Cancer

The Patient Pathway - Cancer

Prevention

Primary prevention has a key role to play in reducing the number of people who are diagnosed with cancer.

Many factors are influential including:

Smoking is the most important preventable cause of cancer in the world. It is a causal factor in at least 14 cancers; lung cancer and the upper aero digestive tract cancers have the highest proportions of cancer cases caused by smoking.

Less healthy diets cause nearly one in ten cancer cases in the UK.  Diets high in fibre and fruit and vegetables may reduce cancer risk whilst a diet high in salt, saturated fats and red or processed meat can increase cancer risk.

Overweight and obesity has been identified as a causal factor in over ten types of cancer including breast and bowel cancer.

Physical Activity can help to prevent cancer, it has been estimated that 3400 cases could be prevented in the UK each year by keeping active.

Alcohol causes 7 types of cancers including breast, mouth and bowel cancers. It is thought to be responsible for around 4% of UK cancers, about 12,800 cases per year.

HPV Vaccination is offered to girls between the ages of 11-14 and will prevent at least 70% of cases of cervical cancer in future years.

Supporting actions in Prevention

Web resources

Work with local providers, such as Solutions 4 Health to refine approach

Rationale and evidence for giving “Very brief advice” – Ask, Assess, Advise, Assist, Arrange

NICE guidance (and wider pathway) – Smoking Cessation in secondary care services

Screening - saving lives

Bowel Screening data in Thames Valley highlights uptake rates are performing above average in only two CCG areas in the region

Breast screening data highlights strong performance in all but two CCG areas in the region

Cervical screening data for the 25-49 age range is poor across Thames Valley and reflects the national performance. Oxfordshire CCG has been working nationally to produce guidance on possible interventions to encourage uptake locally

Supporting actions in Screening

Web resources

Evidence of how combined, tailored approaches can have an effect on increasing bowel screening uptake (CRUK)

National awareness weeks in Cervical Cancer/Screening take place every six months (January/June) – free resources and tools can be accessed here

For people with learning disabilities – a strategy document and toolkit has been developed in the South West (including letter templates to be used) by the National Development Team for inclusion

Early Diagnosis & Assessment

Earlier awareness, detection and assessment is crucial to enable a greater prospect of survival and improved quality of life for those experience cancer symptoms or a diagnosis.

Awareness & Support

Societal and behavioural norms can delay in getting medical help when faced with possible symptoms; fear of what a doctor may find, worry about wasting practitioner’s time, lack of knowledge about specific cancer signs and symptoms and an inability to book a GP appointment can all contribute to presentation at a GP.

Detection

a dual focus on primary care education and appropriate/prompt referrals from primary care are key to driving this agenda

Earlier diagnosis has the greatest potential for improving outcomes and survival. Variation exists across the region which helps identify this opportunity. The implication of earlier diagnosis is “ramped up” diagnostic referral volumes to match the demand.

While under 75 mortality rates across Thames Valley are average, early detection remains a high priority as 1 year survival rates could be much improved (click for data)

Improvement in staging has been seen across the whole TV region, with South Reading and Wokingham CCGs seeing the biggest improvements in staging coverage (click for data)

Case mix of cancers being detected at an early stage will have an impact on the proportion of early cancer detection. Breast is more likely to be detected at an early stage, vs Lung so areas with higher proportion of breast cancers will have better outcomes than those with higher proportion of lung (click for data)

Insufficient Capacity for Diagnostics in Thames Valley

Rising demand for referrals in secondary care is playing a role in the increasing time it takes to reach diagnosis.

England’s rates of endoscopy for lower gastrointestinal cancers per 100,000 population lag behind comparable countries.  Endoscopy services themselves, also vary in quality with many not JAG accredited (the marker of a quality service) and some patients experiencing 6+ and 13+ week waits for endoscopy. The impact of this is felt in England’s poorer cancer outcomes for bowel cancer than in comparable countries.

Thames Valley SCN completed a cancer diagnosis demand & capacity project in March 2016- full details and reports including the modelling tool can be accessed from the link opposite.

Top Line findings of the report

Between now and 2021, suspected cancer referrals will rise between 7 and 31% in the Thames Valley

Cancer Standards

Preparation for implementation of the 28 day cancer standard (from 2020) highlights current performance across Thames Valley is poor (click for data)

Upper Gastroenterology & Urology (per CCG)

Lung & Skin (per CCG)

Head/Neck & Lower GI

Breast & Gynaecology (per CCG)

GP direct access requests only account for 1/4 of all tests used to diagnose or discount cancer. This will significantly increase once all pathways are developed in accordance to NICE guidance (click for access)

Supporting Actions to achieve Early Diagnosis & Assessment Ambitions

Living With & Beyond Cancer

There are 2 million people living with or beyond cancer (anyone who has had a diagnosis of cancer) in the UK. This figure is set to rise to 4 million by 2030.

Supported aftercare should be in place to improve the lives of people affected by cancer (often people who have finished treatment report having life difficulties – financial, medical, emotional, practical etc);

Recovery Package – key interventions when delivered together can greatly improve lives

Holistic Needs Assessment – identifies the individual needs of the person affected which contributes to a consultation, with care plans developed and onward referrals to be made

Treatment Summary – developed by a multidisciplinary team to inform health services and family of the care and treatment received. This can also inform emergency/unplanned admissions

Cancer Care Review – 6 month GP practice review following diagnosis to enable self-management

Health & Wellbeing Clinics – educational sessions to provide holistic information to enable rehabilitation and self-management

Supporting actions for Living with and beyond cancer ambitions

End of Life/Palliative Care

Palliative care can play an important role at all stages of the cancer pathway, particularly for people with active and advanced disease.  It should be seen as an essential component of management, not something that commences when active treatment ceases.

Patient Experience

The result of the National Cancer Patient Experience Survey for Trusts and CCGs was published in July 2016.  It is not possible to directly compare data from the 2015 survey to findings of the previous CPES survey even for identical questions due to the changes made in the questionnaire and its administration to take into account changes in patterns of service use, policy and the regulatory landscape.

The 2015 survey adopted the CQC standard for reporting comparative performance, based on calculation of “expected ranges”.  This means that Trusts/CCGs will be flagged as outliers only if there is statistical evidence that their scores deviate (positively or negatively) form the range of scores that would be expected for Trusts/CCGs of the same size.

Across Thames Valley the performance of each CCG against each of the 12 sections that make up the survey was average with the majority performing within the expected range for a CCG of similar size.  Across the range of questions, there were 16 instances where some of the Thames Valley CCGs were positive outliers and 41 instances where they were negative outliers.  The table below provides a summary:

The above table is a summary of Outlier Performance (rating 1 or 3). If no positive or negative outlier exists, it isn’t shown. For example. NHS Newbury & District CCG is not on the table as it has no outlier (rating either 1 or 3).

As indicated in the chart above, overall within Thames Valley the majority of CCGs performed within the expected range for their size although they also performed lower than the national average. As shown performance for Q59 within the “Your overall NHS care” section, Oxfordshire CCG was a negative outlier as it performed lower than the expected range for a CCG of similar size.

Performance for Question 2 within the “Seeing your GP” section, both Milton Keynes and Aylesbury CCGs were negative outlier as they performed lower than the expected range for a CCG of respective size.

Performance for Question 8 within the “Finding out what was wrong with you” section, Winsor, Ascot and Maidenhead CCG was a negative outlier performing lower than the expected range for a CCG of respective size. Both North & West Reading and Wokingham CCGs were positive outliers performing higher the expected range for a CCG of their respective size.