1. IMPROVING EARLY DIAGNOSIS OF Cancer
Jay Smith (CRUK facilitator for Herts & Beds) E: T:
Intro:
Facilitator role
Focus on screening and prevention
Questions – not clinician.

2. How much has cancer survival changed since the 1970’s?
When looking at survival it is common to look at the % of people surviving their cancer for 10 years or more.
What % of people would survive their cancer for 10 years of more in the 1970’s? – answer 25%.
What % of people now survive their cancer for 10 years of more? – answer 50%
This is across all cancers. For some (breast, testicular prostate) survival has quite dramatically improved. For others (pancreatic, brain, lung, oesophageal) is has remain very low.
Ambition: within 20 years survival will be 3 in 4.

3. IS CANCER INCIDENCE INCREASING?
MALES FEMALES PERSONS
OBSERVED CASES = SOLID
PROJECTION = DASH
Aim of the slide: To introduce the topic of cancer and that cancer cases are on the rise
Adaptations:
Some audiences may already know this, so you may not want to include this slide
Key points:
In the UK incidence rates for all cancers combined have increased by 12% since the early 1990s (until 2014). This includes a larger overall increase for females than for males.
This increase in cancer cases is set to continue, with incidence rates projected to rise by 2% in the UK between 2014 and 2035, to 742 cases per 100,000 people by 2035.
For males, incidence rates in the UK are projected to rise by less than 1% between 2014 and 2035, whereas for females, rates are projected to rise by 3% between 2014 and 2035
If this projection is accurate, there will be an increased burden on the health system, which could impact patient experience and outcomes. The figures emphasise the need to plan now for the increased demand we can expect to see, if outcomes are to be maintained or improved.
The continuing rise in cases is in part due to the ageing and growth of the population, a result of the overall success of the healthcare system in tackling premature mortality over the last 50 years as people are less likely to die from other conditions, such as cardiovascular disease. But it is also because our changing lifestyles are increasing our individual risk; prevention efforts have, as yet, been unable to stop or reverse this trend at an overall level.
Extra information
90% of all cancers are diagnosed in people over the age of 50, so as people are living longer we would expect to see more people being diagnosed with cancer
Source: (heading one and heading three)
Age standardised incidence rates are used here. For more information on why this is used, see the CRUK stats pages:

4. ONLY 54% OF CANCERS ARE DIAGNOSED AT AN EARLY STAGE
THERE IS VARIATION IN STAGE DISTRIBUTION BY CANCER TYPE
Aim of this slide: To give some information on the proportion of cancers that are currently diagnosed at an early stage
Adaptations:
Note: This data is for England. Facilitators in Scotland, Wales and Northern Ireland may want to remove this slide or keep it in but explain it uses English statistics
Key points:
Overall, just over half of all cancers (54%) are being diagnosed at an early stage (stage I and II)
As you can see from the infographic, some cancer types tend to be diagnosed earlier than others. For example 85% of breast cancers are diagnosed at stage I and II, whereas only 25% of lung cancers are diagnosed at stage I and II
Extra information
Data for the ‘early and late’ infographic comes from Public Health England and is from data should be available soon

5. Aim of this slide: To use statistics to show the link between stage and survival
Adaptations:
This data is for England. Facilitators in Scotland, Wales and Northern Ireland may want to remove this slide or keep it in but explain it uses English statistics
For non clinical audiences you might want to simplify the message. You could say something like ‘Studies have shown that you’re more likely to survive your cancer for a year or more if it is diagnosed at an early stage. Unfortunately, for some cancers the majority of patients aren’t being diagnosed until they are at a late stage’.
Key points
If we look at the national statistics we can see evidence that early diagnosis saves lives.
This infographic shows that:
Around 8 in 10 lung cancer patients who are diagnosed at stage I will survive their cancer for at least a year, but for lung cancer patients diagnosed at stage IV (ie late stage) less than 2 in 10 of them will survive for at least a year or more.
We see a similar picture for bowel cancer patients. More than 9 in 10 bowel cancer patients survive their cancer for one year or more if it is diagnosed at the earliest stage (stage I) , but for bowel cancer patients diagnosed at stage IV (ie late stage) only around 4 in 10 of them will survive for at least a year or more.
This shows that if we diagnose people earlier, they have a higher chance of survival. This is particularly pertinent when we know that more and more people will be diagnosed with cancer as the population ages. Early diagnosis could make a big difference in improving the survival rates for cancers such as lung and bowel as currently the majority of patients aren’t being diagnosed until they are stage III and IV.
The picture is similar across many cancer types - An analysis of East of England data by CRUK found that when looking at 8 cancers combined, 10 year survival increased by more than threefold when cancers were diagnosed at an early stage.
Extra information:
Cancer is the leading cause of death in the UK, it accounted for 27% of all deaths in the UK in 2015 (Source:
Data for the ‘survival’ infographic came from the Office for National Statistics (ONS) and Public Health England and was put together by the Cancer Intelligence team at CRUK. It looks at people diagnosed in 2014
The cancers included in the East of England analysis were bladder, bowel, breast, cervical, womb, malignant melanoma, ovarian and testicular cancers, which together account for more than 40 per cent of all cancer cases in the UK. The data was from We blogged about the findings here:
There are also survival gains to be made by shifting patients from stage IV to III, or from III to II – for more information contact the early diagnosis team at
You can find more information on the link between early diagnosis and survival in this paper from Sara Hiom, published in 2015:

6. AND COULD CUT THE COST OF TREATMENT
Aim of this slide: To show that treating cancer when it is at an early stage is less expensive than at a later stage
Adaptations: this study just looked at England but we would expect a similar picture for Scotland, Wales and Northern Ireland
Key points
In 2014, CRUK commissioned a study to look at the potential cost savings of early diagnosis. The study showed:
Earlier stage treatment costs considerably less - treatment for stage III and IV colon, rectal, lung and ovarian cancer costs the NHS nearly two and a half times the amount spent on stage I and II services.
This is because treatment for the earlier stages of cancer is often less intensive or invasive than treatment for more advanced disease.
The NHS could potentially make significant savings if they were able to achieve earlier diagnosis
Extra information:
The information comes from CRUK’s report ‘Saving Lives, Averting Costs’:
This report comes with a number of caveats, mainly around limitations on available data. This means that while it is useful for national level messaging on the importance of and opportunity that early diagnosis presents, it is not robust enough to be applied to local level business planning. Also, the report was published in 2014, and therefore does not account for the cost of newer therapies. We have identified this area as a research gap and are currently undertaking further analysis in the health economics field. For more information contact the early diagnosis team at
This is the most up to date infographic for this report. Please do not use older infographics as they are not on brand and are out-of-date
You can find more information on this research on the early diagnosis guidance document.

7. WHY IS SCREENING IMPORTANT?
Screening reduces the number of people dying from cancer by:
Detecting cancer early
63% of cancers detected through screening are at an early stage (stage I)
Preventing cancer
Bowel scope screening and cervical screening can both prevent cancer
Aim of this slide: To explain why we encourage people to participate in the screening programmes
Key points:
Screening is a great way to spot cancer when it is at an early stage (63% of cancers detected through screening are stage I)
This early diagnosis, coupled with prevention of cancers developing in the first place (in bowel scope screening and cervical screening) is how screening saves lives.
Adaptations
The infographic uses data from England, but we’d expect to see a similar picture for other UK countries
Extra information
Be aware that you may get questioned about overdiagnosis at this point. For example, lots of early stage breast cancers are picked up by screening that didn’t need to be treated in the first place. If this is raised, acknowledge that this is an issue with screening and stress that that is why it is important to give people information on the harms as well as the benefits so they can make an informed choice. Also explain you will cover this in more depth later on in the presentation
These statistics come from Routes to diagnosis analysis from NCIN (now known as NCRAS).
The analysis looked at ten cancer types: bladder, breast, bowel, kidney, lung, melanoma, non-Hodgkin lymphoma, ovarian, prostate and uterine cancers, between 2012 and 2013.
Of the total 574,500 cases analysed, screening picked up the highest proportion of early stage cancers
We blogged about the findings here:
Here is the NCRAS Routes to diagnosis webpage:
You can download this infographic from the asset hub:
This infographic will be updated with more recent data in summer 2017

8. What do you know about cancer screening?
What ages are eligible?
How frequently does screening take place?
What is the screening test?
Where does the test take place?
How many national cancer screening programmes are there in the England? (3 – breast, cervical, bowel)
Separate in 3 groups - each looking at a specific screening prog
2 mins to answer these 4 questions

9. Cancer Screening in the UK- Cervical Screening
Women aged 25 to 49 are screened every 3 years
Women aged 50 to 64 every 5 years
Cytology with HPV triage
Conducted at GP practice
Results are sent within a few weeks of test
5,000 lives estimated to be saved each year by screening
National target 80%
Since the start of screening in the 80’s cervical cancer rates have almost halved

10. Percentage of females aged 25–64 attending cervical screening within target period

11. Cancer Screening in the UK – Bowel Screening
Men and women aged 60 to 74 are screened every 2 years
Over 75 can request a screening kit
It involves a stool test (FOBt), looks for hidden blood.
Test is done at home and posted for analysis.
It can help identify polyps which may develop into cancer, these can be removed (cancer prevention)
National target 60%

12. From FOB to FIT
The new FIT test will now be offered to all men and women aged 60 to 74 every two years in a bid to spot the early signs of bowel cancer.
The new kit relies on a method called the Faecal Immunochemical Test (FIT), which looks for hidden blood in stool samples. It is far easier to use than the current method, FoBT, which requires two samples from each of three separate stools.  By contrast the FIT test only needs one sample.
It has been estimated that the new test will increase screening uptake by around 10% - meaning an additional 200,000 people could be tested each year.
This means that hundreds of lives could be potentially saved (Department of Health)
Estimated roll-out = April 2017

14. Cancer Screening in the UK – Breast Screening
Women aged 50 to 70 every 3 years
Women over 70 can request to be screened
Age extension being tested: 47 to 73
Mammography, an X-ray of the breasts
Takes about 30 minutes
Results are sent within two weeks and a copy
is sent to GP
National target 70%

15. National target:
Over 70%

16. How can we increase screening uptake?
18/09/2018

17. Screening resources
(NB: title is hyperlinked to where the resource can be SOURCED)
Resource
Description
GP practice profiles
Outcome and process information related to cancer for every practice including screening data.
Template letters
Various formats – GP endorsement letters, letters to send to defaulters for each of the screening programmes, etc… Please contact CRUK facilitator to access these.
Bowel screening guide
CRUK guide highlighting good practice for increasing uptake of Bowel screening within a patients population (e.g. template letters, READ codes, etc…)
Bowel/ breast screening cards
Wallet card with information on bowel/ breast screening programmes in England, including the contact number to request a new kit/ test.
Cervical screening report
A report from Jo’s cervical cancer trust highlighting case studies and best practice for increasing uptake of Bowel screening
CRUK and Macmillan screening leaflets
A range of resources (posters, leaflets, cards, etc…) from Cancer Research and Macmillan which are free for practices to order for distribution in practice.
CRUK facilitator
Your local CRUK facilitator is Jay Smith ( , They are available to support implementation of any improvement activities.

18. Suggested Good Practice
Where we are now
Screening
A practice cancer screening lead has been appointed
Patient contact details are checked at each encounter/regularly maintain the practice list.
Where appropriate PNLs (Prior Notification Lists) are dealt with promptly.
Check that defaulter lists are received/ produced for the 3 cancer screening programmes.
There is a practice system for checking defaulter lists (monthly or quarterly).
Defaulting patients have their patient notes updated accordingly or READ coded.
A range of approaches are used to follow up with defaulting patients (opportunistic, letters, phone calls)
Screening is actively promoted – posters, leaflets, practice website, videos on screens
The practice takes part in dedicated cancer campaigns (e.g. ‘Be Clear on Cancer’)
Screening data and/ or defaulter lists are reviewed at practice meetings.
All staff have a good understanding of the three cancer screening programmes.
Targeted engagement approaches are for identified populations (e.g. newly eligible, learning disabilities, etc…)
The practice holds contact details for the relevant bowel and breast screening centres
The practice has literature with screening centre contact details to give to patients.
For cervical screening, flexible appointment times are offered (early morning, evening, weekend)
For cervical screening, patients are offered the opportunity to bring someone with them
For cervical screening, a 3rd reminder letter is sent from the GP following the 2 centrally sent letters
For cervical screening, information is provided to patients about what the results mean.
For cervical screening, information is provided to patients to dispel “myths” (e.g. lesbians, virgins, etc…)
For cervical screening, there is a system in place for gathering/ recording patient feedback.
GPs and Practice Nurses are trained in cervical sample taking and attend updates every 3 years.
Practice staff know how to use the FOBt bowel screening kit and can explain it to patients.
Practice staff have access to a sample FOBt kit available for demonstration during consultations

19. Shoutout question

20. B
43%

23. Very Brief Advice for Smoking
ASK: About smoking status ADVISE: Did you know we can offer you free support to stop smoking, and that you are up to four times more likely to stop successfully with this support? ACT: If you ring the number on this card/click on the link on this website, you can get an appointment with your local stop smoking advisor … or… have a word with [insert name] at reception, she can give you an appointment with the stop smoking advisor here in the practice
Talk through the process of ASK, ADVISE, ACT in more detail

24. Go thorough the summary of key findings:
This is a paper that came out just last October - it was led by Oxford based researcher Dr Paul Aveyard and shows the effectiveness of a very brief advice intervention for overweight people
It found that a 30 second opportunistic conversation where GPs advised their patients that the best way to loose weight was to attend a weight loss programme and then offer a referral to an NHS referral weight loss group in their local community. And importantly the GP asked the patient to follow up and feedback on how they are getting on
Go thorough the summary of key findings:
The intervention only took 30 seconds during the consultation
40% of patients attended the weight loss programme
They generally lost 2-4 kg (compared to 1kg in the control group)
25% of the people in the active group lost 5% of their bodyweight
And 4 out of 5 patients agreed that the conversation was appropriate
Advise them to look up a copy of the paper and read it
Tuesday, September 18, 2018
View <Headers and Footers> to alter this text

25. FACILITATING LIFESTYLE CHANGE
elearning.rcgp.org.uk/course
Aim of slide: To highlight that there are a number of different tools and techniques to encourage behaviour change; the strongest evidence is for brief interventions.
Key points:
There are a range of different tools and techniques to facilitate lifestyle change within a clinical setting (see further information and a summary of definitions in NICE Guidance 2014: 
Whilst these definitions are often used interchangeably, the techniques themselves are different and the evidence base varies between them. 
There is strong evidence supporting the use of brief interventions to encourage healthy living and behaviour change (largest evidence base around smoking cessation and alcohol).
This approach involves a tailored conversation with an individual around current behaviour and opportunities to make a change. 
The length of time to undertake brief interventions within primary care has been identified as a key barrier (whether real or perceived).
Other techniques which have aimed to address this barrier, such as very brief advice (VBA) have been developed.  
Emerging evidence suggests the time taken to conduct VBA is shorter than for a brief intervention (30 seconds vs 5-10 minutes). 
VBA has a stronger focus on giving information and signposting to services (with less focus on assessing current behaviours or motivations to make a change).
However there is currently no clear evidence of the effectiveness of VBA in making lifestyle changes.
CRUK has worked with RCGP to produce the Behaviour Change and Cancer Prevention e-learning module, which has the potential to contribute to the evidence base for VBA.
VBA has been endorsed by RCGP, as seen by the development of this module.  
You can use the RCGP/CRUK module for tips on how to open a discussion about smoking cessation, alcohol or weight with your patients.
Extra information:
NICE recommends the use of brief interventions: “Encourage health, wellbeing and social care staff in direct contact with the general public to use a very brief intervention to motivate people to change behaviours that may damage their health. The interventions should also be used to inform people about services or interventions that can help them improve their general health and wellbeing.”
CRUK’s Cancer Intelligence team will continue to monitor the developing evidence base around the range of behaviour change tools to support practitioners to discuss cancer prevention with their patients.
References:
Brief interventions & referral for Smoking Cessation in Primary Care & other settings

26. Prevention resources # Resource Description
(NB: title is hyperlinked to where the resource can be SOURCED) #
Resource
Description 1
Preventable cancers poster
Poster highlighting proportions of cancer cases in the UK linked to risk factors which are theoretically preventable by lifestyle and other changes. 2
Talking about cancer course
Free online course will give you the confidence and ‘know-how’ to separate cancer myths from facts and encourage healthy lifestyle changes. 3
Newsletters for Health Professionals
CRUK provides a wide range of useful information in a number of different newsletters for Health Professionals. 4
CRUK leaflets
Wide array of healthy lifestyle leaflets for patients. 5
Talk cancer training
Cancer Research UK training programme to help you feel confident talking to people about ways to reduce the risk of cancer, spotting cancer early and screening. 6
Womens Own – Cancer magasine
CRUK has partnered with Woman’s Own to create a special edition copy of the magazine to be distributed to GP surgeries, providing patients with information about cancer prevention and early diagnosis in a unique and engaging way. 7
Macmillan patient leaflets

27. THANK YOU
cruk.org/facilitators