Lung cancer campaign: Information for practice teams

There are around 34,900 [1] new cases of lung cancer in England each year and more than 28,100 [1] people die from it. Although the survival rates are rising slowly, the improvement has been slower than for other common cancers.

Survival rates in Britain are worse than those in some comparative European countries and it was estimated that around *1,300 deaths  from lung cancer could be avoided in England each year if survival rates matched the best in Europe [2]. The poor survival seen with 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 rates, alongside improved access to diagnostics and optimal treatment.

When diagnosed at its earliest stage, around 73% of patients with non small cell lung cancer and around 56% of patients with small cell lung cancer will survive their disease for at least one year after diagnosis [3]. But around 70% of lung cancer patients in England are diagnosed at a late stage [4].

References

1. Office for National Statistics http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/sty-lung-cancer.html

2. British Journal of Cancer (2009) 101, S115–S124.  doi:10.1038/sj.bjc.6605401. Published online 3 December 2009 http://www.nature.com/bjc/journal/v101/n2s/full/6605401a.html

3. Walters, S et al. Lung cancer survival and stage at diagnosis in  Australia, Canada, Denmark, Norway, Sweden and the United Kingdom: a  population-based study, 2004-2007. Thorax 2013.

4. National Lung Cancer Audit, Open data - December http://data.gov.uk/dataset/national-lung-cancer-audit-open-data-december-2012

Adverts ran on TV, radio and in the press from 10 March until the end of April 2014 highlighting the symptom of a persistent three-week cough in line with NICE guidelines.  The campaign’s key message to the public is: ‘Been coughing for three weeks? Tell your doctor.’

As this was a ‘reminder’ campaign, the advertising was less intense than previous lung cancer campaigns. As an indication, for the first national lung cancer campaign which ran from May to July in 2012, 92% of the target audience were likely to have seen the TV advert 12 times. This time, 90% are likely to have seen the advert 10.8 times.

Earlier diagnosis of cancer will not be achieved overnight – it’s important to keep running these campaigns to maintain the public’s awareness of the key symptoms.

You may not notice the effect straight away – but you might see more patients coming into the practice a few weeks into the campaign and even after the campaign has ended.

The first national lung cancer campaign ran in 2012 and results from the campaign period are promising. The results below may also help you to plan for the current activity:

• More people with a persistent cough went to their GP than during the same time in the previous year. When looking at the period May to July 2012 compared with May to July 2011 the number of patients aged 50+  presenting with a persistent cough went up 64% - the equivalent to around 3.1 additional visits per practice per week [1].
• More patients were referred for a chest x-ray by a GP during the first month of the campaign (May 2012) compared to the month before (April 2012) – up 20%[2]
• There was an 8% rise in GP referred CT scans per working day in May 2012 compared with April 2012 [2].

If a patient has a persistent cough that lasts for three weeks or more, then it could be a sign of lung cancer or another serious respiratory condition. We are encouraging GPs to continue to use their clinical judgment and to refer for further tests as appropriate.

References

1. Be Clear on Cancer national lung cancer awareness campaign evaluation –  impact on patients attending GP appointments. Produced by Mayden, February 2014 for NHS IQ

2. NHS England. Diagnostic Imaging Dataset.http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/

More than 90% of patients with lung cancer are symptomatic at diagnosis, with cough being the most common presenting symptom [1]. Weight loss is an indicator of systemic disease (widespread disease that affects a number of organs and tissues, or affects the body as a whole) and is the second most prevalent symptom of lung cancer. Dyspnoea (shortness of breath) develops early in up to 60% of patients and is usually associated with increasing cough and sputum (mucus).

There are other symptoms of lung cancer too, however, when developing the campaign for the general public, it was important to lead with one clear symptom that they would be able to easily understand and identify. The symptom of a  persistent cough for three or more weeks also reflects the NICE guidelines.

The Be Clear on Cancer information leaflet highlights some other symptoms of  lung cancer, as well as the risk factors associated with the disease. Case studies emphasise that smokers shouldn't put a persistent cough or change in cough down to 'just a smoker's cough'.

References

1. 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

Results from previous lung cancer activities indicate that Be Clear on Cancer is changing levels of public awareness and behaviour. There are also early indications that clinical outcomes are improving too. There are some statistically significant findings following the first national lung campaign in 2012:

• There was an increase in unprompted public awareness of a persistent/prolonged cough (from 12% pre-campaign to 15% post-campaign). When given a list of possible symptoms and asked how much of a warning sign of lung cancer each was, a cough for three weeks or more was the symptom that saw the largest increase – up 15 percentage points (18% - 33%) [1]
• There was an increase of 32% in two-week-wait referrals for suspected lung cancer in  the campaign months compared with the previous year, with the majority of additional referrals in the over 50s [2]
• Around 700 more people were diagnosed with lung cancer when compared with the same period in the  previous year. Approximately 400 more people had their cancer diagnosed at an early stage and around 300 additional patients had surgery as a first treatment of diagnosed lung cancer [3].

However, despite these promising results, there is still a great deal of potential to improve lung cancer survival in England, and for this reason, Public Health England is running the lung cancer campaign again.

References

1. TNS-BMRB report for the national lung  cancer campaign 2012. Produced for Public Health England

2. National lung cancer awareness campaign: Analysis of urgent GP  referrals. An analysis looking at the impact of the national lung cancer  awareness campaign on the number of urgent GP referrals for suspected lung  cancer. Produced by Trent Cancer Registry, July 2012

3. National Lung Cancer Audit. Data provided by HSCIC

Lung cancer is more common in older age, with 97% of people diagnosed in England aged over 50 [1]. Tobacco is by far the biggest cause of lung cancer – smoking causes more than eight in ten lung cancers in the UK. People who smoke, used to smoke, or are exposed to second-hand smoke have an increased chance of developing the disease [2].

But it’s important to remember that an estimated 17% of lung cancers in the UK are caused by factors other than being a current or past smoker.

References

1. Office for National Statistics http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/sty-lung-cancer.html

2. Parkin DM. 2. Tobacco-attributable cancer burden in the UK in 2010. Br J Cancer  2011;105(S2):S6-S13.

When developing the campaign for the general public, research showed it was important to lead with one clear symptom that they would be able to easily understand and identify. As such, the adverts focus on a persistent three-week cough. However, there are other symptoms to look out for including:

• A cough that gets worse or changes
• Coughing up blood
• Breathlessness
• Repeated chest infections
• Unexplained weight loss
• Feeling more tired than usual
• Chest/shoulder pain

If a patient presents with any of these symptoms, NICE guidelines recommend an urgent referral for a chest X-ray as a first step. Chest X-ray is a key diagnostic test for the detection of lung cancer and the average cost for a plain film X-ray is just £30. If the chest X-ray is suggestive of lung cancer, GPs can refer the patient urgently under the two week wait referral system. An urgent two week referral is also recommended for smokers and ex-smokers older than 40 years with persistent ‘haemoptysis’  (coughing up blood).

Nurses may see patients with a persistent cough as part of other clinics, such as smoking cessation sessions, or as part of supporting patients with long-term conditions, e.g. COPD (chronic obstructive pulmonary disease) or asthma. Therefore they are well positioned to help patients monitor any potential symptoms and encourage prompt presentation to their GP if symptoms persist.

If you have concerns about a patient, encourage them to make an appointment with their doctor without delay.

A range of Be Clear on Cancer materials have been developed centrally for lung cancer, including several posters, aimed at the target audience and the people that can influence them (family and friends), and symptom cards. PDFs for these and other materials are available to download and can be used as part of activities to promote and support the campaign locally.

The adverts encourage those with persistent symptoms to see their GP, but nurses also have a crucial role to play. People can delay going to see their GP for a variety of reasons. They may not realise their symptoms are serious; may worry about wasting the GP’s time; or if they suspect cancer, may fear the diagnosis and treatment.

Patients may be more willing to discuss symptoms with a nurse. They might speak to a nurse initially, to see if an appointment with the GP is warranted; they may feel they have more time to explain their symptoms and how they feel;  or they may find it easier to talk to nurses, especially if it’s a nurse/person they see regularly.

There are lots of opportunities for nurses to speak to patients and keep a  look out for those most at risk. For example, during an initial appointment with someone who has just joined your practice; when caring for patients with long-term conditions in the community; as part of health checks; or when  delivering stop smoking support. In some cases they know patients very well, so are in a good position to notice an unexplained or persistent symptom.

Brief colleagues. It is important  that the whole practice team are aware that there is a lung cancer campaign.  Make sure your team knows that there is a range of briefing sheets available; encourage everyone to watch the TV advert on NHS Choices to refresh their memory; and tell receptionists that there may be an  increase in the number of patients wanting appointments for a cough symptom. From research, we know that making the appointment is a significant barrier to some people as they don’t want to waste the GP’s time and think that they won’t be able to get an appointment easily.

Don't forget your patient groups too. There is a community briefing sheet that they may find useful.

Download community groups and volunteers briefing sheet

Expect and plan for a potential increase in appointments. It’s difficult to predict the exact increase, but try and anticipate the possible impact – think back to the last lung cancer campaign and the number of  requests for appointments your practice had during and after the Be Clear on Cancer advertising. Be prepared for an increase in the number of people sent for  diagnostic tests and referred via the urgent two week wait referral system.

Also, use the data from the first national lung cancer campaign in 2012 to help you plan:

• More people with a persistent cough went to their GP than during the same time in the previous year. When looking at the period May to July 2012 compared with May to July 2011 the number of patients aged 50+ presenting with a persistent cough went up 64% - the equivalent to around 3.1 additional visits  per practice per week [1].
• More patients were referred for a chest X-ray by a GP during the first month of the campaign (May 2012) compared to the month before (April 2012) – up 20% [2].
• There was an 8% rise in GP referred CT scans per working day in May 2012 compared with April 2012 [2].

Make every contact count: The campaign may prompt people who have previously ignored symptoms to talk to a member of the practice team. A patient may have come to see the practice nurse about something else, but it may be an opportunity to ask about any other concerns. The care provided by nurses working in the community might not involve frequently reassessing patients, but they may notice a recent change or persistent symptom. Even if the patient doesn’t have cancer, it’s a great opportunity to discuss prevention or lifestyle changes.

Give permission: the target audience often feel they need permission to make an appointment.  Where appropriate, encourage patients with symptoms to make an appointment – even if they are in the practice about something else. It may be the push they need to get themselves checked out.

Promote the campaign: Display posters and leaflets and encourage your colleagues to talk about the campaign. TV advertising is incredibly powerful at raising awareness of symptoms, but it is often face-to-face discussions that change behaviour. Encourage everyone to watch the TV advert on NHS Choices.

You can order free posters and leaflets www.orderline.dh.gov.uk or by phoning 0300 123 1002.

References

1. Source: Be Clear on Cancer national lung cancer awareness campaign evaluation –  impact on patients attending GP appointments. Produced by Mayden, February 2014  for NHS IQ

2. NHS England. Diagnostic Imaging Dataset. http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/

Be Clear on Cancer is the overarching brand for a programme of work, which aims to improve early diagnosis of cancer by raising awareness of symptoms and making it easier for people to discuss them with their GP. Each campaign is tested locally to see how people respond and what impact it has on their behaviour. The results inform whether the campaign is taken forward more widely.

In early 2011, the Department of Health ran the successful regional Be Clear on Cancer bowel cancer pilot – the first test of the Be Clear on Cancer  campaign. Lung cancer then became the focus of a regional pilot in the Midlands,  running from 10 October to 13 November 2011. In addition, a number of local teams ran Be Clear on Cancer activities for breast, bowel and lung in  2010/11.

The Department of Health launched the first national Be Clear on Cancer campaign to raise awareness of bowel cancer signs and symptoms in 2012 – it ran  from January to March; 18 local projects also ran activities to raise awareness  of the symptom of blood in urine (for bladder and kidney cancers), breast cancer in women over 70 and oesophago-gastric cancer; and in May 2012 the lung cancer campaign rolled out nationally too.

Over the past few years, the programme of work has continued to develop  further. At a national level, there have been campaigns on bowel and lung cancer  – including ‘reminder’ campaigns which have boosted awareness of the symptoms of  cough and ‘blood in poo’. There have also been national campaigns for ‘Breast  Cancer in Women Over 70’ and ‘Blood in Pee’. At this time, these campaigns have only run once at a national level and the evaluation results will be assessed to  determine if there should be ‘reminder’ campaigns.

Regionally, there have been pilots on oesophago-gastric cancers and ovarian cancer. The next pilot to run locally will be a skin cancer campaign later this year. The evaluation results from each pilot will be examined to determine if they should progress to a national or regional level.

A local pilot was also conducted on a generic campaign ‘Know 4 sure’ that looks at four common symptoms of cancer. At this time, we are still reviewing the evidence on this campaign to determine the best way to progress.

Be Clear on Cancer campaigns will continue to run throughout 2014/145, led by Public Health England working in partnership with the Department of Health and NHS England.

For more information about Be Clear on Cancer, or if you have any queries, please contact partnerships@phe.gov.uk.