Reviewing the impact of 11 national Be Clear on Cancer public awareness campaigns, England, 2012 to 2016: A synthesis of published evaluation results

Clinical characterisation of patients diagnosed with cancer following emergency self-referral

BACKGROUND

Despite their frequency and potential impact on prognosis, cancers diagnosed via self-referral to the emergency department are poorly documented. We conducted a detailed analysis of cancer patients diagnosed following emergency self-referral and compared them with those diagnosed following emergency referral from primary care. Given the challenges associated with measuring intervals in the emergency self-referral pathway, we also aimed to provide a definition of the diagnostic interval for these cancers.

METHODS

A retrospective observational analysis was performed on patients diagnosed with 13 cancers, either following emergency self-referral or emergency referral from primary care. We analysed demographics, tumour stage, clinical data (including 28 presenting symptoms categorised by body systems), and diagnostic intervals by cancer site, then testing for differences between pathways.

RESULTS

Out of 3624 patients, 37 % were diagnosed following emergency self-referral and 63 % via emergency referral from primary care. Emergency self-referrals were associated with a higher likelihood of being diagnosed with cancers manifesting with localising symptoms (e.g., breast and endometrial cancer), whereas the likelihood of being diagnosed with cancers featuring nonspecific symptoms and abdominal pain (e.g., pancreatic and ovarian cancer) was higher among patients referred from primary care. Diagnostic intervals in self-referred patients were half as long as those in patients referred from primary care, with most significant differences for pancreatic cancer (28 [95 % CI -34 to -23] days shorter, respectively).

CONCLUSION

These findings enrich the best available evidence on cancer diagnosis through emergency self-referral and showed that, compared with the emergency referral pathway from primary care, these patients had a significantly increased likelihood of presenting with symptoms that are strongly predictive of cancer. Since the starting point for the diagnostic interval in these patients is their emergency presentation, comparing it with that of those referred from primary care as an emergency is likely to result in biased data.

NHS cancer services and systems-ten pressure points a UK cancer control plan needs to address

In this Policy Review we discuss ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence we provide points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.

Time to Diagnosis and Presenting Symptoms of Patients Diagnosed With Cancer Through Emergency and Nonemergency Routes: A Large Retrospective Study From a High-Volume Center

PURPOSE

The symptoms with which a patient with cancer presents and the route taken to diagnosis (emergency v nonemergency) may affect the speed with which the diagnosis of cancer is made, thereby affecting outcomes. We examined time to diagnosis by symptom for cancers diagnosed through emergency and nonemergency routes (NERs).

METHODS

We performed a retrospective review of patients diagnosed with 10 solid cancers at Hospital Clínic of Barcelona between March 2013 and June 2023. Cancers were diagnosed through emergency presentation and admission (inpatient emergency route [IER]), emergency presentation and outpatient referral (outpatient emergency route [OER]), and primary care presentation and outpatient referral (NER). We assessed the effect of diagnostic routes on intervals to diagnosis for 19 cancer symptoms.

RESULTS

A total of 5,174 and 1,607 patients were diagnosed with cancer through emergency routes and NERs, respectively. Over 85% of patients presenting with alarm (localizing) symptoms such as hematuria through emergency routes were diagnosed with the expected cancer, whereas those with nonlocalizing symptoms such as abdominal pain had a more heterogeneous cancer-site composition. Median intervals were shorter for alarm than nonlocalizing symptoms and tended to be shorter in IERs than OERs. However, for most symptoms, intervals in both routes were invariably shorter than in the NER. For example, diagnostic intervals for hematuria and abdominal pain were 3 and 5 days shorter in IERs than OERs, but they were 5-8 and 17-22 days shorter than in the NER, respectively.

CONCLUSION

For patients with alarm symptoms, intervals were shorter than for those with nonlocalizing symptoms and, for most symptoms, intervals were shorter when patients were evaluated by emergency routes rather than NERs.

Exploration of Preliminary Objective Triage by Menopause Score and CA 125 Result Prior to Accelerating Fast-Track Booking for Suspected Ovarian Cancer-A Role for the Pathway Navigator?

The 28-days-to-diagnosis pathway is the current expected standard of care for women with symptoms of ovarian cancer in the UK. However, the anticipated conversion rate of symptoms to cancer is only 3%, and use of the pathway is increasing. A rapid triage at the moment of receipt of the referral might allow resources to be allocated more appropriately. In secondary care, multidisciplinary teams (MDTs) use the risk of malignancy index (RMI) score, (multiply menopausal status pre = 1 or post = 3 × ultrasound score = 0 - 3 × the CA 125 level), using a score of >200, to triage urgency and management in possible ovarian cancer cases. The most powerful determinant of the RMI score variables is CA 125 level, an objective number. Could a simple modification of the RMI score retain a high sensitivity for cancer whilst improving specificity and, consequently, decrease the morbidity of false-positive classification? To test this hypothesis, a retrospective evaluation of an ovarian two-week-wait telephone clinic of one consultant gynaecological oncologist was undertaken. Enquiry re menopause status was scored as one for pre- and three for postmenopausal or uncertain. CA 125 levels of >67 u/mL for premenopausal and >23 u/mL for postmenopausal women were used to precipitate urgent cross-sectional imaging requests and MDT opinions. These CA 125 cut thresholds were calculated using an assumption that the RMI imaging score, regardless of whether the result was available, could be three. We contemplate that women who did not exceed a provisional RMI score of >200 might be informed they are extremely unlikely to have cancer, removed from the malignancy tracker and appropriate follow-up arranged. One hundred and forty consecutive cases were analysed; 43% were deemed premenopausal and 57% postmenopausal. Twenty of the women had cancer, eighteen (90%) of whom had an RMI > 200. One hundred and twenty were benign, and only twenty-three (19%) classified as urgent cases in need of accelerated referral to imaging. In contrast, CA 125 > 35 u/mL, whilst retaining the sensitivity of 90%, misclassified 36 (30%) of the benign cases. It is possible that a telephone triage via a questionnaire determining menopausal status and the CA 125 result could offer a sensitivity for cancer of 90% and urgent expert review of under 20% of benign cases. This rapid initial telephone assessment could be presented by a trained pathway navigator, physician associate or nurse specialist. Substantial savings in NHS cancer services resources, anxieties all around and reduced patient morbidity may occur as a result.

The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit

BACKGROUND

Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies.

METHODS

We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom.

RESULTS

Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex.

CONCLUSION

We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

The future of cancer care in the UK-time for a radical and sustainable National Cancer Plan

Cancer affects one in two people in the UK and the incidence is set to increase. The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record. There are severe and widening disparities across the country and survival rates remain unacceptably poor for many cancers. This is at a time when cancer care has become increasingly complex, specialised, and expensive. The current crisis has deep historic roots, and to be reversed, the scale of the challenge must be acknowledged and a fundamental reset is required. The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection. The UK finds itself at a crossroads, where the political decisions of governments, the cancer community, and research funders will determine whether we can, together, achieve equitable, affordable, and high-quality cancer care for patients that is commensurate with our wealth, and position our outcomes among the best in the world. In this Policy Review, we describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money.

The relationship between patient enablement and help-seeking in the context of blood cancer symptoms

OBJECTIVE

Approaches to improve earlier diagnosis of cancer often focus on symptom awareness as a key driver of help-seeking behaviour and other psychological influences are less well understood. This is the first study to explore the role of patient enablement on help-seeking for people experiencing potential blood cancer symptoms.

METHODS

A cross-sectional, nationally representative survey was completed by 434 respondents (>18 years). Questions asked about symptom experiences, medical help-seeking and re-consultation. Existing patient enablement items were included in the newly developed Blood Cancer Awareness Measure. We collected data on patient socio-demographic characteristics.

RESULTS

Of those responding to the survey 224/434 (51.6%) reported experiencing at least one potential blood cancer symptom. Half of those experiencing symptoms (112/224) had sought medical help. Results from logistic regression analysis showed that higher scores on patient enablement were associated with being less likely to seek help (Odds Ratio [OR] 0.89, Confidence Interval [CI] 0.81-0.98) after controlling for socio-demographics. Separate analyses showed that higher enablement was associated with being more comfortable to re-consult if symptoms didn't go away or got worse (OR 1.31, CI 1.16-1.48); after a test result suggested there was nothing to worry about, but symptoms persisted (OR 1.23, CI 1.12-1.34) or to request further tests, scans or investigations (OR 1.31, CI 1.19-1.44).

CONCLUSIONS

Contrary to our hypotheses, patient enablement was associated with lower likelihood of help-seeking for potential blood cancer symptoms. Yet enablement appears to play an important role in likelihood of re-consulting when symptoms persist, get worse or need further investigation.

Engaging lower screening groups: a field experiment to evaluate the impact of a multiwave national campaign on participation in the National Bowel Cancer Screening Program

OBJECTIVES

This field study evaluated a multiwave media campaign that aired in 2019 to promote participation in the Australian National Bowel Cancer Screening Program (NBCSP), which provides free biennial mailed-out immunochemical faecal occult blood test (iFOBT) kits to Australians aged 50-74 years.

DESIGN

Adjusted negative binomial regression models determined rate ratios of iFOBT kits returned during and following three campaign waves compared with 2018 (baseline). Interaction terms determined whether effects differed by gender×age group, socioeconomic status (SES) and previous participation.

SETTING

Australia.

PARTICIPANTS

All Australians eligible for the NBCSP (men and women aged 50-74 years) who returned an iFOBT kit between 1 January 2018 and 30 October 2019.

INTERVENTIONS

A multiwave national integrated media campaign to promote participation in the NBCSP.

MAIN OUTCOME MEASURES

iFOBT kit return rate and number of iFOBT kits returned during and immediately following campaign activity overall and within historically lower screening groups (men, 50-59 years old; lower SES; never participants).

RESULTS

The rate of iFOBT kits returned increased significantly during all three campaign waves, with evidence of carry-over effects of the second wave coinciding with a general practitioner mail-out strategy (all p<0.001). At each wave, effects were observed among men and women in the younger (50-59 years old) age group, but were less consistent for the older age group. Each SES group and both never and previous participants had increased return rates at each wave, but increases were stronger among mid-higher SES and those who had never participated. An estimated 93 075 extra iFOBT kits were returned due to the campaign.

CONCLUSIONS

The campaign increased participation, especially among those who were younger and never previously screened-key groups to recruit given reparticipation rates of over 80%. Ongoing investment in national integrated media campaigns of sufficient duration and intensity can increase bowel cancer screening and ultimately save lives.

Cancer awareness in older adults: Results from the Spanish Onco-barometer cross-sectional survey

BACKGROUND

About half of all cancers are diagnosed in adults older than 65, making them the age group at highest risk of developing this disease. Nurses from different specialties can support individuals and communities in the prevention and early detection of cancer and should be aware of the common knowledge gaps and perceived barriers among older adults.

OBJECTIVES

The goal of the current research was to investigate personal characteristics, perceived barriers, and beliefs related to cancer awareness in older adults, with a special focus on perceptions about the influence of cancer risk factors, knowledge of cancer symptoms, and anticipated help-seeking.

DESIGN

Descriptive cross-sectional study.

PARTICIPANTS

Participants were 1213 older adults (≥65 years old) from the representative national Onco-barometer survey conducted in 2020 in Spain.

METHODS

Questions on the perceived influence of cancer risk factors, knowledge of cancer symptoms, and the Spanish version of the Awareness and Beliefs about Cancer (ABC) questionnaire were administered in computer-assisted telephone interviews.

RESULTS

Knowledge of cancer risk factors and symptoms was strongly related to personal characteristics and was limited among males and older individuals. Respondents from lower socio-economic background recognized fewer cancer symptoms. Having personal or family history of cancer had opposite effects on cancer awareness: It was related to more accurate symptom knowledge but also to lower perceptions about the influence of risk factors and more delayed help-seeking. Anticipated help-seeking times were strongly influenced by perceived barriers to help-seeking and beliefs about cancer. Worry about wasting the doctor's time (48% increase, 95% CI [25%-75%]), about what the doctor might find (21% increase [3%-43%]) and not having enough time to go to the doctor (30% increase [5%-60%]) were related to more delayed help-seeking intentions. In contrast, beliefs that reflected higher perceived seriousness of a potential cancer diagnosis were related to shorter anticipated help-seeking times (19% decrease [5%-33%]).

CONCLUSIONS

These results suggest that older adults could benefit from interventions informing them about how to reduce their cancer risk and addressing emotional barriers and beliefs associated with help-seeking delays. Nurses can contribute to educating this vulnerable group and are in a unique position to address some barriers to help-seeking.

STUDY REGISTRATION

Not registered.

Impact of cancer awareness campaigns in Peru: a 5-year Google Trends analysis

Background

The aim of this research was to characterise the interest on the most frequent cancers in Peru through Google Trends, its geographic and temporal relationship with massive awareness campaigns.

Methods

A temporal trends analysis for the last 5 years was carried out, comparing the Relative Search Volume (RSV) with the dates of mass cancer awareness campaigns in Peru. Google Trends application was used to evaluate the interest in the topics: breast, prostate, cervical stomach and colorectal cancer between 1 January 2016 and 31 December 2020, expressed in RSV. The annual RSV for each neoplasm was compared, as well as its annual variation using the Kruskal-Wallis test. The correlation between the RSV and the estimated incidence for each province was measured using the Spearman test.

Results

The topics with the highest RSV were breast (median: 20, range: 6-100) and prostate cancer (median: 28, range: 9-48). The topic 'breast cancer' showed a cyclical punctual increase in October, its awareness month. Searches for cervical, stomach and colorectal cancer were smaller and did not show peaks of interest. It was observed that the RSV was variable when compared with previous years (p < 0.05 for all the evaluated topics). Geographically, different provincial configurations of interest were observed according to neoplasia. When correlating the RSV with the incidence by province, a non-significant positive correlation (p > 0.05) was found for breast, cervical and colorectal cancer.

Conclusions

This study suggests a positive temporal correlation between RSV and awareness cancer campaigns in Peru specially to breast cancer and, to a lesser extent, prostate cancer. Significant variations of interest were demonstrated for each neoplasm among the evaluated years. No significant correlation was found between the incidence rate and the average RSV among Peruvian provinces.

Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review

BACKGROUND

The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults.

AIM

To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms.

DESIGN AND SETTING

Mixed-methods systematic review.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines.

RESULTS

Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms.

CONCLUSION

This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.

Primary healthcare professionals' perspectives on patient help-seeking for lung cancer warning signs and symptoms: a qualitative study

BACKGROUND

Lung cancer is the leading cause of cancer incidence and mortality worldwide. Prompt patient help-seeking for signs and symptoms suggestive of lung cancer is crucial for early referral, diagnosis, and survivorship. However, individuals with potential lung cancer symptoms tend to delay help-seeking. This qualitative study explored perceived barriers to patient help-seeking and strategies to enhance help-seeking for lung cancer warning signs and symptoms from the perspective of primary healthcare professionals.

METHODS

Semi-structured focus groups and individual interviews were conducted with 36 primary healthcare professionals. Data were collected via videoconferencing. Inductive thematic analysis was conducted.

RESULTS

The following two themes were created from the data: (i) perceived barriers to patient help-seeking for signs and symptoms of concern and (ii) facilitating early patient presentation for signs and symptoms of concern. Some participants believed that the high cost of a general practitioner visit, long waiting times, and previous bad experiences with the healthcare system would deter patients from seeking help for symptoms of lung cancer. Perceived patient-related barriers to help-seeking related to the different emotions associated with a potential cancer diagnosis as well as stigma, embarrassment, and guilt felt by smokers. Sociodemographic factors such as drug use, homelessness, living in rural areas, and being male and older were also perceived to impede patient help-seeking. The negative impact of the COVID-19 pandemic on cancer help-seeking also featured strongly. Participants recommended several strategies to enable patients to seek help for symptoms of concern including targeted educational campaigns focussing on symptoms (e.g., cough) rather than behaviours (e.g., smoking), accessible and free health services, and using patients' support networks.

CONCLUSIONS

Patient-related and healthcare system-related barriers to help-seeking for lung cancer warning signs and symptoms include cost of healthcare, cancer fear, and various sociodemographic factors. Participants suggested that increased awareness and early patient help-seeking for symptoms of concern could be achieved through targeted patient education, national campaigns, the use of community support networks, and free and accessible targeted screening services.

A prospective evaluation of the fourth national Be Clear on Cancer 'Blood in Pee' campaign in England

Objective

To assess the impact of the fourth Be Clear on Cancer (BCoC) ‘Blood in Pee’ (BiP) campaign (July to September 2018) on bladder and kidney cancer symptom awareness and outcomes in England.

Methods

In this uncontrolled before and after study, symptom awareness and reported barriers to GP attendance were assessed using panel and one‐to‐one interviews. The Health Improvement Network (THIN), National Cancer Registration and Analysis Service (NCRAS) and NHS Cancer Waiting Times (CWT) data were analysed to assess the impact on GP attendances, urgent cancer referrals, cancer diagnoses and 1‐year survival. Analyses used Poisson, negative binomial and Cox regression.

Results

Symptom awareness and intention to consult a GP after one episode of haematuria increased following the campaign. GP attendance with haematuria (rate ratio (RR) 1.17, 95% confidence interval (CI): 1.07–1.28) and urgent cancer referrals (RR 1.18 95% CI: 1.08–1.28) increased following the campaign. Early‐stage diagnoses increased for bladder cancer (difference in percentage 2.8%, 95% CI: −0.2%–5.8%), but not for kidney cancer (difference −0.6%, 95% CI: −3.2%–2.1%).

Conclusions

The fourth BCoC BiP campaign appears to have been effective in increasing bladder cancer symptom awareness and GP attendances, although long‐term impacts are unclear.

Impact of the third national 'Be Clear on Cancer' Breast Cancer in Women over 70 Campaign on general practitioner attendance and referral, diagnosis rates and prevalence awareness

OBJECTIVE

More than a third of women diagnosed with breast cancer in England, and over half of those who die from it, are over 70. The Be Clear on Cancer Breast Cancer in Women over 70 Campaign, running three times, 2014-2018, aimed to promote early diagnosis of breast cancer in England by raising symptom awareness and encouraging women to see their general practitioner (GP) without delay. We sought to establish whether the third campaign had successfully met its aims.

METHODS

Metrics covering the patient pathway, including symptom awareness, attending a GP practice with symptoms, urgent GP referral, diagnosis and stage of cancer, were assessed using national cancer databases and two household surveys.

RESULTS

The third campaign was associated with an increase in urgent cancer referrals, and therefore mammograms and ultrasounds performed. This was associated with an increase in breast cancers diagnosed. There was a delayed effect on GP attendances. Awareness of breast cancer prevalence for the 70-and-over age group improved. Impact on these metrics diminished across successive campaigns.

CONCLUSIONS

Future campaigns should focus on harder-to-reach women and include GPs as targets as this campaign showed a potential to affect referral behaviour.

A qualitative exploration of women's perspectives and acceptability of including new cancer awareness information in all-clear breast or cervical screening results

Objective

This study explored women's perspectives on the acceptability of including new cancer information with an all‐clear breast or cervical screening result letter (using ovarian cancer as a case study).

Methods

In 2016, six focus group discussions were conducted with women aged 25–70 years old, eligible for invitation to the NHS breast or cervical screening programme and resident in England. The focus groups lasted 60–90 min and were held in community venues. Data were analysed using thematic analysis.

Results

Thirty‐eight women aged 25–67 years old participated in the focus groups. Data analysis yielded six descriptive themes: general cancer awareness, taking advantage of a ‘teachable moment’, a double‐edge sword, barriers to accepting and using new cancer information, motivators for accepting and using new cancer information and wider strategies to increase cancer awareness in women. Women welcomed the inclusion of new cancer information in all‐clear screening results but highlighted pertinent lessons to be considered to maximise the usefulness of the approach.

Conclusion

While women perceived this approach as acceptable, it is pertinent to note the potential of the new cancer information to stimulate anxiety and potentially widen inequalities by excluding non‐attenders at screening programmes. Specific complementary and tailored approaches are necessary to mitigate these limitations.

Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care

Background

It remains unclear to what extent reductions in urgent referrals for suspected cancer during the COVID-19 pandemic were the result of fewer patients attending primary care compared to GPs referring fewer patients.

Methods

Cohort study including electronic health records data from 8,192,069 patients from 663 English practices. Weekly consultation rates, cumulative consultations and referrals were calculated for 28 clinical features from the NICE suspected cancer guidelines. Clinical feature consultation rate ratios (CRR) and urgent referral rate ratios (RRR) compared time periods in 2020 with 2019.

Findings

Consultations for cancer clinical features decreased by 24.19% (95% CI: 24.04–24.34%) between 2019 and 2020, particularly in the 6–12 weeks following the first national lockdown. Urgent referrals for clinical features decreased by 10.47% (95% CI: 9.82–11.12%) between 2019 and 2020. Overall, once patients consulted with primary care, GPs urgently referred a similar or greater proportion of patients compared to previous years.

Conclusion

Due to the significant fall in patients consulting with clinical features of cancer there was a lower than expected number of urgent referrals in 2020. Sustained efforts should be made throughout the pandemic to encourage the public to consult their GP with cancer clinical features.

The role of multimorbidity in short-term mortality of lung cancer patients in Spain: a population-based cohort study

AIM

Chronic diseases often occur simultaneously and tend to be associated with adverse health outcomes, but limited research has been undertaken to understand their role in lung cancer mortality. Therefore, this study aims to describe the prevalence and patterns of having one (comorbidity) or ≥ 2 chronic diseases (multimorbidity) among lung cancer patients in Spain, and to examine the association between comorbidity or multimorbidity and short-term mortality risk at six months after cancer diagnosis.

METHODS

In this population-based cohort study, data were drawn from two Spanish population-based cancer registries, Girona and Granada, and electronic health records. We identified 1259 adult lung cancer patients, diagnosed from 1st January 2011 to 31st December 2012. We identified the most common patterns of individual comorbidities and their pairwise correlations. We used a flexible parametric modelling approach to assess the overall short-term mortality risk 6 months after cancer diagnosis by levels of comorbidity after adjusting for age, sex, smoking status, province of residence, surgery, cancer stage, histology, and body mass index.

RESULTS

We found high prevalence of comorbidity in lung cancer patients, especially among the elderly, men, those diagnosed with advanced-stage tumours, smokers, and obese patients. The most frequent comorbidities were chronic obstructive pulmonary disease (36.6%), diabetes (20.7%) and heart failure (16.8%). The strongest pairwise correlation was the combination of heart failure with renal disease (r = 0.20, p < 0.01), and heart failure with diabetes (r = 0.16, p < 0.01). Patients with either one or two or more comorbidities had 40% higher overall mortality risk than those without comorbidities (aHR for comorbidity: 1.4, 95%CI: 1.1-1.7; aHR for multimorbidity: 1.4, 95%CI: 1.1-1.8), when relevant confounding factors were considered.

CONCLUSIONS

The presence of comorbid diseases, rather than the number of comorbidities, was associated with increasing the risk of short-term lung cancer mortality in Spain. Comorbidity was a consistent and independent predictor of mortality among lung cancer patients, six months after diagnosis. The most common comorbid conditions were age-, obesity- and tobacco-related diseases. Our findings highlight the need to develop targeted preventive interventions and more personalised clinical guidelines to address the needs of lung cancer patients with one or more comorbidities in Spain.

Abdominal cancer symptoms: Evaluation of the impact of a regional public awareness campaign

OBJECTIVE

A regional 'Be Clear on Cancer' (BCoC) campaign developed by Public Health England aimed to promote public awareness of key abdominal cancer symptoms in people aged 50 years and over.

METHODS

Data were analysed for metrics at different stages in the patient care pathway including public awareness, GP attendance and referrals, to cancer diagnosis.

RESULTS

There was significantly higher recognition of the BCoC abdominal campaign in the campaign region compared to the control area (Post Campaign/Control, n = 401/406; 35% vs. 24%, p < 0.05). The campaign significantly improved knowledge of 'bloating' as a symptom (p = 0.03) compared to pre-campaign levels. GP attendances for abdominal symptoms increased significantly by 5.8% (p = 0. 03), although the actual increase per practice was small (average 16.8 visits per week in 2016 to 17.7 in 2017). Urgent GP referrals for suspected abdominal cancer increased by 7.6%, compared to a non-significant change (0.05%) in the control area. For specific abdominal cancers, the number diagnosed were similar to or higher than the median in the campaign area but not in the control area in people aged 50 and over: colorectal (additional n = 61 cancers), pancreatic (additional n = 102) and stomach cancers (additional n = 17).

CONCLUSIONS

This campaign had a modest impact on public awareness of abdominal cancer symptoms, GP attendances and cancers diagnosed.

Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England

Background

To date, research exploring the public’s awareness of bowel cancer has taken place with predominantly white populations. To enhance our understanding of how bowel cancer awareness varies between ethnic groups, and inform the development of targeted interventions, we conducted a questionnaire study across three ethnically diverse regions in Greater London, England.

Methods

Data were collected using an adapted version of the bowel cancer awareness measure. Eligible adults were individuals, aged 60+ years, who were eligible for screening. Participants were recruited and surveyed, verbally, by staff working at 40 community pharmacies in Northwest London, the Harrow Somali association, and St. Mark’s Bowel Cancer Screening Centre. Associations between risk factor, symptom and screening awareness scores and ethnicity were assessed using multivariate regression.

Results

1013 adults, aged 60+ years, completed the questionnaire; half were of a Black, Asian or Minority ethnic group background (n = 507; 50.0%). Participants recognised a mean average of 4.27 of 9 symptoms and 3.99 of 10 risk factors. Symptom awareness was significantly lower among all ethnic minority groups (all p’s < 0.05), while risk factor awareness was lower for Afro-Caribbean and Somali adults, specifically (both p’s < 0.05). One in three adults (n = 722; 29.7%) did not know there is a Bowel Cancer Screening Programme. Bowel screening awareness was particularly low among Afro-Caribbean and Somali adults (both p’s < 0.05).

Conclusion

Awareness of bowel cancer symptoms, risk factors and screening varies by ethnicity. Interventions should be targeted towards specific groups for whom awareness of screening and risk factors is low.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10536-y.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.