Be Clear on Cancer campaigns for early diagnosis

Update event for ‘Blood in Pee’ national campaign –October - November 2013

Chair: Sean Duffy, National Clinical Director for Cancer, NHS England

Introduction

Welcome and setting the scene

Aims of the event

Sean Duffy, National Clinical Director for

Cancer – NHS England

1.00

The ‘Blood in Pee’ Campaign

The ‘Blood in Pee’ Campaign – part of Be Clear on Cancer

A PHE perspective on Be Clear on Cancer

National development, creative, evaluation and learning

What happens when it goes live – a voice from the pilots

Jane Allberry - DH

Prof Kevin Fenton– PHE

Yvonne Ridley - PHE

Laura McGuinness - CRUK

Suzanne Thompson and Jo Cresswell –

Northern England

1.10

1.20

1.45

What is the likely impact of the Blood in Pee national campaign? John Osmond - DH 2.05

Q&A – fresh tea and coffee available 2.20

Future plans for 2013/14 Be Clear on Cancer Campaigns Sean Duffy – NHS England 2.40

Aligning national and local delivery – new accountabilities, organisations

and ways of working

A panel with an opportunity to ask questions, chaired by Sean Duffy.

Hilary Walker – NHS IQ

Paul Roche – NHS England

Richard Roope - GP

Jane Allberry – DH

Yvonne Ridley – PHE

Laura McGuinness – CRUK

3:00

Summary of next steps and close Sean Duffy – NHS England 3.50

Agenda

Aims of this event

This event is intended to:

• Provide an update on the national ‘Blood in Pee’

campaign running Oct-Nov 2013, including modelling of

the estimated impact on the NHS

• Share experiences from Be Clear on Cancer ‘Blood in

Pee’ pilots

• Review the impact of the BCOC campaigns so far

• Share latest plans for BCOC February 2014 campaigns

• Be an opportunity for you to give us feedback on your

experience of the campaigns and to gather suggestions

for how these could be improved

Setting the scene

Cancer Reform Strategy (2007)

• Launch of National Awareness and Early Diagnosis Initiative

Improving Outcomes: A Strategy for Cancer (2011)

• Sets out the Government’s ambition to save an additional 5,000 lives per annum by 2014/15, through earlier diagnosis and better access to treatment

Be Clear on Cancer Campaigns

• Launched in 2010/11

• Approach developed over time in consultation with stakeholders and panels of experts, using research with healthcare professionals and target audience

Cancer survival

• 1 year and 5 year survival rates are generally lower in England than comparable countries in Western Europe

• Coleman et al (Lancet 2010): Up to date survival trends show improvements in cancer survival, but the gap between countries remains. Differences are consistent with late diagnosis and differences in treatment

• Whether the gap in survival rates is due to differences in stage at diagnosis or treatment, it is generally recognised that earlier diagnosis is a major issue

• 10,000 deaths could be avoided each year in England if our cancer survival rates matched those in the best countries in Europe

Breast ~ 2000 Endometrial 250

Colorectal ~1700 Leukaemia 240

Lung ~1300 Brain 225

Kidney / Bladder ~990 Melanoma 190

Oesophagogastric ~950 Cervix 180

Ovary ~500 Oral/Larynx 170

NHL/HD 370 Pancreas 75

Myeloma 250

[NB Prostate has been excluded as survival ‘gap’ is likely to be due to

differences in PSA testing rates.]

Data derived from Abdel-Rahman et al, BJC Supplement December 2009

Avoidable deaths per annum if survival

in England matched the best in Europe

Rationale

• Generally the earlier the stage of cancer when it is diagnosed, the

better the chances for survival

• If kidney and bladder cancers are diagnosed at the earliest stage,

one year survival is as high as 92-97%

• At a late stage, it drops to just 25-34%

• If the number of people in England who survived bladder and kidney

cancers matched the best in Europe, around 1,000 lives could be

saved each year

• Around 16,600 people in England are diagnosed with kidney and

bladder cancer each year and 7,500 die from them

Achieving earlier diagnosis (1)

• Raise symptom awareness amongst the public

and patients

• Encourage prompt presentation to the GP

• Support GPs to refer on appropriately

• Ensure sufficient capacity in secondary care

Achieving earlier diagnosis (2)

• Focus on the biggest killers

• Funding provided through IOSC - £450million

over this Spending Review period to support

work to improve earlier diagnosis

• The importance of evaluation – we are still

learning

‘Blood in pee’ campaign –

part of Be Clear on Cancer

Jane Allberry

Deputy Director Sexual Health, Screening and Early Diagnosis

Department of Health

Overall approach

• Campaigns – link to national priorities

• Start local, scale up to regional, go national

• What these levels of campaign involve:

- deciding focus: views of expert stakeholders etc

- determining messaging

- local activity

- adding in TV at regional level

- going national

- stakeholder engagement

- other support, e.g. shopping centre events

• ‘Blood in pee’ campaigns to date:

- 3 local pilots (2012)

- regional pilot in Tyne Tees and Borders TV regions

(Jan-March 2013)

Public Health England:

Perspective on Be Clear on Cancer

Professor Kevin Fenton

Director of Health and Wellbeing

Public Health England

Yvonne Ridley

Public Health England

Tuesday 10th September 2013, London

Be Clear on Cancer

Be Clear on Cancer – Campaign Roll-out

Blood in Urine

• Why Kidney & Bladder Cancer

• Why focus on blood in urine

• Who’s at greatest risk

Creative Approach

Task:

Get people who notice blood in their

pee to see their GP straight away

Insight:

Men don’t talk about their problems

whilst women are more open and

happy to discuss

Creative Development Research

• TV Whistle

• TV Maybe

TV - Whistle

TV - Maybe

Creative Work – Press ads and Posters

Direct Mail

Blood in Pee – Leaflet & Pharmacy Bag

National Media Roll-0ut

Oct 15th – 20th November

• TV

• Radio

• Press & Outdoor posters

• GP surgery’s

• Direct mail and Events

• PR

Be Clear on Cancer

‘Blood in Pee’

campaign evaluation

Evaluation• We recognise there is a lot of stakeholder interest in the impact of

these campaigns

• Comprehensive evaluation of all campaigns to date has been coordinated by Cancer Research UK (CR-UK)

• As of April 2013 National Cancer Intelligence Network (NCIN) will lead the evaluation working with CR-UK to ensure consistency

• Evaluation metrics have been selected to reflect the different points along the patient pathway

• Data from a range of sources: bespoke studies (eg awareness tracker surveys, GP attendances), routine data collections (egdiagnostic activity), commissioned datasets (cancer registry data)

• Some measures can take months to come through due to complex nature of the data (eg cancer incidence & stage)

Evaluation Metrics for Be Clear on Cancer activityMetric Broad questions we’re seeking to answer

Cancer and campaign

awareness

Are people seeing the campaign and is it raising

awareness of the signs and symptoms?

GP attendance Are we seeing more people going to their GP

with the symptoms promoted by the campaign,

and is there any shift in the profile of patients

presenting?

Urgent referrals for

suspected cancer

Are we seeing more people referred urgently for

suspected cancer, and is there any shift in the

profile of these patients?

Conversion rates Of those referred urgently for suspected cancer,

how many actually turn out to have that cancer?

Impact on investigations Are we seeing an increase in diagnostic

investigation activity, or the length of time

patients are waiting for tests?

Cancer incidence and

staging

Are we seeing an increase in the numbers of

patients diagnosed with cancer, and/or a shift

towards earlier stage disease?

Local and Regional ‘Blood in Pee’ Pilots

• Local pilot (i.e. no TV)

• Held in 3 pilot areas

– Avon Somerset and Wiltshire

– Nottingham

– Greater Manchester and Cheshire

• In total 18 PCT areas were covered by the pilots

• The pilots ran predominantly from January to end of March 2012

• Regional pilot (including TV and direct mail)

• Covered the previous North of England Cancer Network footprint

• 13 PCTs (17 CCGs from April 2013)

• Tyne Tees and Borders TV region

• Activity ran from 14 January to 17 March 2013

Are people seeing the campaign and is it

raising awareness? YES

Regional Pilot

• Knowledge that blood in pee is a definite warning of kidney/bladder cancer increased significantly from 41% before the campaign to 65% after the campaign. This increase was noted in both men and women

• Encouraging response to the campaign, particularly by men, 69% of men found the advertising was relevant and 51% of men felt it told them something new

• After the campaign there was a significant increase in people saying they would see the GP the same day if they noticed any changes to pee or bladder habits, up from 18% to 27%

Are more people going to their GP with the

symptoms? YES

Local • Avon, Somerset and Wiltshire was the only pilot to conduct formal

GP attendance analysis.

• Overall there was a higher level of attendances in 2012 compared

with 2011 for people presenting with campaign - specific symptoms

(macroscopic haematuria), but no clear increase to correspond

with the start of the campaign

Regional • Data extraction carried out late August with results due early

Autumn

Purpose

• This slide set represents the interim findings from

the analysis of data from 52 GP practices.

• Data from a further 444 GP practices has been

included as a ‘control’ group to compare activity

against.

• It has been compiled specifically to provide an initial

view on whether the campaign has had an impact or

not on patient attendances.

• The study has been commissioned by NHS IQ

• The final report is due in September 2013.31

To consider the impact of the ‘Be Clear on Cancer’ blood in pee

awareness campaign on patients visiting their GP with the

symptoms highlighted in the campaign.

• No clear increase in attendances for the symptom highlighted in

the campaign (macroscopic haematuria) following the launch of

the campaign, based on the week by week profile.

• Activity during the campaign in 2012/13 was 25% higher

compared with the previous year (0.18 additional visits per

practice per week), however it was 9% higher compared with the

eight weeks prior to the campaign – the same increase was

seen in practices outside the targeted area.

• Attendances for men increased by 15% within the targeted

area during the campaign compared with the eight weeks prior

to the campaign, whereas outside the area, attendances

increased by 12%.

32

Summary

Evaluation

results

Objective

Campaign vs control symptomsPractices within targeted area (aged 50+)

% change in attendances from 2011/12

25%

-22%-10% -14%

-5%

-30%

-20%

-10%

0%

10%

20%

30%

40%

Macroscopic haematuria

Neck pain

Shoulder pain

Knee pain

UTI

% c

ha

nge

in a

tte

nd

an

ce

s fro

m

20

11

/12

Pre

Live

Post

GP attendances for the control symptoms decreased by 12% during the campaign in

2012/13, compared with the previous year.

Attendances for the control symptoms increased by 10% during 2012/13, compared with the eight

weeks prior to the campaign. Attendances for macroscopic haematuria increased by 9%.

33

Are we seeing more people urgently referred

for suspected cancer? YES

Local • 26% increase in 2WW urgent referrals for suspected urological cancer within

the pilot area compared with an 18% increase in the control area

Regional • Analysis investigated the impact of the regional campaign, by considering

the change in the number of urgent GP referrals for suspected urological

cancer, from January – April 2012 to January – April 2013

• The campaign appears to have had an impact on referrals for suspected

urological cancers, with a 28% increase in the regional pilot campaign

areas, compared to a 9% increase in the control areas

• Within the site-specific campaign areas, the increase in urological referrals

was similar for men (27%) and for women (30%)

NB* the urological cancer referral pathway covers several cancer types in addition to kidney and bladder.

Are we seeing an increase in diagnostic

investigation activity? YES

Local• Cystoscopy figures for 18 PCTs covered by the local campaigns indicate a 5.9%

increase (adjusted for working days) compared with the same months in 2011

– Nottingham City PCT has a 19% increase

– Greater Manchester and Cheshire a 12% increase

– Avon, Somerset and Wiltshire a 2% reduction. Within this, some PCTs have

seen increases while others have seen decreases

• There appears to be no adverse effect on waiting times following the local pilots

Regional

• Results show strong growth in the number of cystoscopies in pilot PCTs in the period

following the campaign. However, this series is affected by some large changes in

activity for hospitals in the area (DM01 data)

Are we seeing an increase in numbers of

patients diagnosed?

Local

• Comparing Jan – May 2011 to Jan – May 2012

• 5.3% increase in the number of bladder or kidney cancers

diagnosed following a 2WW urgent referral for suspected urological

cancer within the pilot area

Regional

• Initial analysis expected at the end of 2013 using the Cancer Wait

Time database. This will cover the duration of the campaign and the

period after the campaign, to assess any increases in the diagnosis

of urological cancer

Conclusions so far

• Knowledge that ‘blood in pee’ is a definite warning of

kidney/bladder cancer increased in both men and women

• Campaign advertising seen as relevant and agreement that this

was new information

• Increases in 2WW referrals and diagnostic investigations both

locally and regionally

• From anecdotal feedback we have received throughout the two

pilots (local and regional level) we have consistently heard that the

campaign is well received by health professionals

• Need to sustain cancer awareness campaigns and other initiatives

in the longer term to bring about desired behaviour change more

widely and achieve better outcomes in cancer

What happens when it goes live

– voices from the regional pilotSuzanne Thompson (Clinical Network Manager) and Jo

Cresswell (Chair of Urology Network Site Specific Group)

• What did we do?

• What did it feel like?

• A secondary care

perspective

• Finally, planning for

October

Clinical Engagement – What did we

do?• Launch event & WebEx open to all stakeholders

– Modelling tool

• Education events aimed at primary care

• Briefing sessions for health champions/trainers

• Pharmacy engagement

• NECN website

• E-bulletin to all stakeholders

• Communication resource pack

• Resources: CRUK factsheets, Blood in Pee risk assessment tool

What did it feel like?

• We carried out a short online survey to find out

– how well informed people were about campaigns

– the impact people felt the campaigns had on services

• To inform delivery of similar work in the future.

• Online survey developed with support of Department of Health’s BCOC central team and Cancer Research UK

• It was sent to 606 people. 108 (approx. 18%) responded

– Acute Trust Cancer Managers, Urology NSSG including urology nurses. It was also sent to GP practices (Managers)

A secondary care perspective

• What we did to prepare for the campaign

• The impact of the campaign

• Planning for the national campaign

What happens after referral?

• The haematuria clinic

– Consultation

– Examination

– Urine tests

– Flexible cystoscopy

– Imaging – USS/CT scan

How did we prepare?

• Expected increase in workload• Estimated from previous campaigns

• Increased haematuria clinic provision• In advance or response to increased demand

• Unclear how many additional diagnoses

expected• Provision of elective surgery less predictable

A secondary care perspective

- the impact

57

5

64

8

78

1

78

0

68

5

78

7

72

0

76

9

75

8

83

9

82

0

83

2

74

7

77

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89

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9

71

5

89

7

93

8

85

4

88

9

10

25

11

14

10

22

10

60

0

200

400

600

800

1000

1200

January February March April May June July August September October November December

NECN - Two Week Wait Referrals - Urology

2011 2012 2013

48

75

55

94

65

30

60

43

58

90

66

45

61

30

64

20

64

04

63

46

66

76

59

07

58

95

64

75

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27

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78

53

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72

33

69

36

62

89

79

20

74

67

62

48

6550

68

02

72

80

71

77

77

86

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

January February March April May June July August September October November December

NECN - Two Week Wait Referrals - ALL

2011 2012 2013

A secondary care perspective

- the impact

0

50

100

150

200

250

300

350

02

-Jan

09

-Jan

16

-Jan

23

-Jan

30

-Jan

06

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13

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26

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NECN - Two Week Wait Referrals - UrologyJanuary to December - by Week

2012 2011 2013

Observations

• Initial lag period with most notable increases from March onwards

• Perception that increased referral of Visible Haematuria (public awareness) Non-Visible Haematuria (Health Care Professional awareness)

• Pilot coincided with difficult period for bed occupancy (elective capacity affected)

• Key data – how did increased referrals translate into increased diagnoses?

Finally, October

• Working with national partners to share

our learning

• Informing key local stakeholders

• Engaging with new partners and

developing relationships

Intelligence Report

Likely impact of the 2013 national Blood in Pee

awareness campaign on the NHS

Dr David Halsall, Laura Bown and Katrina Walker

Outcomes Analytical Team

NHS England

Presented by John Osmond, DH

From the experience of the regional pilot, we are going to predict

what might happen during the rollout of the national campaign

City Hospitals

Sunderland NHS

Foundation Trust

North Tees and

Hartlepool NHS

Foundation Trust

South Tees

Hospitals NHS

Foundation Trust

County Durham and

Darlington NHS

Foundation Trust

Gateshead Health

NHS Foundation

Trust

Newcastle upon

Tyne Hospitals

NHS Foundation

Trust

Northumbria

Healthcare NHS

Foundation Trust

The regional campaign was held in the North East from January to March

of this year

Incidence of kidney cancer has been rising over the past 10

years, particularly in the 20-64 age group, whereas the incidence

of bladder cancer has been decreasing over the past 10

years, except in the older age group

Source: NHS England Analysis of ONS Cancer Registrations data

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

0-19 20-64 65-74 75+ 0-19 20-64 65-74 75+

Bladder Kidney

Incidence of Bladder and Kidney Cancer in 2000 and 2010, projected to 2020

2000

2010

2020

0

100

200

300

400

500

600

700

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Emergency Admissions for Bladder and Kidney Cancer in England

2012 13 2011 12 2010 11 2009 10

Emergency admissions for kidney and bladder cancer have

been falling year on year

Source: NHS England Analysis of HES (2012/13 results preliminary)

0

10

20

30

40

50

60

70

80

90

100

Surv

ival

Pe

rce

nta

ge

One and Five Year Survival for Bladder Cancer

1 year survival 5 year survival

Survival for kidney and bladder cancer is generally

on the increase, with survival in kidney cancer

matching survival for bladder cancer in recent years

Source: NHS England Analysis of ONS data

The fall in survival for bladder

cancer is likely due to the

increasing proportion of

bladder tumours now being

coded as uncertain

0

10

20

30

40

50

60

70

80

90

100

Surv

ival

Pe

rce

nta

ge

One and Five Year Survival for Kidney Cancer

1 year survival 5 year survival

9,170 new bladder cancer cases

8,500 new kidney cancer cases

if 1.8%/year historical growth per year continues

GP

62,000 direct access

Kidney or Bladder

Ultrasounds

28,500 direct access

Chest/Abdomen

CT scans

2WW Other Emergency

2,830 (32%) 2,120 (24%) 1,600 (18%)New cases*

Bladder

Kidney

Other Outpatient

1,150 (13%)

1,640 (20%) 2,130 (26%) 2,050 (25%) 1,480 (18%)

What impact will the Be Clear on Cancer campaign have on

bladder and kidney cancer routes to diagnosis? Is this what

we would expect to see in 2013?

290,000 Cystoscopies

Source: NHS England Analysis of data from ONS, DiD, DM01 and *NCIN routes to diagnosis 2008

9,170 new bladder cancer cases

8,500 new kidney cancer cases

if 1.8%/year historical growth per year continues

GP

2WW Other Emergency Other Outpatient

How many lives would we expect to save if we switched half of

emergency admissions to 2WW?

2WW GP - Other Emergency Other Outpatient

1 year survival – Bladder Cancer 83% 79% 36% 77%

1 year survival – Kidney Cancer 79% 80% 38% 82%

Number of patients surviving 1 year now 3,650 3,375 1,355 2,100

Number of patients surviving 1 year after

cutting emergency admissions by half5,115 3,375 680 2,100

Difference 1465 - -675 -

790 lives could possibly be saved if emergency admissions are halved

A rise in ultrasounds in January, February and March and a rise in GP

referred CT scans in January and February coincided with the regional

Blood in Pee pilot – but is this significant?

Source: NHS England analysis of DiD dataset

Regional Blood

in Pee Pilot

Regional Blood

in Pee Pilot

Each trust can expect to see an extra 6 ultrasound referrals and between 6-12 extra CT

scan referrals per week during the campaign – however, it is likely that not all of these will

be for suspected urological cancer

Source: NHS England analysis of DM01 dataset

Each trust should expect to

see on average an extra 5

cystoscopy referrals per week

over the campaign period

Cystoscopy activity peaked in April after the campaign

finished, although this was within normal variation. Waiting lists

for the procedure increased slightly during the campaign

but, again, this was within the normal limits.

Despite concern over trusts not being able to cope with an

increased number of patients, the waiting times don’t seem

to have changed significantly relative to the past 2 years

Source: NHS England Analysis of DM01 dataset

The increase in 2WW referrals during the campaign period looks

consistent with the effect that we would have expected

Source: NHS England Analysis of Cancer Waiting Times database

Each trust should expect

on average 6 extra

referrals per week during

the campaign period

During the months immediately after the campaign we saw an

increase in the number of patients being treated for urological

cancer after being referred through the 2WW pathway

Source: NHS England Analysis of Cancer Waiting Times database

Looking at secondary care, there has been an increase in the

number of patients having a diagnostic endoscopy of the bladder

who have received a cancer diagnosis relative to trusts not

covered by the regional pilot

Source: NHS England Analysis of HES (2012/13 results preliminary)

We haven’t yet seen an increase in the number of operations

relating to bladder and kidney cancer although this is likely to be

due to data lags

Source: NHS England Analysis of HES (2012/13 results preliminary)

• In the pilot area, a 25% increase in 2WW referrals was seen over

the short term. On average, each trust should expect to see an

expect to see an extra six 2WW referrals per week.

• The consequence of this increased number of referrals did

not, however, adversely affect diagnostic waiting times. Each

trust should expect, on average, an extra 5 cystoscopy

referrals, 6 ultrasound referrals and between 6-12 CT scan

referrals each week during the campaign period.

• Given the relatively small proportion of bladder and kidney

cancers that are diagnosed via the 2WW pathway, there are

potentially significant gains to be made if patients are diverted

from the emergency route to the 2WW route, contributing to the

overall aim of saving 5,000 cancer lives.

Summary: anticipated impact of Blood in Pee campaign

Refreshments break

Sean Duffy

National Clinical Director for Cancer

NHS England

Plans for early 2014 campaigns

February – March 2014

• National - Breast cancer in women over 70

• Regional pilots:

– Oesophago-gastric

– Ovarian

Breast 70+ key message

Oesophago-gastric key messages

Ovarian key message

Aligning national and local

delivery – new

accountabilities, organisations

and ways of working.

A panel with an opportunity to

ask questions, chaired by Sean

Duffy

Summary of next steps

Sean Duffy, National Clinical

Director for Cancer, NHS England