Saving 1000 Lives
Improving Outcomes: A Strategy for Earlier Diagnosis of
Cancer in London
Commissioning guidance for London PCT clusters
March 2012
Strategy for Increasing Early Diagnosis in London
Foreword
The Model of Care for Cancer Services in London (CSL August 2010) gives
recommendations for implementation that would most certainly contribute to improving
survival rates to meet the best in Europe and could translate into saving 1,000 Londoners’
lives annually. This is reflected in Improving Outcomes: A Strategy for Cancer (IOSC, DH
January 2011) which commits to the challenge of saving 5,000 lives from cancer in England,
every year, by 2014/15.
It summarises the actions that are needed in 4 categories:
 those that reduce the incidence of preventable cancer through lifestyle changes, those
that improve access to screening services where there is evidence
 that this will save lives
 those that will achieve earlier diagnosis
 those that will ensure that all patients have access to the best possible treatment.
Within this framework, it states that;
‘diagnosis of cancer at a later stage is generally agreed to be the single most
important reason for the lower survival rates in England’.
The aim of this strategy is to improve survival from cancer for Londoners through ensuring
that cancer is diagnosed earlier. Achieving this will lead to the saving of lives set out in the
model of care and will be measured initially by one year survival rates (a proxy measure for
later stage at diagnosis) and, in due course, by improved five year survival. Studies
comparing five year survival in England to the best in Europe have shown that much of the
difference in survival occurs in the first year following diagnosis - highlighting the importance
of earlier diagnosis. The image shown on the front cover of this document is from the Office
of National Statistics (ONS) 2010. It shows 1 year survival from all cancers in 2006 and
illustrates clearly that inequalities exist across London. Out of 100 people with cancer from
the areas shaded in lighter yellow, 5 more will die within a year of diagnosis than those from
the darker blue areas. At the same time all of London lags behind the best in Europe – our
task is to take actions that paint all of London a uniform and darker blue!
Given the number of lives that are there to be saved – deaths that can be avoided – there are
no more important or urgent actions than those proposed to be commissioned in this
document. Both the model of care and the IOSC set out the key elements of the early
detection pathway that are integral to the National Awareness and Early Detection Initiative
(NAEDI). To improve earlier detection and diagnosis in London we need to:

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
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increase public awareness of cancer signs and symptoms
overcome barriers to presentation to primary care
overcome clinical and system barriers to prompt onward referral within and between
primary and secondary care
improve GP access to diagnostic tests to help confirm or exclude a diagnosis of
cancer

ensure that, once cancer is suspected, there is improved access to specialist
pathways in secondary care and that the same guidelines are applied to patients who
present to hospitals through non-urgent or emergency care pathways.
This document recommends priority actions for a systematic spread of the most effective
interventions for earlier detection across all of London.
The very nature of London with its existing health inequalities and socio-economic diversity
means that this pan-London approach needs be matched by integrated action at Health and
Well Being Board and CCG levels. Understanding gained from local needs assessments
should inform actions to ensure that they are effective across the whole population. Without
this, there is a risk of widening inequalities. Existing and emerging network/cluster and
borough level strategies and actions must be supported, strengthened, and integrated with
this London strategy to ensure that inequalities are tackled.
The proposed priorities are based on national commissioning guidance and represent
accepted best practice. It is necessary for there to be a whole London and whole systems
approach involving all stakeholders as a key objective. We have an important opportunity,
through this strategy, to enable and support clinicians to respond to the individual needs of
their patients, by referring on through evidence-based pathways.
This opportunity is enhanced by the announcement that the prevention and earlier detection
of cancer will be one of three key workstreams of the Mayor’s London Health Improvement
Board (LHIB). It is essential that the commissioning guidance herein should integrate with
the Proposals for Action of the LHIB workstream.
The implementation plan included in this document should respond to and coordinate with
those of the LHIB workstream and programme management of implementation should be
integrated wherever possible.
There are well understood approaches for cost-effective action and, without the coordinated
commissioning and whole systems implementation of these actions, we will not reach the
projected saving of lives. The section below on screening highlights that, following a
programme of targeted interventions, for example, the uptake of breast screening in inner
East London has improved very significantly. Uptake now approaches the national minimum
standard and is an important illustration that the behaviour of people in deprived and diverse
communities is amenable to focussed action.
Dr Tony Brzezicki
Chair
Public Health and Primary Care Sub Group of the London Cancer Review
Contents
Foreword
Executive summary and recommendations
5
1.
Background
8
2
London Health Improvement Board
9
3.
Aims and Objectives
9
4.
Baseline
10
4.1 Survival
10
4.2 Stage at presentation
10
4.3 Co-morbidity
10
4.4 Screening
11
4.5 Population awareness
11
4.6 GP referrals
11
Priorities for London
12
Information and intelligence
13
Public awareness
14
GP engagement
14
Access to diagnostics
14
Integrated Cancer System
15
6.
Resources
16
7.
Commissioning support tools
17
8.
Implementation plan
18
Appendix 1. Potential lives saved
20
Appendix 2. Incidence of breast colorectal and
lung cancer rates in London boroughs
21
Appendix 3. Survival from breast colorectal and
lung cancers in London boroughs
22
5.
Executive Summary
Early detection and treatment for cancer is critical for survival; for example 90% of women
diagnosed with breast cancer at stage 1 will survive at least 5 years, whilst 90% of those
diagnosed at stage 4 will have died before 5 years. Early detection has therefore become the
key government strategy for improving cancer. It is estimated that 11,000 lives could be
saved nationally if survival rates in England were the same as the best in Europe. This
corresponds to saving, by 2014/15, 1,000 lives in London per year, every year.
London has survival rates for cancer that are some of the best and the worst in the country.
Research and analysis about stage at presentation and co-morbidities is needed to inform
our understanding and should be required from all Trusts.
Local and national surveys have shown that awareness of cancer symptoms is poor in
general and is worse in men, lower socio-economic groups and BME groups. These surveys
also show that many people perceive barriers that prevent them going to their GP.
Although screening is not formally within the scope of this strategy, cancer screening
programmes make a significant contribution to early diagnosis. Uptake of all screening
programmes is poorer in London than the national average with rates particularly low in Inner
London PCTs. Nevertheless, there have been encouraging improvements over the last year
in a number of PCTs. It is key that implementation of this strategy and those for cancer
screening, led by the London Screening Improvement Board, are closely linked and that
commissioning arrangements are aligned. This will include the potential impact on the bowel
screening programme of the national bowel cancer awareness campaign.
Although there has existed a fast track pathway for suspected cancer patients for 10 years,
less than half of patients with cancer are referred via this pathway; a quarter of cancer
patients first present at A&E. Many PCTs across London have developed training and audit
programmes to support GPs to improve referrals. Comprehensive programmes need to be
developed to further support primary care practitioners in early diagnosis.
Cancer networks and PCTs, working with public health and primary care colleagues, have
implemented a number of early detection initiatives, many funded with Department of Health
or National Cancer Action Team (NCAT) funds. These initiatives now need to be developed
into a sustainable programme of work across London to address the following key areas:

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
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increase public awareness of cancer signs and symptoms
overcome barriers to presentation to primary care
improve GP access to diagnostic tests to help them to confirm or exclude a diagnosis of
cancer
overcome clinical and system barriers to prompt onward referral within and between
primary and secondary care.
A number of actions have been identified and prioritised to help improve early diagnosis
across London. These are set out below in the order of the patient pathway:
It is recommended that:
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A pan London, high quality, cancer intelligence service should be configured,
through the coordination and focusing of existing resources and expertise, to
ensure that implementation is based on assessment of needs and effectiveness,
and that the impact of actions are monitored and evaluated. This will integrate
with, be part of and not separate from, overall intelligence functions as they
emerge from the transition to the new NHS commissioning system and including
Public Health England.
Beginning with the National Bowel Cancer Symptoms Awareness Campaign,
measures that improve both the public awareness of symptoms of cancer and
encourage early presentation to primary care and, where appropriate, improve
uptake of screening services must be commissioned and implemented. This will
best be achieved by the configuration of a small specialist team at a London level
in coordination with action and ‘advocacy’ at a local level.
Primary care leadership is essential to the whole of the early detection pathway. It
is recommended that each CCG should identify a Primary Care Cancer Lead
(PCCL) resourced with a minimum of one and up to 2 sessions per week who
should be supported by robust cancer network level leadership sustainably
resourced in line with national guidance. Primary Care leadership will have an
important role in ensuring that GPs have up to date knowledge of cancer
guidelines for referral and diagnosis.
Commissioners should ensure that all GPs in London have direct access to the
four diagnostic tests identified by Improving Outcomes: A Strategy for Cancer and
should request tests in line with the guidance and pathways to be issued by the
Department of Health. Primary care should ensure that access to these tests
following patient presentation is rapid. In addition, providers should ensure that
results and reports are available within two weeks and that abnormal findings
result in the direct referral into specialist pathways.
In alignment with NICE guidance, there needs to be information and support
available for those with raised familial risks of cancer so that they access primary
care and, where appropriate, screening services, as early as possible.
The output specifications of the commissioned pathways of Integrated Cancer
Systems (ICS) should include measures for improved one year survival, as a
proxy for longer term survival, and stage at presentation and emergency
presentation proxies for one year survival. ICSs should work closely with primary
care, CCGs and networks across the whole of the early detection pathway but
with a particular emphasis on optimising referral from primary care. They must
ensure ongoing prompt access to specialist enhanced pathways once cancer is
suspected and the Acute Oncology Services should provide an enhanced
pathway for those who continue to present as emergencies.
The cost of cancer in England, including both direct NHS costs and societal costs such as the
loss of productivity, has been estimated at approximately £18 billion per annum
(Featherstone and Whitham, Policy Exchange 2010). The same source proposes that if UK
survival rates improve to the best in Europe then a substantial reduction in cost will result,
£10 billion cumulatively by 2020. These economic benefits will be available to, and important
for, London and Londoners.
The DH financial impact assessment of the NAEDI strategy, published in January 2011, sets
out detailed cost modelling and analysis of the impact of earlier diagnosis, on five different
cancers. There is potential for increases in diagnostic costs partially offset by a reduction in
treatment costs and it is also recognised that there are timing effects as elements of the
diagnostic costs are brought forward to an earlier period. Their overall conclusion is that
earlier detection would represent value for money but would not be cost saving. This is
consistent with the conclusion reached in the model of care.
There are difficulties and variability in estimating these effects. The DH work was based on
national statistics; the impact on London needs to be better understood as there are
differences from the national picture, for example the lower levels of screening uptake.
The financial impact will also depend on the speed at which implementation, including for
screening, is planned and delivered. The next stage of analysis will be take the model used
by the DH and use data and assumptions that are appropriate for the capital so that the
overall financial impact can be included in a business case.
It is recommended that commissioners should:
Allow for an expected increase in use of diagnostic and treatment costs in
risk reserves for 2012-13 until detailed plans are developed
Include provision in commissioning strategy plans for awareness
campaigning at the level of £100,000 per 200,000 population,

Pick up the current non-recurring DH/NCAT funding of network GP leadership
allowing £150,000 for London-wide GP leadership and, in addition, CCGs
should budget for PCCL posts at 1 or 2 sessions per week per CCG.
The best practice pathways being developed as the basis of contracts with the ICSs for
cancer care will reflect base practice to support earlier diagnosis. Commissioners and trusts
will need to work closely to model capacity and activity in key diagnostic areas.
Commissioners will also need to ensure that provision is made for ongoing programmes to
improve population awareness. Although some programmes may be centrally or regionally
funded, the success of awareness programme in improving early diagnosis will also depend
on local responses in primary care. The LHIB early diagnosis campaigns will have an
important contribution to make to this work.
Health services will need to work closely with local government to make sure that strategies
and plans are joined up. Harnessing the power of the voluntary sector to support these
programmes will greatly enhance the potential impact.
There is a need to move away from short term, project based work to embedding
organisational and cultural changes in the delivery of health and other services to ensure a
sustained and ongoing engagement of patients and staff in early cancer detection.
It is important to acknowledge that the delivery model for earlier detection is complex and this
is particularly the case as the NHS moves to the new commissioning arrangements and, for
London, the Integrated Cancer Systems develop. Implementation plans will require further
development as changes emerge, and to ensure clarity on leadership and responsibility and
accountability for actions.
Recommendation: The implementation plan included in this document should be
developed and taken forward at London level and be aligned with the London Health
Improvement workstream and with the full range of NHS structures in transition to
the new commissioning arrangements
1. Background
In general, the earlier a cancer can be diagnosed the greater the prospect of survival.
The National Cancer Director has often illustrated this with breast cancer: If breast cancer is
diagnosed early at ‘Stage 1’ then 90% of patients will survive beyond 5 years whereas if
diagnosed late at ‘Stage 4’ then 90% will die within 5 years. In Improving Outcomes - a
Strategy for Cancer, the Government made a commitment to bring England's cancer survival
rates up to the European average by 2014/15. This would be equivalent to saving roughly
5,000 additional lives per year in England. The model of care for London identified that
around 1,000 lives a year are lost in London when compared to the best in Europe.
Studies comparing five year survival in England to the best in Europe have shown that much
of the difference occurs in the first year following diagnosis. The majority of these avoidable
deaths are likely to be due to late diagnosis. We now need to attain the overall objective for
London to save lives by detecting and diagnosing cancer as early as possible.
The National Awareness and Early Detection Initiative (NAEDI), the public sector/third sector
partnership between the Department of Health, the National Cancer Action Team (NCAT)
and Cancer Research UK set out three key workstreams for commissioning.

Increase public awareness of cancer signs and symptoms, and consequent
presentation to primary care.

Facilitate onward clinical referral within and between primary and secondary care.

Improve GP access to diagnostic tests to help them to confirm or exclude a diagnosis
of cancer.
Cancer networks, working with PCTs, public health, primary care and the full range of
stakeholders, have led significant progress in implementing local awareness and early
detection initiatives. Whilst some PCTs have prioritised significant investment, many of these
initiatives have been funded by the Department of Health and the NCAT through competitive
bidding processes. This strategy, through the London Cancer Commissioning Intentions,
proposes cost effective investments for a sustainable programme of actions to deliver the
targeted saving of lives whilst providing a framework to take advantage of any continuing
central funding flows and initiatives.
Local and national surveys show that public awareness of cancer symptoms is generally low
not only for rarer cancers but also for common cancers except breast. In addition, although
great improvements have been made in the last 10 years in establishing urgent referral
pathways, only a minority of patients are referred through these pathways and delays
continue to occur in the patient pathway.
It is also important to ensure that improved access to specialist diagnostics once cancer is
urgently suspected is maintained regardless of where the patient first presents, even though
the majority of cancer diagnosis will be through the non-urgent referral route or as
emergencies in A&E departments.
The purpose of this strategy therefore is to impact on the behaviour of Londoners so that they
present as early as possible to their doctor who should use evidence based treatment and
care pathways to optimise and improve outcomes.
2. London Health Improvement Board – Cancer Prevention and Early Diagnosis
Project
The London Health Improvement Board (LHIB) has been established in shadow form,
pending legislation, under the chairmanship of the Mayor, with the aim of improving the
health of all Londoners.
The Board has included the prevention and early diagnosis of cancer as one of its first
priorities for action. This work stream will concentrate on tobacco control and smoking
cessation for the prevention aspect of work and on enabling a London wide conversation
about cancer to challenge existing attitudes of Londoners and aid earlier presentation.
Close and careful integration of plans and project management will provide unique
opportunities to save lives through the prevention and early diagnosis of cancer.
3. Aims and Objectives
3.1 Aim: To improve cancer survival through ensuring patients get diagnosed earlier.
3.2 Objectives:

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To increase public awareness of cancer symptoms
To reduce perceived barriers to accessing primary care
To enable/encourage earlier presentation
To reduce inequalities
To reduce the numbers of patients whose first presentation is in A&E
To enable greater access for GPs to diagnostic tests and specialist advice to facilitate
decision making and improve referral pathways
To reduce the delays before diagnosis and treatment in secondary care
To ensure that staging data are accurate and complete to enable effective monitoring
To improve patient experience along the whole of the cancer pathway
3.3 Outcomes
The expected outcomes are:

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Improved public awareness of cancer symptoms (as measured through CAM surveys
or similar)
Higher proportion of cancers referred through ‘2 Week Wait’ pathways
Reduced emergency presentations with cancer.

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Higher proportion of people diagnosed with cancer at an earlier stage.
Improved one and 5 year survival. However, these outcomes will not be known till
some years later.
Improved clinical pathways in primary and secondary care with reduced delays
Improved access to and uptake of diagnostics from primary care
A reduced economic and social impact from cancer on Londoners and London
The aim is to save 1000 lives in London in line with the model of care. If survival across
London matched the best in England, the table in appendix 1, summarised below, shows the
number of lives that could be saved and illustrates the potential to meet the aim set by the
model of care.
Potential number of lives
saveable
Breast
325
Lung
576
Colorectal
388
Total
1289
However, it is recognised that improved prevention of cancer could save up to half of
those lives currently lost and cancer prevention should remain an important priority
4. Baseline
4.1 Survival rates from cancer in London
One year survival is recognised as being a reasonable proxy for late diagnosis. The latest
available data are for people diagnosed in 2006-8 (cancer commissioning toolkit). One
year survival from the main cancers, breast, colorectal and lung is widely variable across
London with some of highest and the lowest rates in the country (Appendix 2). Five year
survival is also highly variable. Two London PCTs (Barking & Dagenham and Waltham
Forest) have both one and five year survival rates in the lowest national quintiles for all 3
cancers. Conversely 2 PCTs (Westminster and Hammersmith & Fulham) have one year
survival rates in the highest national quintile for all 3 cancers. However, national rates are
worse than international rates, so relatively good performance does not mean that
improvement cannot be achieved.
4.2 Stage at presentation
The aim of the NAEDI programme is to ensure that people present, are referred and
diagnosed earlier. To measure whether this is happening, stage at diagnosis is an
essential monitoring tool. Currently the availability of staging data is incomplete, with the
extent of completeness varying from Trust to Trust and tumour to tumour. Although
almost all solid tumours will be staged, clinically or pathologically, the data are not always
recorded in a retrievable way and may not be routinely available. ICSs should be held to
account for recording and routinely making available appropriate staging data. Thames
Cancer Registry will have a key role in the collation of these staging data.
4.3 Co-morbidities and outcomes from cancer
Good outcomes from cancer are also critically affected by the general health and comorbidities of patients. This emphasises the importance of overall prevention and health
and wellbeing strategies such as those concerned with smoking, alcohol misuse, obesity
and mental health (particularly in respect of depression and its impact on compliance with
treatment). These factors may contribute to the poor outcomes regardless of stage at
presentation. It will be essential to measure these co-morbidities if the impact of earlier
detection initiatives is to be understood and intelligently targeted.
4.4 Population Awareness
Population awareness of symptoms of cancer is vital to improving early diagnosis so that
people know what to look for and when to go to their GP. Most cancer networks have
conducted surveys of public awareness in their populations using the validated set of
questions in the CRUK (Cancer Research UK) Cancer Awareness Measure (CAM) tool.
NE London used the Breast CAM in 3 PCTs to focus specifically on breast cancer
awareness, while NW London has used the Lung CAM in 2 PCTs.
These surveys showed that only a small minority of people were able to spontaneously
recall cancer symptoms other than lumps. Particular groups have been identified in local
surveys as having lower levels of awareness – these include BME groups, lower socioeconomic groups, and males. People also perceived a range of barriers to accessing GPs
if they thought they had a symptom.
4.5 Increasing Awareness of Cancer Symptoms
All London cancer networks have initiated public awareness campaigns, using different
methodologies, to raise public awareness. These have generally been targeted on
specific tumour sites – bowel, breast or lung - and specific population groups. For
example, 5 of the 6 London sectors have targeted bowel cancer, one has targeted breast
and three lung cancer. In previous campaigns, three have targeted skin, one has targeted
head and neck tumours and one has targeted oral cancer.
The DH national campaign for bowel cancer awareness has been rolled out in early 2012
and local support was mobilised to maximise effectiveness.
PCTs have bid for funding to pilot additional cancer awareness programmes centering on
oesophogogastric, bladder and breast cancers in 2011-12.
A further national campaign to raise awareness of lung cancer symptoms will be rolled out
in May-June 2012.
4.6 Screening
Cancer screening programmes make a significant contribution to early diagnosis.
Uptake of all screening programmes is poorer in London than the national
average with rates particularly low in Inner London PCTs. It is recognised that one
important factor in low uptake is the high mobility of the population. However in
2009/10, no London PCT met the standard of 80% uptake for breast screening
and only a third met the minimum standard of 70%. There have been substantial
and encouraging increases in breast screening uptake in several London PCTs in
the last year, particularly in East London where targeted campaigns have been
initiated. For cervical screening only 3 PCTs met the minimum national standard
of 80% coverage.
4.7 GP Referrals
GP Audits
Practice cancer profiles developed by NCIN provide a useful means by which practices
can assess their referrals and cancer statistics against local and national benchmarks.
GP audits of cancer cases in 2010 identified significant problems in the primary care
stage of the pathway. Local audits supported national findings that a quarter of cancer
cases present in A&E and around a fifth of cases have metastatic disease at diagnosis.
Variation in GP Referral Patterns
Nationally less than half (42%) of people with cancer were referred through the urgent two
week wait (2ww) route (Cancer Waiting Times stats), whilst 23% came through A&E
(National GP audit). In London there is large variation among PCTs in the proportion of
cases coming via 2ww, from 22% (Hammersmith & Fulham) to 56% (Tower Hamlets)
(Fig. 1). It is also true that there is variation within PCTs and between tumour sites and
this needs to be analysed and understood if intelligence driven action is to be taken. In
Newham, for example, the lower number of 2ww referrals for lung cancer is explained by
the standard good practice pathway that fast tracks patients with suspicious chest X-rays
direct to the specialist diagnostic pathway.
Fig 1
GP referrals; % of cancer cases referred via 2ww, by PCT
(source: Cancer Commissioning Toolkit)
60
50
40
30
20
TH
Havering
Redbridge
WF
B&D
Camden
Bexley
Harrow
Kingston
CH
Croyden
Lambeth
Greenwich
Enfield
Sutton and Merton
Soutwark
Barnet
Islingtom
Haringey
R&Tw
Lewisham
Brent
Bromley
Newham
Wandsworth
Hillingdon
Westminster
K&C
Ealing
Houslow
0
Ham'th & Fulham
10
GP Training
The level of GP training is usually a PCT led process and has been very variable between
and within Networks. Most London networks are developing a comprehensive learning
programme.
Primary Care Leadership
All Networks have a GP lead with varying time commitments and continuity of funding.
£25,000 was made available in August 2011 by the DH for primary care leadership in all
networks on a non-recurring basis for 2011/12. The number of GP leads is likely to
change with the transition from PCTs into the emerging GP Clinical Commissioning
Groups (CCG). Primary care leads are key to leading local actions with GPs.
5. Priorities for London
Six priority areas have been identified for the earlier detection of cancer. Effectively
implementing these priorities will need a whole systems mobilisation across London. It will
need involvement and engagement of the public and communities, patient partnership
groups, the business community, Local Authorities, Public Health services, the Third
Sector in general and the Cancer Charities in particular, as well as the NHS including its
primary, secondary and tertiary care and the Integrated Cancer Systems in particular.
These priorities need to be explicitly commissioned and it will need the pan London
agreement of commissioning intentions and the commitment of resources needed.
Because of the socioeconomic and cultural diversity of London’s populations, priorities will
need to be implemented with local design input to ensure success and to ensure that they
do not, perversely, widen inequalities. Implementation plans will need to be clear on
accountabilities and actions whilst ensuring that London’s ‘cancer stakeholders’ are
involved. Implementation of these priorities will need to involve the sharing of best
practice from England and from Europe as well as current findings from ongoing initiatives
in London. This will be particularly important where local actions have focused on
particular communities and population segments; evaluated actions can be spread across
other parts of London where appropriate. All of the actions will need to consider best
practice in service and process re-design and ‘Lean Thinking’.
Information and Intelligence
NAEDI (and all cancer commissioning) must be supported by high quality data and data
analysis in order to:
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show evidence of need and target interventions
show effectiveness of interventions
support commissioning decisions that underpin NAEDI
support Joint Strategic Needs Assessments (JSNAs)
coordinate the analyses of ‘practice profiles’ and RCGP Audits
monitor and report on output and outcome measures
It would not be possible to develop or recommend appropriate interventions, or to assess
them, without high quality data and data analysis support. In order to maximise quality
and efficiency, this should be provided by a single, high quality team.
This can be achieved by the collaboration of existing resources including, for example,
intelligence and public health experts within the current cancer network teams, more
general information analysts within London Health Programmes, performance
management analysts for cancer in NHS London and, of critical importance, linking with
the Thames Cancer Registry (TCR) and to the National Cancer Intelligence Network
(NCIN).
In particular it will be essential to have complete, accurate and timely staging data for all
cancers to determine changes in presentation patterns together with the recording of
emergency presentations of cancer through A&E. Commissioning of pathways and
contracts with providers must reflect this requirement.
A key deliverable, as a commissioning support tool, will be an ‘outcomes framework’ and
reporting mechanism for earlier detection (in addition to the output specification metrics
for the ICSs). This will need to align with national models, including NICE Quality
Standards, and integrate with the output specification metrics for the Integrated Cancer
Systems. This could include, for lung cancer as an example:
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5 year survival
1 year survival
curative resection rates
stage at presentation
emergency/A&E presentation rates
lung cancer awareness measure scores
% cancers referred through direct x-ray requests
It will also be important to develop and agree metrics for measuring co-morbidities and to
respond to the data collection arrangements for uptake of diagnostic tests from primary
care as these are introduced by the Department of Health.
Evidence-based Interventions to Improve Public Awareness
Where there is good evidence for measures that support early diagnosis, these should be
introduced across London. The evaluation of national and local pilots is contributing to the
evidence base on effectiveness of public awareness campaigns. All areas will have local
solutions for local issues but maximum health gain requires an overall pan London
approach. These measures should include:

Public awareness – The National Bowel Cancer Awareness Campaign ran for two
months from the end of January 2012. A national lung cancer awareness will run for
two months in May-June 2012. National campaigns require clear and careful panLondon and local implementation for maximum effect. DH/NCAT funded pilot projects
with evaluation are underway for breast, bowel and lung cancer and more are in
preparation for other tumour sites. DH is also funding pilot projects for campaigns to
raise awareness of oesophagogastic cancers. These campaigns will require local
‘advocacy’ and engagement and possibly design modifications to ensure effective pan
London spread and to ensure that they target groups identified as having poorer
awareness.

Presentation to primary care – Implementation of awareness campaigns needs to
be mirrored with initiatives to ensure that people, in addition to being aware of the
importance of their symptoms, present to primary care. These initiatives may be locally
or population segment specific but remain an essential element of the pan London
approach.

Screening for breast, cervix and bowel cancer is critical to improving early detection
and therefore to the commissioning strategy plans of commissioning groups. This is a
particular area where the evaluation of local improvement strategies needs to be
shared across London where communities and population segments can be shown to
benefit from specific approaches.
To maximise the effectiveness of these interventions, and the tackling of inequalities, we
recommend a London wide approach. This may best be delivered by a small specialist
team to ensure co-ordination and implementation and to support local action.
GP Engagement and Service Improvement
We recommend that each CCG has a primary care cancer lead (PCCL) with a minimum
of one and up to 2 sessions per week for cancer work (to reflect population needs). The
role of this post will include the need to improve early diagnosis and the most effective
use of diagnostics through:

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raising awareness of and implementing London wide NAEDI initiatives locally
identifying solutions to address local needs (in cancer)
ensuring implementation and appropriate use of diagnostic pathways
ensure maximum GP participation in education and training programmes:
- Early diagnosis of cancer
- Use of diagnostics

GP involvement in the cancer pathway to include follow up where appropriate
reviewing practice cancer profiles and carrying out local cancer audits. These may
include audits such as:
- Review of last 2 years cancer diagnoses looking for delays
- Practice level audits of patient awareness
- Root analysis of cancers diagnosed at A&E or by Acute Oncology Services
(AOS)
Macmillan Cancer Support have already made specific and updated recommendations on
this within their role description of a Macmillan primary care cancer lead which has a
wider remit beyond earlier detection.
Direct GP Access to Diagnostics
Direct access to the following should be available to and accessed by all GPs in London
as per national guidance:




chest X-Ray for lung cancer
non obstetric ultrasound for pelvic gynaecological cancer, particularly ovarian cancer.
MRI for brain tumours
flexible-sigmoidoscopy and colonoscopy for colorectal cancer
A survey of current commissioning arrangements has indicated that:



all PCTs in London provide direct access to chest x-ray although access to x-ray
through pathways that give rapid access to lung MDTs is variable
all PCTs provide commissioned access to MRI and the large majority to non-obstetric
ultrasound although uptake is variable and cancer specific usage is not known.
direct access to flexi-sigmoidoscopy and colonoscopy is variable with local schemes
and pilots
This analysis of this baseline survey will be developed and validated through primary care
leads and made available as a commissioning support tool.
Most networks have highlighted the need for reviewing current access to diagnostics. In
NE London and NC London, there are local projects to test direct access to colonoscopy.
SW London is testing a direct pathway from pharmacy to secondary care for residents
with suspect lung and bowel cancer symptoms; they are also testing direct access to
sigmoidoscopy. Some localities are exploring models that give direct public access to
diagnostic tests.
As these investigations are primarily designed to diagnose cancer with the intent of
improving outcomes, we have agreed the following principles:



tests should be requested rapidly following presentation
referral for the original test should be seen as the initiation of a diagnostic pathway,
where abnormal findings should result in direct further investigations to diagnose or
exclude cancer without unnecessary delays in the treatment pathway and with the
minimum of hand offs to ensure all patients receive the highest quality care
reports must be available in a timely manner (within one week).
Requesting criteria for direct GP access to these tests and the pathways to general or
specialist diagnostic services are being developed nationally and, when published by the
DH, should be disseminated to all GPs. The DH recognise that data are not available on
current GP use of such diagnostics for the specific indication of suspicion of cancer and
are also developing data collection requirements which should be implemented across
London once agreed.
These diagnostic pathways will need to be commissioned to ensure access across
London. This national strategy is intended to increase the use of these tests from primary
care; PCTs should plan for this increase. The lack of an accurate baseline of current
access and usage constrains the estimate of the cost impact.
Role of Integrated Cancer Systems (ICS) in Reducing Delay
Integrated cancer systems are being developed across London and are an integral part of
achieving earlier detection from cancer.

Earlier diagnosis and better survival at 1 year should be key performance indicators
for the ICS. The ICS will need to work with CCGs, Networks and others across the
whole of the early detection pathway but with a particular emphasis and leadership
role on optimising referral from primary care.

ICS will need to ensure all trusts with specialist cancer services have acute oncology
services to ensure patients presenting with symptoms suspicious of cancer are
investigated on an enhanced pathway. Presentation with cancer as an emergency will
be seen as a key indicator of improving earlier detection of cancer.

All trusts should have clear protocols for scrutiny and transfer of patients with
symptoms suggestive of cancer to an enhanced pathway.

ICS should be commissioned to record and report stage at presentation and the
number of presentations of cancer as emergencies. Output metrics should also
include measures of co-morbidities.
6. Resources
The cost of cancer in England, including both direct NHS costs and societal costs such as the
loss of productivity, has been estimated at approximately £18 billion per annum
(Featherstone and Whitham, Policy Exchange 2010). The same source proposes that if UK
survival rates improve to the best in Europe then a substantial reduction in cost will result,
£10 billion cumulatively by 2020. These economic benefits will be available to, and important
for, London and Londoners.
The DH financial impact assessment of the NAEDI strategy, published in January 2011, sets
out detailed cost modelling and analysis of the impact of earlier diagnosis on five different
cancers. There is likely to be increases in diagnostic costs partially offset by a smaller
reduction in treatment costs. They also recognise the additional increase in diagnostic and
treatment costs while the new policy is implemented. This is the time when the period
between the onset of the disease and the diagnosis is reduced and there is a catch up to
meet the new times. Their overall conclusion is that earlier detection would represent value
for money but would not be cost saving. This is consistent with the conclusion reached in the
model of care.
There are difficulties and variability in estimating these effects; this variation has been
illustrated in the evaluation of the pilot of the national bowel awareness campaign when the
increase in screening uptake has not reached the anticipated levels. The DH work is based
on national statistics, the impact on London needs to be better understood given for example
the lower levels of screening uptake that have been resistant to repeated efforts to improve
them.
The financial impact will also depend on the speed at which implementation, including for
screening, is planned and delivered. The next stage of analysis will be to take the model
used by the DH and use data and assumptions that are appropriate for the capital so that the
overall financial impact can be included in a business case.
It is recommended that commissioners should:
Allow for an expected increase in use of diagnostic and treatment costs in
risk reserves for 2012-13 until detailed plans are developed
Include provision in commissioning strategy plans for awareness
campaigning at the level of £100,000 per 200,000 population, network GP
leadership at £25,000 per network and up to 2 sessions per CCG
7. Commissioning Support Tools
The following are being developed to provide more detailed information to support
commissioning of earlier detection:
a) Summary of delivery responsibilities for key elements of strategy
b) Summary of recommendations and commissioning intentions
c) Early detection pathways with evidence base and best practice interventions. The
programme will explore the development of these on Map of Medicine. The initial
priority will be for colorectal (extract of project initiation document appended no its
not), lung cancer, ovarian cancer and brain cancer reflecting the priority open access
diagnostic tests. These will provide templates for a development programme for other
cancers.
d) Validated analysis, by PCT, of availability and commissioning of direct access to the
four priority diagnostic tests
e) Requesting/referral criteria and pathways for the priority diagnostic tests as they are
issued by the Department of Health
f) Department of Health economic models localised for London
g) A framework of monitoring metrics and reporting process
8. Implementation plan
An outline implementation plan and delivery model is shown below. This will require further
development.
It is important to acknowledge that the delivery model for earlier detection is complex and this
is particularly the case as the NHS transitions to the new commissioning arrangements and,
for London, the integrated cancer systems develop. Implementation plans will require further
development as changes emerge and to ensure clarity on leadership and responsibility and
accountability for actions. It is proposed that the current lead arrangements for the London
cancer programme continue during the transition and for the overall coordination of the
implementation of this strategy reporting to the proposed London (Commissioning) Cancer
Board as it emerges. Current lead arrangements within cancer networks and at borough and
cluster levels, reporting to network boards, should continue in the transition with clear links to
the London level programme. Or: It will be important to maintain the local leadership at
borough and cluster level through and beyond the transition; these will need to have clear
links with the London Programme.
Successfully achieving the lives saved targeted by this strategy will require the integrated
actions of existing and emerging NHS structures including Health and Well Being Boards,
The NHS Commissioning Board and Clusters, Cancer Networks, Integrated Cancer Systems,
Public Health England, the London Screening Improvement Board, Clinical Commissioning
Groups and Primary Care. It will particularly need the careful integration with other strategies
including those of the LHIB and the London Screening Improvement Board.
Priority
Lead
Timescale
PT
Apr 2012
Accurate and complete recording of staging and A&E
presentations to be included in all commissioning
contracts
SCUs
Mar 2012
Pathways and best practice guides
PT
Dec 2011 to
Sept 2012
All areas of London to have plans to raise public
awareness of cancer, with a London wide project team to
co-ordinate
Networks/PT
Sept 2012
Ensure all social marketing campaigns are properly
evaluated and that evaluations are used to provide an
evidence base for effectiveness
Networks
1. Information and Intelligence
Develop outcomes framework of metrics and reporting
process
2. Improving awareness of cancer
Ongoing
3. GP Engagement and Service Improvement
All areas to have GP cancer leads
CCGs
Apr 2012
All areas to have rolling programme of integrated
training programmes for GPs to keep GPs up to date with
guidance
CCGs ?
Apr 2012
GPs to be encouraged to audit pathways of all cancer
cases
GP leads
Ongoing
AOSs* to audit all people with cancer first presenting at
A&E to identify reasons
ICSs
Ongoing from
Dec 2011
SCUs/CCGs
Apr 2011
PT
Oct 2012
ICSs
Dec 2011
ICSs
Apr 2012
ICSs
Ongoing
4. Improving GP access to diagnostics
Commission direct access for GPs to specified
diagnostics with direct onward referral for positive cases;




CXR
Flexible sigmoidoscopy/colonoscopy
Non Obstetric US for ovarian cancer
MRI for suspected brain cancers
Disseminate protocols/guidance for direct access and for
results pathways
5. Reducing delays in secondary care
All A&E departments and trusts with specialist cancer
services to have an acute oncology service to pick up
patients with suspected cancer as per national guidelines
All acute trusts to have protocols and training for the
rapid pathway to ensure all patients with suspected
cancer are transferred to the appropriate clinical dept
irrespective of their route into the trust including A&E and
routine medical and surgical
All trusts should regularly audit their cancer pathways by
tumour site against international best practice and to
identify system delays
Commissioners to monitor compliance with contract
SCU/Networks
Ongoing
LHIB
Ongoing
PT
Jun 2012
LHIB
Focusing on the interventions proposed within prevention
and early diagnosis workstream www.lhib.org.uk
Resources
Localise DH economic models to London and analyse
results
*SCU = Sector Commissioning Unit
AOS = Acute Oncology Service
ICS = Integrated Cancer system
PT = Early Detection project team
Appendix 1. Potential numbers of lives saved in London
These have been calculated by taking the best 5 year survival rates for breast colorectal and
lung in the country and applying them to cancer populations in London PCTs. These
calculations suggest that over 1200 lives could be saved in London for these 3 cancer sites.
Given the complexities of European comparisons, choosing the best in England as a target
seems a more robust benchmark in the short term but aiming for survival rates that compare
to the best in Europe should remain the target. These figures are only indicative and
should not be taken as target figures. Additionally there is considerable variation
within boroughs, eg borough with good survival may have pockets of poor survival
Breast
Colorectal
Sum of breast,
colorectal and
lung
Lung
Lives
Lives
Lives
Incidence saved Incidence saved Incidence saved
2002-4
pa
2002-4
pa
2002-4
pa
cases pa
Lives
saved
pa
Barking and
Dagenham
286
14
239
21
339
16
288
52
Barnet
586
10
437
36
425
13
483
59
Bexley
485
11
356
21
406
14
416
46
Brent
387
6
317
16
318
10
341
32
Bromley
728
11
491
37
526
22
582
70
Camden
311
4
248
14
292
6
284
25
City
&Hackney
263
15
199
5
284
9
249
29
Croydon
654
13
433
20
451
20
513
53
Ealing
452
13
342
20
359
13
384
46
Enfield
475
15
377
31
364
16
405
61
Greenwich
389
9
368
30
418
18
392
58
Hammersmith
and Fulham
214
6
162
11
234
10
203
28
Haringey
297
10
223
8
264
9
261
27
Harrow
443
9
274
14
256
7
324
30
Havering
501
14
409
27
451
20
454
61
Hillingdon
408
10
260
17
402
17
357
43
Hounslow
314
13
262
17
265
10
280
40
Islington
229
8
212
14
318
12
253
34
Kensington
and Chelsea
271
3
204
4
197
0
224
7
Kingston
upon Thames
307
2
240
15
192
8
246
25
Lambeth
409
11
277
15
361
13
349
40
Lewisham
396
12
277
24
375
14
349
50
Newham
269
15
193
13
322
13
261
41
Redbridge
417
13
321
20
315
10
351
43
Richmond
upon Thames
378
7
285
14
278
10
314
31
Southwark
383
13
275
23
394
18
351
54
Sutton &
Merton
663
17
566
30
548
19
592
66
Tower
Hamlets
224
11
190
9
337
10
250
30
Waltham
Forest
309
15
249
28
265
14
274
57
Wandsworth
442
9
303
23
385
13
377
45
Westminster,
358
7
238
0
318
1
305
9
388
10711
1289
London
325
576
* Using numbers of people diagnosed in 2002-4 and 5 yr survival rates for people diagnosed
in 2002-4; NCIN
G
L
LO AN
N D
Ke
D
n s H ON
'n ar
& ro
C w
he
ls
e
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rn
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om
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tm ton
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s
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ro ,
yd
o
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H f iel
il li
d
n
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on
al
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t
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am
n
'th Fo
& res
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av m
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ou
ns g
lo
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am
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h
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G wo
re rth
e
So nwi
u t ch
hw
La ark
m
be
Ba
rk Is l th
in in g
g
To & to
n
w
er Dag
H
am 'm
le
ts
EN
Age standardised registration rate per 100,000
G
LA
Ke
n s LO ND
'n N
& DO
C
he N
ls
e
W Ha a
e s rro
tm w
in
st
er
,
So Bre
u t nt
hw
ar
Ba k
rn
Ba
rk Be et
in
g xle
&
y
D
R ag
ed 'm
br
id
ge
To
w En
er f ie
H ld
a
G ml
re e t
en s
w
i
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om
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il li n
ng
H do
av n
e
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al
th i sh
am am
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re
s
Ea t
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m
b
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ar h
in
ge
W Su y
an tt
ds on
w
or
H
am Ha th
'th ckn
& ey
Fu
lh
a
M m
er
C ton
ro
yd
Ki o n
ng
H sto
ou n
ns
lo
Is w
lin
R gto
ic
hm n
on
d
EN
Age standardised registration rate per 100,000
G
LA
LO N
D
N
D
O
N
Br
e
H nt
ar
ro
w
En
f ie
To
ld
w Ba
er rn
H et
am
So le
ut ts
hw
ar
Be k
xl
N ey
ew
h
H am
a
G ckn
re e
en y
w
Ke
ic
ns
h
'n E
& al i
C ng
he
ls
e
Su a
H t ton
W ari
e n
W stm ge y
al
th i ns
am te
r
Fo ,
re
M st
e
H Ho rto
am u n
'th ns
& low
Fu
lh
La a m
m
b
H et
il li h
ng
d
C on
am
C de n
ro
yd
Ba
o
rk Bro n
in
g ml e
&
y
D
Le ag
w 'm
is
R ham
ed
br
i
H d ge
av
er
Is i ng
lin
R gto
i
W chm n
an o
ds nd
w
o
Ki rth
ng
st
on
EN
Age standardised registration rate per 100,000
Appendix 2. Cancer incidence rates in London boroughs
Appendix 2 shows the incidence rates for breast colorectal and lung cancer in London
boroughs. These rates are age standardised so variations in numbers of cases due to an
older or younger population are evened out. Incidence rates demonstrate health inequalities
between boroughs in London
160
Incidence of breast cancer in London boroughs, 2006-8
140
120
100
80
60
40
20
0
70
Incidence of colorectal cancer in London boroughs, 2006-8
60
50
40
30
20
10
0
Incidence of lung cancer in London boroughs, 2006-8
90
80
70
60
50
40
30
20
10
0
Appendix 3. One and 5 year relative survival rates from breast, colorectal and lung
cancers, national quintiles, in London PCTs
One year survival*
Organisation name
Breast Colorectal Lung
5 year survival*
Breast
Colorectal
Lung
Barking and
Dagenham PCT
93.37
69.7
24.13
76.53
43.12
6.08
Barnet
96.75
74.12
31.62
86.49
45.1
11.33
Bexley Care Trust
98.56
72.03
25.58
84.92
52.62
9.64
Brent Teaching PCT
94.51
78.39
32.7
86.99
54.91
11.01
Bromley PCT
96.43
73.25
34.6
87.12
47.61
7.58
Camden PCT
94.66
82.69
32.99
87.4
53.39
13.69
City and Hackney
PCT
96.59
69.82
29.2
74.37
62.53
10.75
Croydon PCT
95.71
78.28
34.97
85.73
56.38
6.94
Ealing PCT
95.58
74.4
26.98
82.92
52.65
9.14
Enfield PCT
94.59
73.23
30.89
82.24
45.37
7.34
Greenwich Teaching
PCT
94.44
73.3
28.24
84.36
45.48
7.23
Hammersmith and
Fulham
98.95
78.29
35.83
83.15
49.49
6.87
Haringey Teaching
PCT
96.78
70.67
35.27
81.99
58.67
10.18
Harrow PCT
95.21
69.75
33.11
85.73
55.1
11.73
Havering PCT
96.08
68.44
32.27
83.33
50.42
6.95
Hillingdon PCT
95.53
74.32
21.67
84.51
50.3
7.86
Hounslow PCT
99.27
76.96
30.15
79.22
50.1
9.02
Islington PCT
93.44
72.59
35.1
81.39
49.87
8.7
Kensington and
Chelsea PCT
96.02
81.82
43.49
88.44
63.74
20.31
Kingston PCT
97.88
80.87
33.98
89.5
51.6
7.07
Lambeth PCT
97.83
72.37
33.85
83.31
53.36
9.48
Lewisham PCT
97.04
68.76
30.73
82.69
44.24
8.84
Newham PCT
95.3
65.88
28.45
75.05
49.34
8.05
Redbridge PCT
96.09
74.35
26.4
82.6
50.9
10.72
Richmond and
Twickenham
96
80.89
38.22
86.19
55.45
9.32
Southwark PCT
95.62
80.25
33.25
81.42
45.11
6.81
Sutton and Merton
PCT
96.09
71.82
37.45
84.03
54.21
9.65
Tower Hamlets PCT
92.99
70.85
32.17
76.42
56.31
11.56
Waltham Forest PCT
93.57
68.97
27.04
77.03
36.73
4.38
Wandsworth PCT
97.9
76.78
31.89
85.22
47.16
10.45
Westminster PCT
97.37
80.55
42.96
85.64
70.04
18.9
* People diagnosed in 2006-8 (one year), and 2002-4 (5 year). Source: CCT
Lowest quintile
Highest quintile