeted strategies for heart failure treatment optimisation, patient and clinician education at the time of cancer diagnosis, and an increase in multidisciplinary working between cardiologists, oncologists, general practitioners, pharmacists and specialist nurses.

Reference
Ju, C et al. Use of heart failure medical therapy before and after a cancer diagnosis: A longitudinal study, ESC Heart Failure 2024; Jul 23: doi.org/10.1002/ehf2.14981.

Capsule sponge test shown to increase efficiency and replace need for endoscopy in some patients

7th March 2024

A pilot project to help diagnose Barrett’s oesophagus using a capsule sponge test has reduced the need for invasive endoscopy in thousands of low-risk patients, NHS England has announced.

The so-called ’sponge on a string’ test involves patients swallowing a small capsule-shaped device which contains a tiny sponge that collects cell samples for analysis before being extracted via an attached string. It can be carried out quickly in a short appointment without the need for sedation.

NHS England began piloting the test during the Covid-19 pandemic when there was increased pressure on services and a growing backlog for endoscopy. Launched at 30 hospital sites across 17 areas in England including Manchester, Plymouth, London, Kent and Cumbria, over 8,500 patients have now been tested with the capsule sponge.

Of these, almost eight out of 10 were discharged without the need for further testing. Those with positive results who were referred on for an endoscopy had the highest prevalence of Barrett’s oesophagus at 27.2%, compared to zero patients with negative results who completed an endoscopy.

Consultant-led, nurse-run service

Evaluation of the NHS pilot showed that using the capsule sponge was highly cost effective compared to using only endoscopy for diagnosing patients – saving around £400 per patient. It also freed up endoscopy capacity for higher risk patients and those referred for urgent tests for oesophageal cancer, helping to reduce waiting lists.

One of the first pilot sites at East and North Hertfordshire NHS Trust has now performed around 1,400 capsule sponge tests – offering it to both patients with reflux symptoms via a new consultant-led, nurse-run early diagnosis service, as well as to patients who are on an existing Barrett’s surveillance programme.

In the first 1,000 patients, the capsule test identified Barrett’s in 6% of patients with reflux and found two new cancers. It also found three patients with dysplasia who may otherwise have had a longer time to diagnosis. A total of 72% of reflux patients were discharged back to their GP without the need for an endoscopy.

As of January 2024, 368 patients had a positive test result, of whom about half have confirmed Barrett’s oesophagus.

Capsule sponge test has ‘huge benefit‘

Dr Danielle Morris, a consultant gastroenterologist at the trust said: ‘Using the capsule sponge test as a diagnosis triage tool has had huge benefits for patients, avoiding the need for unnecessary gastroscopy in almost seven out of 10 patients, and helping to reduce endoscopy waiting lists enabling us to prioritise those who really need endoscopy to have it done quickly.

‘The test is performed by a single trained practitioner in an outpatient setting, so it is very resource light compared to gastroscopy, and our patients are very supportive of the service – with almost nine in 10 patients preferring the capsule sponge to a gastroscopy.’

With around 9,300 new oesophageal cancer cases in the UK every year, earlier detection of Barrett’s oesophagus before it becomes cancerous is key to saving lives, NHS England said.

Professor Rebecca Fitzgerald, director of the early cancer institute at the University of Cambridge, who developed the test, said: ‘Timely diagnosis is vital for improving outcomes for patients [so] it is very exciting to see the positive results of the NHS England real-world pilot for our capsule-sponge test.

‘This is a major step forward to making this simple test more routinely available outside of clinical trials.’

In 2021, a study found that oesophageal cancer cases had tripled in under 50s over the past 30 years.

Continued smoking after cancer diagnosis increases risk of adverse CVD event

8th June 2023

Ongoing smoking following a cancer diagnosis, elevates the risk of adverse cardiovascular disease (CVD) events, according to the findings of a study by Korean researchers.

Emerging data indicates how continued smoking following a cancer diagnosis increases the risk of cardiovascular disease mortality.

In fact, nearly 20% of cancer survivors continue to smoke. However, the differential effect on adverse cardiovascular outcomes, of either quitting smoking, cutting down or continuing to smoke is less clear.

The current study, published in the European Heart Journal, assessed the effect of changes to smoking habits on adverse cardiovascular outcomes.

Smoking status was assessed two years before and three years after a cancer diagnosis. Participants were categorised as non-smokers; quitters, initiators and relapsers, and continued smokers.

The primary outcome was a composite of CVD events, comprising hospitalisation for myocardial infarction or stroke, or CVD death.

Smoking status and adverse cardiovascular outcomes

Among 309,095 cancer survivors with a median age of 59 years (51.8% women), 80.9% were non-smokers, 10.1% quit, 7.5% initiated or relapsed to smoking and 7.5% continued to smoke.

During a median follow-up of 5.5 years, 10,255 new CVD events occurred. Using non-smokers as the reference point, the adjusted hazard ratio (aHR) for a CVD event among quitters was 20% higher (aHR = 1.20, 95% CI 1.12 – 1.28). But among those who continued to smoke, the risk was 86% higher (aHR = 1.86, 95% CI 1.74 – 1.98).

There were clear benefits for those who quit smoking. For example, the CVD event risk was significantly lower among those who quit compared to participants continuing to smoke (aHR = 0.64, 95% CI 0.59 – 0.70).

These findings were consistent across both sexes as well as when classifying participants according to their primary cancers. Among those who continued to smoke, cutting down had no effect on their risk of a CVD event (HR = 0.99, 95% CI 0.80 – 1.22).

The authors suggested that continued smoking after a cancer diagnosis and its association with CVD events highlighted the urgent need for initiatives to promote smoking cessation and prevent smoking initiation and/or relapse among patients with cancer.

Cancer diagnoses in young people fell but ICU admissions increased during first wave of pandemic

19th November 2021

Cancer diagnoses in young people fell during the first-wave of the pandemic but were associated with a higher rate of ICU admissions

The level of cancer diagnoses in young people fell during the first-wave of the COVID-19 pandemic but there was also an increased likelihood of admission to intensive for cancers diagnosed during the period. This was the finding from a study by researchers from Oxford University, UK who discussed their findings in a poster presentation at the National Cancer Research Institute conference.

The COVID-19 pandemic has had a major impact on cancer services in the majority of countries across the world. In the UK, a survey by Cancer Research UK in July 2020, found that 2 in 3 cancer patients reported that their cancer care had been impacted and that ratings of overall cancer care as ‘very good’ decreased from 75% ‘before lockdown started’ to 37% ‘after lockdown started’. Moreover, other research shows that in England, there were approximately 3.4 million fewer key diagnostic tests performed between March and August 2020 compared with the same period in 2019.

Given the likely impact of delays in diagnostics, the Oxford team were interested in determining how in England, the first wave of the pandemic affected childhood, teenager and young adult cancer incidence rates, diagnostic and treatment time-intervals and cancer-related intensive care (ICU) admissions. They used the QResearch database, which is derived from the anonymised health records of over 35 million patients. In addition, since QReseaerch is also linked to linked to hospital admission, mortality and cancer diagnoses data held with a disease register, it was possible for the researchers to make links between these three factors. For the present study, researchers focused on central nervous system (CNS) tumours, lymphomas, leukaemias, sarcomas and renal tumours in those aged up to 25 years of age. They compared the incidence of these cancer diagnoses between 1^st February to the 15^th August 2020 and compared their findings to the three preceding pre-pandemic years. As well as the number of diagnoses, the team also analysed the length of time before treatment started after diagnosis and whether or not these patients were diagnosed after being admitted to intensive care.

Findings

A total of 2607 cancer diagnoses were made from 1^st January 2017-15^th August 2020, with 380 during the pandemic. Overall, this represented a 17% reduction (95% CI -38% to – 6%) in the incidence-rate-ratio during the first wave of the pandemic. In particular there was a 38% (95% CI -52% to -21%)] decrease in CNS tumours and a 28% (95% CI -45% to -5%) reduction in lymphomas. Interestingly, the researchers observed that childhood cancers that were diagnosed during the pandemic were more than twice as likely to be associated with an ICU admissions (adjusted odd ratio, OR = 2.2, 95% CI 1.33 – 3.47).

The researchers also observed that the median time to diagnosis was not significantly different across the different time periods (+4.5 days, 95% CI -20.5 days to +29.5) and the median time to treatment was actually shorter during the pandemic (-0.7 days, 95% CI -1.1 to -0.30).

The authors concluded that the COVID-19 pandemic led to substantial reduction in the detection of cancer in young adults but was also associated with an increase in cancer-related ICU admissions. They suggested that this was probably due to more severe baseline disease at diagnosis and that overall, their findings demonstrate a clear disruption to cancer diagnostic pathways in this age group which need to be addressed urgently in the recovery phase of the pandemic.

Citation

Saatci D et al. The impact of the COVID-19 pandemic on cancer diagnostic pathways in children, teenagers and young adults: a cohort study in England. NCRI conference 2021