Beating cancer: ambition and action

5. Early Detection and Diagnosis

Our Ambitions

To make early detection of cancer the norm.

To have swift diagnosis and results for clinicians and individuals.

To enhance the role of primary care in beating cancer.

Improving our ability to detect cancer at an early stage will make a significant difference towards achieving our ambition of increasing survival from cancer and in reducing variation in survival rates across Scotland.

Five-year survival rates from cancer in Scotland are lower than other European countries. This difference occurs mostly in the first year after diagnosis, suggesting that advanced stage at disease presentation could contribute to this survival difference.

Diagnosing cancer earlier will often improve quality of life after treatment. For those with advanced disease it can mean that individuals may still be well enough to tolerate treatments that could slow down progression of the disease and prolong life.

Some people also miss the opportunity to join clinical trials because they are often not well enough to participate at the point they are diagnosed. Earlier diagnosis will enable more people to join clinical trials which are recognised as improving outcomes and to support the development of new and effective treatments.

Changing public perceptions and attitudes to cancer will take time, however, through targeting public awareness messaging to those most likely to present with later stage disease and those less likely to participate in screening (those living in the more deprived communities across Scotland) improvements in outcomes can be achieved.

Short-lived early detection programmes alone are unlikely to eradicate Scotland's cancer survival deficit, or fully address the cancer health inequalities gap. By sustaining efforts targeted at earlier stage detection, we will help achieve our ambition of improving survival rates.

Detect Cancer Early Programme (DCE)

The Scottish Government has invested £39 million in the DCE programme since February 2012.^[45] This ambitious programme aims to improve 1-year and 5-year survival rates for people with cancer in Scotland by actively addressing diagnoses and treatment at an early stage.

The programme also aims to reduce differences in cancer survival rates between the most affluent and least affluent areas of Scotland. There are five DCE work streams:

• Public Awareness
• Informed decision making around screening programme participation
• Primary Care recognition and referral behaviour
• Increasing Diagnostic Capacity
• Data, Evaluation and Outcomes

Public Awareness

DCE campaigns are particularly targeted to those living in the more deprived communities empowering individuals to recognise early signs of cancer and balance the value of screening programme participation. This ensures that those more likely to present with later stage disease and those who have poorer outcomes following a cancer diagnosis are particularly targeted. The 'influencers' (friends/family members) of this audience are also key to the social marketing activity.

Successful DCE social marketing campaigns have taken place in breast, lung and colorectal cancer. All marketing activity is extensively tested and is delivered in collaboration with local NHS Board public health departments to engage with the most hard to reach groups, this marketing included targeted television buying, local radio platforms, innovative use of social media and field activity in high footfall areas such as football matches and shopping centres.

As we develop the DCE programme we will continue to take forward our work on detection of breast, lung and bowel cancer as we build for the future.

We will continue to target these campaigns to those living in the most deprived areas to reduce the variation in survival rates between the least and most affluent communities.

The 'Wee c'

A new strand of activity was introduced into the DCE programme in 2015 - the 'wee c'. In partnership with Cancer Research UK, the 'wee c' aims to change perceptions and attitudes to cancer in Scotland in a bid to reduce fear around the disease and encourage earlier presentation. This was accompanied by a generic awareness raising campaign #getchecked.^[46]

Working in partnership we are exploring the barriers to help-seeking behaviour and, where appropriate, using and adapting the creative material developed in the programme to address these barriers and extend the reach of the programme, regularly monitoring and evaluating the impact. We will continue with our programme of early detection and support local tests of change for introducing additional tumour groups into the programme, and as a result of options appraisal, begin with malignant melanoma in 2016-17. Expansion to national activity will be considered following evaluation of local tests of change.

Engagement with Primary Care

As the DCE programme encourages people to visit their GP when they find any unusual or persistent changes to their body or health, working with GPs to promote referral or investigation at the earliest reasonable opportunity to improve cancer outcomes is vital.

The DCE programme has already supported eHealth improvements around notification of bowel screening status to primary care clinicians, and introduced initiatives to facilitate informed and timely discussions with individuals about bowel screening programme participation.

To support GPs to refer people with suspected cancer as early as possible Healthcare Improvement Scotland, funded by DCE, led a review of the Scottish Referral Guidelines for Suspected Cancer.^[47] Published in 2014, these guidelines will help GPs to identify people who are most likely to have cancer and who therefore require urgent assessment by a specialist. By providing up-to-date guidance around signs and symptoms of cancers where early detection can play a critical role we can increase the potential for successful treatment.

The DCE programme is encouraging referral activity that is aligned with the published national guidelines but allows flexibility for clinical suspicion, developing a national framework and promoting local implementation of pathways that accelerate triaged investigation and decision making for people presenting with non-specific symptoms that could indicate cancer.

There is a pilot underway in NHS Tayside looking at the use of faecal immunochemical testing (qFIT) in primary care for symptomatic individuals who may (or may not) have bowel cancer. This pilot enables GPs to identify those individuals who warrant urgent 'straight to test' referral and to reassure those in whom a policy of watch and wait would be the optimal choice.

If this pilot is successful it could transform the management of people with colorectal symptoms so that many would be spared unnecessary invasive investigation and those who need it would need it would have appropriate further tests more promptly. As a consequence of the use of qFIT in routine use in primary care this may also lead to of reduced waiting times. This pilot will be evaluated on completion.

Data, Outcomes and Evaluation

Since the launch of the DCE programme there has been a 6.5% increase in recorded early stage diagnosis for breast, lung and colorectal cancers combined.^[48] The programme is particularly focused on reducing inequalities and has seen the largest increase in stage I diagnoses in the most deprived areas of Scotland, this is a 14% overall increase from baseline.^[49]

There has been significant improvement in the percentage of people recorded as diagnosed with lung cancer at the earliest stage (24.7% increase) since the launch of the programme.^[50]

There has been a 81.1% increase in the number of replacement bowel screening kits requested since the launch of the programme^[51] and latest validated statistics from ISD also show an increase in bowel screening uptake (57.6% from 54.9%) for the period November 2012 to October 2014 compared to pre-DCE. Uptake for women was 60.3% and for men was 54.7%. In particular uptake in the most deprived areas in Scotland has increased (from 41.9% to 45.3%). Men in particular have increased from 39.6% to 43.6%).^[52]

We are also aware of the growing demand for Dermatology services, given increasing public awareness and incidence of skin cancers. Overall, levels of demand are forecast to grow: by as much as 2.4% over the next year. Incidence of malignant melanoma is predicted to increase by 60% by 2027 (5,913 cases to 9,462 cases).^[53]

In order to prepare the NHS for this growth and tackle existing and future demand we will work with health professionals across this service, and with appropriate representatives, to test and spread new ways of working and optimal pathways. This will embrace identified tests of change, initially on a small scale, but quickly driven and scaled up to drive more uniform service benefits.

Earlier Diagnosis

Many people are referred by GPs and other healthcare professionals for assessment or for specific investigations to seek to identify the disease or condition that they may have. For cancer this 'symptomatic' route of referral may include a range of different investigations before a definitive diagnosis is made.

Diagnostic services have an important influence on the diagnosis of cancer and the subsequent delivery of cancer treatment. Statistics from EUROCARE studies suggest that poorer survival in Scotland primarily relates to late presentation.^[54] Imaging plays a vital role in ensuring accurate and timely diagnosis and staging of cancer as do laboratory-based investigations. Diagnostic specialities require specific clinical expertise and specialist equipment, supported by efficient and timely mechanisms for sample collection, transport, processing, imaging, interpretation and reporting.

Significant improvements in the level of detail and discrimination in the use of imaging tests such as computed tomography (CT) and magnetic resonance imaging (MRI) have delivered the ability to detect and treat cancer at earlier stages, thus improving outcomes.

Imaging also has a significant role in assessing the effectiveness of treatment for cancer and in surveillance for recurrent disease. Modern treatment regimens which require more frequent assessment of response to treatment and an overall increase in the number of people treated has led to a requirement for significantly increased capacity to ensure timely access to CT, MRI and Positron Emission Tomography/CT (PET/CT).

We have well-developed and sophisticated diagnostic services across the country, with collaborative working to achieve equitable access across the NHS in Scotland, supported by four national Managed Diagnostic Networks (MDNs) who focus on delivering safe and effective services, always with a focus on continuous quality improvement, in pathology, imaging, clinical biochemistry and microbiology and virology diagnostic specialities.

We also recognise that diagnostic services are subject to a range of pressures. The increasing number of older people, the growth in long-term conditions and ongoing technical and clinical developments have increased demand on all diagnostic services. It is essential that we have a clear picture of future requirements in order that we can plan effectively for the future delivery of these vital services.

The pathway to diagnosis and staging is complex and particularly so for some tumour types. Many people with symptoms and signs initially suspicious of cancer are also going through these same diagnostic (test-focused) pathways but are fortunately found not to have cancer. The demand for this wide-ranging array of tests consequently far exceeds the number of people who are subsequently found to have cancer, sometimes by as much as 100:1 and for rarer cancers an even greater ratio of demand to cancer diagnosed.

In 2015 we invested £3.7 million to fund a Regional Endoscopy Unit at Queen Margaret Hospital, Dunfermline which addresses demand by providing an additional endoscopy facility. This unit is now operational and receiving referrals from NHS Fife and NHS Lothian with plans to expand to NHS Forth Valley and NHS Tayside.

But more is needed. Currently, across Scotland, an estimated number of 223,381 scopes are provided each year for diagnostic purposes. We know that for the future we already need a further 45,000. Recent modelling suggests that demand is likely to increase by up to 20% over the next 10 years. By expanding scoping capacity across the country, we will significantly enhance facilities for the detection of cancer.

By 2021 we will have a network of six new Diagnostic and Treatment Centres across Scotland. The new centres will have a dual function of speeding up cancer diagnoses and ensuring swift access for elective procedures.

Supporting Primary Care

Recent information from the International Cancer Benchmarking Partnership (ICBP) suggests that some features of the interface between primary and specialist care in the UK may constrain the readiness of GPs to refer individuals, and may be important in our poorer cancer survival compared with some other countries. In particular, the study noted the difference in the availability of direct access to CT and MRI scanning for GPs.^[55]

The Scottish Primary Care Cancer Group (SPPCG) and the Scottish Clinical Imaging Network (SCIN) have produced a Pathway paper to support and improve timely and direct access by GPs to clinical imaging for chest, abdomen and pelvis for individuals with unidentified malignancies. We are working with the SPCCG and SCIN to investigate the resource implications associated with this.

Actions - Early Detection and Diagnosis

• We will create new processes to capture activity and waiting times' data for diagnostic tests. We will ensure this is aligned with the Innovative Health Care Delivery Programme and specifically the work to develop a transformed national cancer intelligence system.
• Invest an additional £2 million per annum in a new Diagnostics Fund to support swift access to diagnostics for people with a suspected cancer diagnosis.
• Increase MRI capacity at the Golden Jubilee National Hospital from April 2016.
• We will continue to target our Detect Cancer Early social marketing campaigns to those individuals who are most likely to present with later stage disease and less likely to participate in screening. Add malignant melanoma to the DCE programme, investing £500,000 in local tests of change throughout 2016-17 to expand DCE in this way.
• Expand the collaborative focus for dermatology, and more particularly melanoma, by harnessing the proven methodology of the successful MSK and Orthopaedics Quality Drive^[56] and National ACCESS Programme.^[57] This will provide a renewed focus with measurable outputs.
• Increasing by 40% the number of Nurse Endoscopists in training - who will be available for work in 2017.
• Invest an additional £1 million per annum in additional scopes capacity, which will see an additional 2,000 scopes per annum on a sustainable basis. By investing in diagnostics we aim to give people quicker access to vital cancer tests and their results.
• Participate in projects and audits with partners such as CRUK to understand and improve routes to diagnoses and ensure that any applicable lessons can be incorporated.
• Support primary care education and training in early cancer detection and screening, working collaboratively with third sector colleagues.
• Support further improvements in early diagnosis, cancer prevention and the interface between primary and secondary care. We are working in partnership with Cancer Research UK to develop and expand their health professional facilitator engagement programme across Scotland in 2016-17.