Respiratory symptoms awareness campaign: Overview

What is Be Clear on Cancer?

Be Clear on Cancer aims to achieve earlier diagnosis of cancer by raising awareness of the signs and symptoms. The campaigns encourage people with relevant symptoms to see their GP without delay.

When will activity be running?

The campaign ran from 14 July to 16 October 2016. Activity included television, radio, press, online and out-of-home advertising, and face-to-face events in shopping centres.

The respiratory symptoms awareness campaign was the main national Be Clear on Cancer broadcast campaign for 2016. Advertising for the campaign will ran for longer than usual (14 weeks), with the aim of raising the overall impact on diseases such as lung (including cancer and COPD) and heart disease.

Who is the campaign targeting?

The campaign is aimed at men and women aged 50 and over, as well as their key influencers, such as friends and family. People over 50 are most at risk of having an undiagnosed respiratory disease and make up 97% of lung cancer diagnoses.[1]

What is the main message?

The key messages for the public are:

• If you’ve had a cough for three weeks or more, it could be a sign of lung disease, including cancer. Finding it early makes it more treatable. So don’t ignore it, tell your doctor.
• If you get out of breath doing things you used to be able to do, it could be a sign of lung or heart disease, or even cancer. Finding it early makes it more treatable. So don’t ignore it, tell your doctor.

References

1. National Cancer Registration & Analysis Service (NCRAS) data based on 2010-2014 annual

The respiratory symptoms awareness campaign will be the first Be Clear on Cancer campaign to combine awareness raising activity for lung cancer with a range of other conditions, including lung and heart disease. The campaign aims to cover multiple disease areas with its messaging, with the potential to increase its overall impact by tackling a number of different conditions that share similar symptoms. Cough and breathlessness are linked to illnesses that are causing thousands of deaths in the UK each year – and many have complex diagnostic pathways, which lead to delays in diagnosis. Raising symptom awareness among the public and healthcare professionals is one of the ways to make people more aware of this problem. The conditions include (in addition to lung cancer), chronic obstructive pulmonary disease (COPD) and heart disease, including coronary heart disease (CHD). The campaign will particularly focus on the older population (>50), especially those who are from lower socio-economic backgrounds, who tend to have poorer outcomes.

Public Health England has run several lung cancer campaigns across England, including campaigns that have piloted locally, regionally and nationally. In addition to this, a regional breathlessness campaign ran in the east of England in 2015. There have been encouraging results from these activities, however more work is required in order to improve earlier diagnosis of lung diseases, such as lung cancer, COPD and heart disease.  

Older age in lung cancer is a risk factor for emergency presentation – which is linked to advanced stage disease, often leading to significantly poorer outcomes for patients. In addition to this, individuals from more deprived groups are also at an increased risk of presenting as an emergency.[1] Increased diagnosis by primary care can reduce emergency admissions and improve the prognosis for many lung and heart conditions. Be Clear on Cancer aims to encourage more people who are in the target age group of over 50, from lower socio-economic backgrounds, with appropriate symptoms to present earlier. The aim is for these patients to be referred on promptly for investigation.

An estimated 1,300 deaths from lung cancer could be avoided in England each year if survival matched the best in Europe.[2] The poor survival for lung cancer in Britain compared with Europe is thought to be predominantly due to larger numbers of patients being diagnosed with late stage disease, when the cancer is already locally advanced or has spread, therefore excluding them from potentially curative surgery. Early diagnosis is one of the key ways to improve survival, alongside improved access to diagnostics and optimal treatment.

References

1. Mitchell et al, Risk factors for emergency presentation with lung and colorectal cancers: a systematic review 2015. BMJ Open 2015;5:e006965 doi:10.1136/bmjopen-2014-006965
2. Source: British Journal of Cancer (2009) 101, S115–S124.  doi:10.1038/sj.bjc.6605401  http://www.nature.com/bjc/journal/v101/n2s/full/6605401a.html

For lung diseases such as lung cancer, each year:

• Around 36,500 people in England are diagnosed (19,900 men, and 16,600 women)[1]
• Approximately 28,400 die from lung cancer in England (15,700 men, and 12,600 women)[1]
• In 2013, around 12,700 (35%) lung cancer cases were diagnosed via an emergency presentation,[2] which is often indicative of advanced stage disease when curative treatment is no longer possible
• Most lung cancers are diagnosed at a late stage (74%), compared to 25% at an early stage[1]
• One-year relative survival for those diagnosed via emergency presentation is low at 13%, compared to 43% for those diagnosed via the two week referral pathway[3]
• The earlier lung cancer is diagnosed, the more treatable it is. 83% (81% of men and 85% of women) diagnosed at the earliest stage (Stage I) will live for a year after diagnosis. At a late stage (Stage IV), this drops to 17% (15% of men and 19% of women)[4]

View more lung cancer statistics on Cancer Research UK's cancer statistics pages. 

In addition to lung cancer, figures for chronic obstructive pulmonary disease (COPD) show:

• An estimated one million people in England are diagnosed with COPD, however it is estimated that a further one million people are living with undiagnosed COPD[5]
• 24,000 people die of COPD in England each year (approximately half men and half women)[6]

Heart disease statistics in England show:

• Around 1.8 million are diagnosed with coronary heart disease in England (CHD),[7] an estimated 600,000 people living with coronary heart disease in England who haven’t been diagnosed[8]
• Over 70,000 people died from heart disease in 2014 (figure includes coronary heart disease (CHD, 56,634 deaths in 2014) and ‘other heart diseases’)[9]
• Coronary heart disease is the single biggest cause of death in England, accounting for around 12% of all deaths[10]

References

1. Incidence and mortality data supplied by NCRAS 2016, based on the annual average for 2010-2014
2. Incidence and mortality data supplied by NCRAS 2016, these data are based on a single year (2013)
3. Routes to Diagnosis data http://www.ncin.org.uk/publications/routes_to_diagnosis
4. Office for National Statistics (2016). Cancer survival by stage at diagnosis for England (experimental statistics). Access via: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/cancersurvivalbystageatdiagnosisforenglandexperimentalstatistics/adultsdiagnosed20122013and2014andfollowedupto2015
5. Data calculated by PHE Knowledge and Intelligence Team East based on 2014-15 Quality and Outcomes Framework (QOF) data and  2011 Modelled disease estimates http://www.hscic.gov.uk/catalogue/PUB18887. 2014-15 Quality and Outcomes Framework (QOF) data indicate that 1,034,578 people have been diagnosed with COPD. Modelled disease estimates from 2011 indicate that diagnosed COPD is around 57% of actual prevalence. However these estimates have considerable margin of error and given this uncertainty the gap between the number of people on disease registers and predicted numbers could be as high as 1 million.
6. http://www.opm.co.uk/wp-content/uploads/2016/04/Breathlessness-Report-6April.pdf
7. Quality and Outcomes Framework (QOF) for April 2014 - March 2015, England. Health and Social Care Information Centre http://www.hscic.gov.uk/catalogue/PUB18887
8. Provided by PHE National Cardiovascular Intelligence Unit based on 2011 and 2014 estimated prevalence of Coronary Heart Disease
9. British Heart Foundation (2015), Cardiovascular Disease Statistics. Access via: https://www.bhf.org.uk/publications/statistics/cvd-stats-2015
10. http://webarchive.nationalarchives.gov.uk/20160105160709  http:www.ons.gov.uk/ons/rel/vsob/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2014/sty-what-we-die-from.html

More than 90% of patients with lung cancer are symptomatic at diagnosis, with cough being the most common presenting symptom.[1] Breathlessness is a common symptom of COPD, heart disease and a range of other conditions.[2] The campaign will combine lung cancer and breathlessness, with the aim of encouraging more people with these symptoms to visit their GP earlier. For all of these diseases, finding them sooner will make treating them successfully more likely, which helps to prolong survival.

Patients who are most at risk of these conditions might not interpret their initial symptoms as serious, and may attribute them to ageing, lifestyle, smoking habits or other co-morbidities.[3] In the UK particularly, cancer awareness and beliefs differ to those of our European counterparts, which may contribute to later presentation and therefore a delayed diagnosis.[4] 

Complexity in diagnosis

GPs often face difficulties when evaluating new or evolving symptoms. One-third of lung cancer patients see their GP three or more times before a referral is made, compared to breast cancer where only 3% of patients experience this.[5] The harm in missing a diagnosis can add significant complications to a patient, including an increased risk of mortality. A study has also found that the length of the diagnostic interval affects mortality negatively, indicating that there is a need for earlier detection and prompter investigations.[6] In addition to this, patients with lower socio-economic status, elderly patients and patients with co-morbidities, tend to have longer diagnostic intervals.[7]

Missed opportunities to diagnose earlier

Opportunities to diagnose COPD earlier are also being missed, as GPs and secondary care clinicians are failing to refer patients with lower respiratory symptoms for further investigations, and patients are failing to recognise the significance of symptoms sooner.[8] One particular study found that 85% of patients consulted in primary care 5 years prior to a COPD diagnosis, which confirms that opportunities for the earlier diagnosis of COPD existed long before a diagnosis was made.[8] As decline in lung function seems to be more significant in the early stages of COPD, diagnosing it earlier is important in order to improve patient outcomes. Heart failure, a condition of heart disease is also poorly identified in primary care, with its symptoms often being mistaken for respiratory conditions, such as COPD.[9]

Many people who develop breathlessness as a symptom delay seeking medical help, as they dismiss their symptoms as ‘just a cough’ or don’t warrant the symptoms to any serious underlying illness. There are many complexities in the path to diagnosis, and delays may occur with presentations complicated by co-morbidities, false negative diagnostic tests and delayed referrals.[10] There is also a risk that patients will see multiple teams in a disjointed way, leading to uncoordinated care. It is increasingly important that both doctors and patients are aware of the significance of the symptoms, as well as the importance of being diagnosed early.

References

1. Source: Beckles M A et al; Initial Evaluation of the Patient with Lung Cancer; Chest.  2003; 123(1_suppl):97S-104S. doi:10.1378/chest.123.1_suppl.97S
2. http://www.nhs.uk/Conditions/shortness-of-breath/Pages/Introduction.aspx
3. Brindle L, Pope C, Corner J, Leydon G, Banerjee A (2012) Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study. BMJ Open 2: e001977
4. Forbes LJ, Simon AE, Warburton F, Boniface D, Brain KE, Dessaix A, …, Wardle J International Cancer Benchmarking Partnership Module 2 Working Group (2013) Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? Br J Cancer 108: 292–300
5. Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP (2013) Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers. Br J Cancer 108: 686–690
6. Torring et al, Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care. Eur J Cancer. 2013 Jun;49(9):2187-98. doi: 10.1016/j.ejca.2013.01.025. Epub 2013 Feb 27.
7. Guldbrandt L M et al. The role of general practice in routes to diagnosis of lung cancer in Denmark: a population-based study of general practice involvement, diagnostic activity and diagnostic intervals. BMC Health Services Research201515:21 DOI: 10.1186/s12913-014-0656-4
8. Rupert C M Jones, MDa, Prof David Price, MDb, c, , , Dermot Ryan, MDd, e, Erika J Sims, PhDc, f, Julie von Ziegenweidtc, Laurence Mascarenhas, MScc, g, …, Prof Eric D Bateman (2014) Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort, The Lancet Respiratory Medicine, Volume 2, Issue 4, April 2014, Pages 267–276
9. Cardiovascular Disease Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/217118/9387-2900853-CVD-Outcomes_web1.pdf
10. Mitchell ED, Rubin G, Macleod U (2013) Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports. Br J Gen Pract 63: e37–e46.

Lung cancer

Lung cancer is more common among the older population, with 97% of all lung cancer cases diagnosed in people over 50.[1]

Other risk factors for lung cancer include:[2]

• Smoking is the main avoidable risk factor for lung cancer, accounting for nearly 9 out of 10 cases diagnosed
• More than 1 in 10 cases are linked to occupational exposure (primarily in men) occurring decades ago before these carcinogens were banned (e.g. asbestos)
• Around 1 in 20 cases can be linked to exposure to radiation for medical reasons e.g. radiotherapy. However, this risk should be taken in context of the obvious benefits of medical imaging and treatments which use radiation
• Just under 1 in 10 cases are accounted for by deficiency of fruit and vegetables in one’s diet.

Chronic Obstructive Pulmonary Disease

The condition usually affects people over the age of 35. In addition to older age, other risk factors include:[3]

• Smoking is a big lifestyle risk factor for COPD. It is thought to be responsible for around 90% of cases and 25% of smokers develop COPD
• Passive smoking
• Fumes and dust
• Air pollution
• Genetic tendency – there is a rare genetic tendency to develop COPD called alpha-1-1antitrypsin deficiency. However, this only effects about 1% of the population. People who have this deficiency usually develop COPD at a younger age, often under 35.

Heart disease

Heart disease usually affects people of older age, it includes a number of conditions including coronary heart disease, heart failure and heart attack. There are a number of factors that increase the risk of conditions such as heart disease, these include:

Medical risk factors include:[4]

• Obesity
• High Blood Pressure
• Diabetes
• High Cholesterol

Behavioural risk factors include:

• Smoking
• Poor diet (e.g. not getting ‘5 a day’ fruit and veg)
• Physical inactivity
• Alcohol consumption

References

1. Incidence and mortality data supplied by NCRAS, based on the annual average for 2010-2014
2. Parkin, D.M., Boyd, L. and Walker, L.C. (2011) the fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer. 105, S77-S81
3. http://www.nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Causes.aspx
4. https://www.bhf.org.uk/heart-health/risk-factors

In England, lung cancer has one of the lowest relative survival of any cancer because around two-thirds of patients are diagnosed at a late stage when curative treatment is not possible. Reducing time to diagnosis leads to more timely treatments, and earlier interventions can extend survival and improve quality of life. Earlier diagnosis of conditions such as COPD, heart disease and lung cancer can make them more treatable and lead to improved outcomes. If doctors can identify the disease earlier, patients are more likely to have successful treatments, a better quality of life, and potentially extend their survival.

Cost savings of earlier diagnosis

Earlier diagnosis of conditions such as COPD, followed by appropriate intervention also has the potential to save the NHS an estimated £1 billion over 10 years.[1] Most people with COPD report breathlessness as being the major disabling symptom that interferes with everyday life. However, both GPs and patients are failing to recognise the significance of the symptoms, therefore delaying appropriate investigations and delaying diagnosis.[2] Patients who suffer from conditions such as COPD often experience exacerbations of symptoms, which in turn accelerate the decay of lung function, leading to quicker disease progression, reduced mobility and an overall poorer quality of life.[2] The earlier a diagnosis is made, the more chance of earlier intervention and therefore successful treatment. Some of the potential co-morbidities associated with the disease progression of COPD include a higher prevalence of conditions such as cardiovascular disease and an increased risk of lung cancer.[2] Some studies suggest that clinical improvements can be realised in patients who are detected at early disease or GOLD stage II (a standard for evaluating COPD symptom severity).[3]

Earlier diagnosis and specialist care has the potential to improve patients’ quality of life, it could also reduce the risk of disease progression and lead to considerable cost savings for the NHS. For example, there is a 50-fold difference in associated costs when comparing mild and very severe COPD, which strongly indicates the need for early diagnosis.[4] These numbers further demonstrate the need to raise awareness of the symptoms of these conditions, and that more work is needed to increase earlier diagnosis of lung and heart disease. 

References:

1. Department of Health. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England (2010) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_113279.pdf
2. Rupert C M Jones, MDa, et al (2014) Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort, The Lancet Respiratory Medicine, Volume 2, Issue 4, April 2014, Pages 267–276
3. Decramer M, Cooper C B, Treatment of COPD: the sooner the better? 2010, Thorax 2010;65:837-841 doi:10.1136/thx.2009.133355
4. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf

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, 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 now form part of the 2015 recommendations of the Independent Cancer Taskforce, Achieving World-Class Cancer Outcomes: A strategy for England 2015-2020. If the strategy’s ambitions 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 previous campaigns.

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