‘Blood in pee’ campaign: Information for GPs and other healthcare professionals

In England around 17,450 people are diagnosed with bladder or kidney cancers each year [1], and approximately 8000 die as a result. [2]

In 2013, 3,340 bladder and kidney cancers were diagnosed through an emergency presentation [3]. When people are diagnosed at this stage, the majority are likely to be in advanced disease, when treatment is less successful and survival is much poorer. 

Outcomes in England are worse than those in some European countries; it has been estimated that around 1,000 deaths from bladder and kidney cancers could be avoided each year if five-year survival rates matched the best in Europe.

References

1. Incidence and Mortality data supplied by Public Health England based on the NCRS dataset (2009-2013)

2. Deaths data supplied by Public Health England based on the ONS mortality data,2012-2016 

3. Data supplied by Public Health England using Routes to Diagnosis 2006-2013

Visible haematuria is the most common symptom of bladder [1] and kidney [2] cancers. However, when asked to recall signs or symptoms of cancer via a Cancer Awareness Measure, only 16% of the public mentioned ‘blood in pee’ [3]. This indicates a need to raise public awareness of the significance of this symptom.

There are varying reports on the proportion of bladder [4] and kidney [5] cases likely to present with visible haematuria, which you can read more about in the references provided below.

There are other symptoms of these diseases, yet the most recent evidence concludes that visible haematuria is the most common symptom and a powerful predictor of these cancers in primary care.

The Be Clear on Cancer ‘blood in pee’ campaign leaflet and NHS Choices (link is external) (the public-facing website that publicises the campaign messages) highlight the following key symptoms:

Learn about bladder cancer symptoms (link is external)

• Haematuria
• Cystitis (a urinary tract infection) that is difficult to treat or comes back quickly after treatment
• Pain when peeing

Learn about kidney cancer symptoms (link is external)

• Haematuria
• A pain in the side, below the ribs, that doesn’t go away
• Weight loss

Order free campaign materials through the Campaign Resource Centre (link is external)

Find out more about bladder and kidney cancer symptoms (link is external)

References

1. Clinical features of bladder cancer in primary care. Shephard EA, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Br J Gen  Pract. 2012 Sep; 62(602):e598-604

2. Clinical features of kidney cancer in primary care:  a case-control study using primary care records. Shephard E, Neal R, Rose P,  Walter F, Hamilton WT. Br J Gen Pract. 2013 Apr; 63(609):e250-5

3. Published Cancer Awareness Measure (2014)

4. Wallace, DM, et al. Delay and survival in bladder cancer. BJU Int. 2002 Jun; 89(9): p868-78

5. Tobias J & Hochhauser, D. Cancer and its management (6th edition). 2010: Blackwell publishing

Blood in urine is a common symptom in bladder and kidney cancers, but it can be a symptom of other cancers, such as prostate cancer.

The strongest risk factor for prostate cancer is age, with very low risk in men under the age of 50. Family history and ethnicity are also established risk factors for prostate cancer. The latest England-wide data [1] show that black men have a higher risk of prostate cancer than white men, while men of Asian and Chinese ethnicity have a lower risk than white men. [2]

References

1. Public Health England and Cancer Research UK. Cancer Incidence and Survival by Major Ethnic Group, England 2002-2006 (PDF 2.6MB). 2009. http://www.ncin.org.uk/view.aspx?rid=75 (link is external)

2. In this report the ‘Black’ ethnic group includes Caribbean, African and ‘Other Black’; the ‘White’ ethnic group includes White British, White Irish and ‘Other White’; and the ‘Asian’ ethnic group includes Indian, Pakistani, Bangladeshi and ‘Other Asian’

The aim of the Be Clear on Cancer campaign is to provide clear information on a specific cancer symptom with a motivating call to action, encouraging people to present to a GP with suspected symptoms.

When the Be Clear on Cancer ‘blood in pee’ message and materials were tested during development for the first national ‘blood in pee’ campaign (autumn 2013), GPs advised that descriptions of what  blood in urine might look like, such as different colours, could be confusing for the public, or might cause anxiety.

This was echoed by the men and women involved in the testing, who preferred a straight-forward, symptom-led message and a specific call to action: If you notice blood in your pee, even if it’s ‘just the once’, tell your doctor.

Be Clear on Cancer campaigns aim to use everyday language to help people feel more comfortable when discussing symptoms with their GP. During testing, the word ‘pee’ was universally accepted.

Research tells us that men and women may respond differently to finding blood in their urine. Men might ignore the symptom, especially if it only happens once, and we are keen to encourage women not to pass the symptom off as a urinary tract infection (UTI). It’s estimated that half of all women in the UK will have a UTI at least once in their life, but if they have blood in their urine, they should see their GP.

View Male advert (link is external)

View Female advert (link is external)

Men and women over the age of 50 from lower socio-economic groups, and the key people that influence them, such as their friends and family. Although the adverts do not mention age, communication channels and activities used to promote the key campaign messages will primarily be targeted at reaching an over 50s audience.

Bladder and kidney cancer affects both men and women, although they are more common in men. Most people diagnosed with bladder or kidney cancer are aged 50 and over:

• Around 97% (8,600 cases) of people diagnosed with bladder cancer each year  are over the age of 50. [1]
• People aged 50 and over make up 90% of all kidney cancer diagnoses in England; this equates to around 7,800 cases each year. [1]

Other risk factors include:

• Smokers have a much higher risk of developing bladder and kidney cancer, with nearly four in 10 bladder cancers, and one in four kidney cancers estimated to be caused by smoking [2]
• Being overweight or obese accounts for one in four cases of kidney cancer [2]
• Around one in 40 cases can be linked to exposure to radiation for medical reasons e.g. radiotherapy. This risk should be taken in context of the obvious benefits of medical imaging and the treatments which use radiation [2]
• Exposure to, or working with, certain chemicals. It has been estimated that in the UK around 7% of bladder cancer cases in men and 2% in  women are linked to occupational exposures [3, 4]
• Some other medical conditions, such as kidney failure
• Having a family history of certain cancers.

Incidence of kidney cancer has risen by one third since 2002 [1]. While it is thought that some of this is due to better detection methods, such as CT scans and ultrasound, part of the increase is likely to be due to lifestyle factors. [5, 6]

Cancer Research UK has more information on the risk factors for bladder and kidney cancer, including the risks associated with certain occupational exposures and various medical conditions and their treatments.

References

1. Incidence and Mortality data supplied by Public Health England based on the NCRS dataset (2009-2013)

2. Parkin DM, Boyd L, Walker LC.  (2011) the fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer; 105 Suppl  2:S77-81

3. Parkin DM. Cancers attributable to occupational exposures in the UK in 2010. Br J Cancer 2011; 105(S2):S70-S72; doi: 10.1038/bjc.2011.487

4. Rushton L, Bagga S, Bevan R, et al. Occupation and cancer in Britain. Br J Cancer 2010; 102:1428-1437

5. Chow WH, et al rising incidence of renal cell cancer in the United States. JAMA, 1999. 281(17): p.  1628-31

6. Tate R, et al.Increased incidence of renal parenchymal carcinoma in the Northern and Yorkshire region of England, 1978-1997. European Journal of Cancer, 2003. 39: 961-967

We know from qualitative research and anecdotal information on existing cancer awareness projects that including messages about unhealthy lifestyles in the main advertising materials can act as a barrier to early presentation. Using smoking as an example (which we know to be a risk factor), by including a stop smoking message, smokers may feel they will be chastised by their GP, and therefore delay going to see them promptly. Conversely, non-smokers may perceive the information as not relevant to them, ignoring a symptom as a result.

In all Be Clear on Cancer communications we aim to avoid coming across as negative or nagging, we need to be supportive and encourage earlier presentation.

For these reasons, risk factors and healthy lifestyle messages are restricted to the Be Clear on Cancer ‘blood in pee’ leaflet only.

Browse ‘blood in pee’ campaign materials

After the 2016 national campaign, Luke Hounsome reported the analysis indicating that the campaign was a success in raising awareness of the key messages. Further data is currently being reviewed but this video summary is still relevant.

Early diagnosis of cancer is a very high priority for the Government. Improving Outcomes: A Strategy for Cancer (link is external), which was published in January 2011, set out the ambition to prevent 5,000 deaths from cancer per year by 2014/15 to bring survival rates in England up to the average for Europe. Be Clear on Cancer is one of a number of actions to support the NHS to  improve survival rates, by tackling late diagnosis through raising awareness of  symptoms and encouraging more people to see their GP earlier.

Patients urgently referred for suspected cancer by their GP still have a right to be seen within two weeks under the NHS Constitution. In Q2 2015-16, 93.5% of patients in England urgently referred for suspected cancer by their GP were seen by a specialist within the two-week period. For suspected urological malignancies (excluding testicular), 94.4% were seen within two weeks in England. 

References

1. Provider based Cancer Waiting Times: https://www.england.nhs.uk/statistics/provider-based-cancer-waiting-times-for-q2-2015-16/ (link is external)

The NICE referral guidelines recommend making an urgent two-week wait (2WW) referral for bladder and kidney cancers, if a patient is aged 45 and over and has:

• unexplained visible haematuria without urinary tract infection (UTI), or
• visible haematuria that persists or recurs after successful treatment of UTI.

And, for bladder cancer only, if:

• a patient is aged 60 and over and has unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

The guidelines also recommend considering a non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.

If you are a healthcare professional and have concerns about a patient, encourage them to make an appointment with their GP without delay. It’s not normal to have blood in your urine, whatever the reason, so it needs checking out.

Note, research has found that women are over twice as likely as men to see their GP three or more times before being referred for diagnostic tests for bladder and kidney cancers, even when they have blood in their urine. [1]

References

1. Lyratzopouloa G, Neal RD, Barbiere JM, Robin GR, Abel GA. Variation in number of general practitioner consultations before hospital  referral for cancer: findings from the 2010 National Cancer Patient Experience  Survey in England. The Lancet Oncology 2012; 13: 353-365

The Be Clear on Cancer materials promote the potential benefits of early presentation and reassure people that the symptom is unlikely to be cancer, but that it’s best to get it checked. The tone is balanced, practical and reassuring.

GPs interviewed as part of initial campaign testing felt that, in the case of blood in urine, they would prefer their patients to present at any sign of this symptom, regardless of duration.

There was overwhelming support from the public following the first national Be Clear on Cancer bowel cancer campaign in January 2012, with 92% of the public and 89% of GPs, saying it is important for the Government to communicate these kinds of messages. [1], and this has remained high for subsequent campaigns.

References

1. Sourced from a TNS BMRB awareness survey commissioned by Public Health England (2012)

As a GP, you can:

1. Be prepared. It is difficult to predict the exact demand each campaign will have on NHS services, but think back to the last ‘blood in pee’ campaign and note the impact it had in your local area. Consider the number of requests for appointments, diagnostic tests and urgent 2WW referrals that your practice had during and after previous Be Clear on Cancer advertising.

• A moderate increase in GP visits is expected during, and eight weeks following the campaign. This estimate is based on results from the first national ‘blood in pee’ campaign, which ran from October to November 2013, and saw an 18.5% increase in weekly GP visits during the campaign, equating to an additional 0.15 visits per GP practice, per week (analysis of data from a sample of 265 GP practices) [1]. The increases were highest around the beginning and end of the campaign. A 29% increase in GP visits was also observed for eight weeks following the campaign, with the largest increase at three weeks, post-campaign. Continue to use your clinical judgement and refer for investigation as appropriate.
• However, the number of new diagnoses of these two cancer types per GP is typically small - put into perspective, a GP will see a  bladder or kidney cancer case once every 29 months [2].

It is worth remembering, approximately 1/5 of bladder and kidney cancer cases each year are diagnosed via emergency presentation [3], which can have a detrimental impact on a patient’s chances of successful treatment. Only a small proportion of those diagnosed are currently referred via the two-week wait referral system (30% of bladder cancers and 19% of kidney cancers) [4], so there is a clear role for GPs in improving the early diagnosis of these cancers.

2. Talk about the campaign. It may prompt people who’ve previously ignored blood in their urine to come and see you. The primary target audience of over 50s in particular, may be embarrassed, not find it easy to communicate their symptoms, be worried about wasting your time, or fear painful or prolonged treatment if it is cancer.

3. Make the most of available support. There is a wealth of information to support you when making urgent referral decisions.

• Review NICE guidelines for suspected cancer: If your patient is aged 45 and over; has unexplained visible blood in their urine without UTI; or has blood in urine that persists or recurs after successful treatment of UTI; or for bladder cancer specifically, is aged 60 and over and has unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test, NICE guidelines recommend making an urgent referral via two-week wait (2WW).
• Review the British Medical Journal learning online education tool: ‘Tackling late diagnosis of cancer’
• Review guidance on safety netting to improve early cancer diagnosis in primary care

4. Work with your GP lead. The NHS and local authorities are encouraged to work together in planning for campaigns. Your CCG may have a GP cancer lead, who can give you further information relating to your area. Many GPs have found it useful to work more closely with secondary care clinicians to make improvements in the patient pathway too.

If you have any queries, or to source contact details for the GP lead in your area, email partnerships@phe.gov.uk with ‘GP lead query’ in the subject line.

5. Encourage your colleagues to support the campaign. Practice nurses, receptionists and practice managers all have an important role to play. Make sure everyone is aware that the national ‘blood in pee’ campaign will run and encourage them to visit this site, so they can support the ‘blood in pee’ campaign and can prepare for more patients coming to your practice as a result of the campaign.

As the gatekeepers to investigation and referral, you occupy a pivotal role in a patient’s pathway to early diagnosis. With your support, we aim to improve patient outcomes for bladder and kidney cancer, by detecting more cases earlier.

Review NICE guidelines for suspected cancer (link is external)

Review British Medical Journal online education tool ‘Tackling late diagnosis of cancer’ (link is external)

Review guidance on safety netting

References

1. Data analysis supplied by Public Health England

2. http://www.hscic.gov.uk/catalogue/PUB10394/nhs-staf-2002-2012-medi-dent-tab.xlsx (link is external)

3. Incidence and Mortality data supplied by Public Health England based on the NCRS dataset (2009-2013)

4. http://www.ncin.org.uk/publications/routes_to_diagnosis (link is external)

Since pharmacies are often the first port of call for people suffering with urinary infections, you have an opportunity to be vigilant for patients who may be showing symptoms of bladder or kidney cancer and encourage them to see their doctor.

As a pharmacist, you can:

1. Make it part of your day. During your regular consultations, such as medicine-use reviews, or in conversations with customers, be aware that people might want to talk about the campaign. It may prompt those who have previously ignored their symptoms or discounted them as a one-off, to do something. People may come to your pharmacy looking for over the counter (OTC) medicines or advice for a symptom that could be a sign of bladder or kidney cancer.

2. Give permission. We know from research with this target audience that they often seek permission to visit their GP. People try to gauge if their symptoms are severe enough, others think the GP will not want to see them or it will be a waste of their doctor’s time. Be confident and urge any customers that mention having blood in their urine to visit their GP, whether it’s just the once or as part of a recurring urinary tract infection (UTI). If you feel comfortable, tell the customer to mention that their pharmacist or a member of the pharmacy team has sent them. It may be the push they need to get themselves checked out.

GPs will be following NICE guidelines, which recommend an urgent referral if: a patient is aged 45 and over and has unexplained visible blood in their urine without UTI; or has blood in urine that persists or recurs after successful treatment of UTI; or for bladder cancer specifically is aged 60 and over and has unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

3. Promote the campaign. Put up posters in your pharmacy and ensure you have some ‘blood in pee’ campaign leaflets readily available for customers.

4. Talk about it. Tell your friends, family, customers and colleagues about the Be Clear on Cancer ‘blood in pee’ campaign. We need to talk about cancer and make it less of a taboo subject. This campaign gives us all the chance to do that.

If your customer/patient complains of blood in their urine, even if it’s just the once, or is using an OTC medicine to treat repeated UTIs, urge them to visit their doctor.

Order free campaign materials through the Campaign Resource Centre (link is external)

As a practice manager, you can:

1. Brief colleagues: Your whole team needs to be aware of this campaign and why it’s running, tell your patient groups too. Briefing sheets for key groups will be available, in the meantime encourage people to review the autumn 2016 campaign materials. Encourage everyone to view the adverts on NHS Choices (link is external) to understand what your patients will be seeing during the campaign.

Inform receptionists there may be an increase in the number of patients requesting appointments, it is essential patients are welcomed when they seek help. From research we know that making a GP appointment is a significant barrier to many people, for various reasons, for example, they don’t want to waste the GP’s time or think they won’t be able to get an appointment easily.

2. Prepare for the campaign. It’s difficult to predict exactly how many more patients will come through your doors as a result of the campaign. It is anticipated that this will be manageable. Results from the regional ‘blood in pee’ pilot showed an overall increase in the number of patients presenting with blood in urine during the campaign period:

• Across 265 GP practices this equated to an additional 0.15 visits per practice, per week [1].

We recommend you review the uplift in GP appointments experienced during the previous national ‘blood in pee’ campaigns, as uplift is likely to have varied across the country. This will help you to plan for the campaign.

Be prepared for an increase in the number of people sent for diagnostic tests and referred via the urgent two-week wait (2WW) referral system too.

• The second national ‘blood in pee’ campaign (autumn 2014) saw a statistically significant increase of 34% in the number of 2WW referrals for suspected urological cancer, during the campaign period [1].

You may not notice the impact of the campaign straight away, during the regional ‘blood in pee’ campaign, the North of England Cancer Network team noted it caused a steady increase in demand, rather than a sudden spike, and this lasted up to three months after the campaign had finished.

3. Promote the new campaign. Display posters and leaflets, and encourage your colleagues to talk about the ‘blood in pee’ campaign. TV advertising is incredibly powerful at raising awareness of symptoms, but it is often face-to-face discussions that influence behaviour change. Talking might prompt someone to make an appointment or open up about their symptoms.

Watch TV ads and listen to radio ads on NHS Choices (link is external)

Order free campaign materials through the Campaign Resource Centre (link is external)

References

1. Data analysis supplied by Public Health England

If you are a member of the pharmacy team you can:

1. Be confident and follow your normal protocol. If you are concerned about a customer and feel uncomfortable talking about cancer, ask your pharmacist to speak to them. Or, if that isn’t possible, urge the customer to go to see their GP and get their symptoms checked out. It may be nothing serious, it might be an infection or kidney or bladder stones, but may still need treating. If it is cancer, it’s better for it to be detected early.

Opening conversations about cancer can be difficult. A Cancer Research UK Nurse who specialises in communicating about cancer advises:

‘It’s important for pharmacy staff to feel confident and to try and make cancer a normal part of conversation. Practise and find phrases that you are comfortable with. For example, if you wanted to mention cancer as part of a medicine-use review, talking about it in the same breath as heart disease, stroke and diabetes may make it easier. If you are worried about someone who has repeatedly bought an OTC medicine for a suspected cancer symptom, you could ask:  “What does the doctor say about that?” or “Do you think it might be a good idea to discuss your symptoms with your GP?”’

Order free campaign materials through the Campaign Resource Centre (link is external)

As a nurse, you can:

1. Make every contact count. You are well placed to be vigilant for patients who may have concerns about a symptom of bladder or kidney cancer. The campaign could have prompted people who have ignored symptoms or have had recurring UTIs to talk to you; however they may be afraid, embarrassed, or worried about what might follow if it is cancer.

• If a patient comes to see you about something unrelated, e.g. new patient check or a specialist clinic, or if you are treating patients with a long-term condition, ask if they have any other concerns
• Use these opportunities to discuss healthy lifestyle changes too
• Have campaign leaflets at hand in clinics and when out in the local community

2. Give permission. Our target audience can delay going to see their GP and often seek permission to make an appointment. Where relevant, encourage patients to visit their GP. Suggest they see their GP again if their symptom doesn’t go away. For extra reassurance, tell them to mention that the nurse sent them. It may be the nudge they need to get themselves checked out. Recommend they come back and tell you how they got on.

3. Encourage your colleagues to support the ‘blood in pee’ campaign. Encourage people you work with to watch the TV adverts and listen to the radio ads on NHS Choices (link is external)

• Brief health care assistants about the campaign so they can bear it in mind in their day-to-day work and direct all colleagues to  the relevant briefing sheets available on this site
• Be prepared for more patients mentioning symptoms to you as a result of the campaign.

View guidance on ‘safety netting’ to support you in making sure patients with persistent symptoms continue to be followed up. Reassure patients that if symptoms persist following an initial visit with their GP, they should make a further GP appointment.

Order free campaign materials through the Campaign Resource Centre (link is external)

You can order or download free copies of leaflets, posters and other collateral through the Campaign Resource Centre (CRC) (link is external) or by calling Orderline on: 0300 123 1002.

For all healthcare professionals:

• The public-facing web pages for the Be Clear on Cancer campaigns can be found on NHS Choices. (Link is external)
• A free toolkit developed by Lancashire & South Cumbria Cancer Network (link is external) is free to access and download. It has a dedicated section on bladder cancer.
• Review guidance on safety netting (link is external)

For GPs:

• Review NICE guidance (link is external)
• Review British Medical Journal online education tool (link is external)
• Review the Doctors.net e-learning module to support in the early detection of urological cancers in primary care (link is external)
• Review Doctors.net e-learning module for risk of cancer patients with diabetes that covers urological symptoms (link is external)

If you have any queries, or to source contact details for the GP lead in your area, email partnerships@phe.gov.uk with ‘GP lead query’ in the subject line.

For practice managers and their teams:

• Review the National General Practice Profiles (link is external) with cancer data for individual practices.
• Publich Health England (PHE) also has a Urological Cancer Profile tool (link is external) that allows you to compare incidence and mortality rates for major urological cancers, survival, and  influencing factors, such as deprivation, with other areas in England. You can view this data by local authority, PCT or Cancer Network.
• You can order or download a leaflet that explains Urgent Referrals from Cancer Research UK. These can be used to help patients who have been urgently referred with suspected cancer.

For pharmacists and their teams:

• One source of support that can help you raise the subject of cancer with patients is the British Oncology Pharmacy Association’s E-learning Centre (link is external).

The centre has training for pharmacists and pharmacy team members about raising awareness of cancer in a pharmacy setting, with modules on different cancer types. This is free to access once you have registered on the website.

There are a number of tools and available data detailing local cancer statistics:

• You can find out more about the cancer statistics for your practice, and others in your area, using Public Health England's (PHE) National General Practice Profiles (link is external).
• PHE has a Urological Cancer Profile (link is external) tool that allows you to compare incidence and mortality rates for major urological cancers, survival, and influencing factors, such as deprivation, with other areas in England. You can view this data by local authority, PCT or Cancer Network. It also has a Cancer e-Atlas (link is external) that you can use to view cancer incidence and mortality statistics for the UK more broadly.
• Cancer Research UK has a local cancer statistics tool which allows you to search by your healthcare area and compare statistical information and intelligence about cancer with other Clinical Commissioning Groups (CCG) or former Primary Care Trust areas across the UK. This tool now includes CCG level data for cancer incidence and mortality. You will also find information on early diagnosis, screening and smoking.
• You can compare and benchmark cancer indicators in your local authority area with others in England using data collated from PHE through the Public Health Outcomes Framework Data Tool (link is external). Public Health England (link is external) has also collated various data which can help give you an indicator of lifestyle factors in your area that increase the risk of kidney and bladder cancer, such as smoking and obesity.

The campaign was initially set up as part of the Government’s strategy for improving cancer. This outlined the ambition to prevent 5,000 deaths per year, by 2014/2015, and aimed to bring survival in England up to the average for Europe. In line with the NHS Outcomes Framework, the CCG Outcomes Indicator Set 2015/16 (link is external), continues to highlight cancer survival as a key area for improvement under indicator one: preventing people from dying prematurely.

The Be Clear on Cancer campaigns also form part of the 2015 recommendations of the Independent Cancer Taskforce, Achieving World-Class Cancer Outcomes: A strategy for England 2015-2020. If the ambitions of the strategy are achieved, it is estimated that an additional 30,000 patients per year will be surviving cancer for 10 years or more by 2020. Of these, almost 11,000 will be through earlier diagnosis. This ambition is reflected in the mandate to NHS England for 2016-17.

Be Clear on Cancer is a vital part of the work to drive the earlier diagnosis of cancer.

See the background to the campaign including evaluation results from other campaigns.

For more information, or if you have any queries, please contact partnerships@phe.gov.uk.