Impact of cancer symptom awareness campaigns on diagnostic testing and treatment

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2 Impact of cancer symptom awareness campaigns on diagnostic testing and treatment Abigail Bentley, Erika Denton, Lucy Ironmonger, Sean Duffy September 2014

3 Content Background Methods Key results Discussion Limitations Further work Acknowledgements References

4 Relative survival Background: Lung Cancer in England Most common cause of cancer death (~28,000/year) Long-term survival is poor & worse than elsewhere 20% 15% 10% 5% 0% 5 year age-standardised relative survival Australia Canada Denmark Norway Sweden England Coleman et al Reasons: Differences in quality/access to treatment? Later diagnosis? Walters et al & Holmberg et al

5 Background: Public Awareness Campaigns Small community-based intervention in Doncaster Athey et al DH funded local pilot interventions Aim: raise awareness of persistent cough as a lung cancer symptom & encourage GP visits Regional pilot: East & West Midlands Oct Nov 2011 National campaign: England May June 2012 Note: National campaign repeated July/Aug

6 Methods Data collected on a range of metrics: Public awareness Presentations to primary care 2WW referrals Diagnostics (Diagnostic Imaging Dataset) Diagnoses (National Lung Cancer Audit / Cancer Waiting Times and Monitoring Dataset) Stage at diagnosis (National Lung Cancer Audit) Surgical resection rate (National Lung Cancer Audit)

7 Methods Data collected pre-campaign CHANGE MEASURED Significance tested with χ 2 Data collected during campaign (May-July 2012) Same period previous year (May-Jul 2011) Month prior (April 2012) DIFFERENCE MEASURED Significance tested with poisson regression Surgical resections Diagnostics Compared to time control Diagnoses Stage

8 Key results: CXR Year Tests/organisation /working day April (precampaign) May-July (campaign) % change P- value GP-referred chest x-rays % < (control) % <0.001 All chest x-rays % < (control) % < % increase in GP-referred CXRs between pre-campaign & campaign (p<0.001) -0.8% decrease in all CXRs between pre-campaign & campaign (p<0.001) Data source: Diagnostic Imaging Dataset Campaign: first national lung May-June 2012

9 Key results: CT Year Tests/organisation /working day April (precampaign) May-July (campaign) % change P- value GP-referred chest +/- abdominal CTs % < (control) % All chest +/- abdominal CTs % < (control) % < % increase in GP-referred CTs between pre-campaign & campaign (p<0.001) 4% increase in all CTs between pre-campaign & campaign (p<0.001) Data source: Diagnostic Imaging Dataset Campaign: first national lung May-June 2012

10 Key results 9% increase in lung cancers diagnosed during May-July 2012 compared to May-July 2011 (p<0.001) 18% increase in diagnoses following a 2WW referral (p<0.001) Data source: National Lung Cancer Audit/Cancer Waiting Times and Monitoring Dataset Campaign: first national lung May-June 2012

11 Percentage point change between 2011 & 2012 Key results 9% increase in lung cancers diagnosed during May-July 2012 compared to May-July 2011 (p<0.001) 18% increase in diagnoses following a 2WW referral (p<0.001) Evidence of a stage shift at diagnosis: * Stage I Stage II Stage III Stage IV * Control (Feb-April) Campaign (May-July) 3.1 percent point increase in stage 1 diagnoses and corresponding 3.5 percent point decrease in stage 4 diagnoses (p<0.001) during May-July 2012, compared to 2011 * Statistically significant change; p<0.05 Data source: National Lung Cancer Audit Campaign: first national lung May-June 2012

12 Proportion of patients receiving surgical resection Key results 9% increase in lung cancers diagnosed during May-July 2012 compared to May-July 2011 (p<0.001) 18% increase in diagnoses following a 2WW referral (p<0.001) Evidence of a stage shift at diagnosis: 2.3 percentage point increase in proportion of patients receiving surgical resection as a first definitive treatment during May-July 2012, compared to 2011 (p<0.001) * * Statistically significant change; p< Campaign period (May-Jul) Control period (Feb-Apr) Data source: National Lung Cancer Audit Campaign: first national lung May-June 2012

13 Discussion Substantial increase in GP-requested chest x-rays Decrease in imaging requested via all routes First data to show a shift in stage at diagnosis following a campaign Surgical resection = Rx most likely to improve long-term survival Anticipate that increased receiving surgery will lead to reduction in lung cancer mortality

14 Limitations No strict control available Data quality of the DID Provisional data for 2013

15 Further work Impact on CXR reporting times Impact on emergency presentations Impact on survival and mortality rates Cost-effectiveness Negative & other positive impacts Longevity of impact Effect of repeating the campaign Preparing a manuscript for peer review

16 Acknowledgements We would like to thank the following organisations: Cancer Research UK Department of Health Diagnostic Imaging Dataset team National Lung Cancer Audit team and the Health & Social Care Information Centre NHS England Public Health England

17 References Athey V, Suckling R, Tod A, et al. Early diagnosis of lung cancer: evaluation of a community-based social marketing intervention. Thorax 2012;67: Coleman MP, Forman D, Bryant H, et al. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet, 2011;377: Holmberg L, Sandin F, Bray F, et al. National comparisons of lung cancer survival in England, Norway and Sweden : differences occur early in follow-up. Thorax, 2010;65: Walters S, Maringe C, Coleman MP, et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the United Kingdom: a population-based study, Thorax 2013;68:

18 Since this presentation, these results have been published in the British Journal of Cancer: Ironmonger L, Ohuma E, Ormiston-Smith N, Gildea C, Thomson CS, Peake MD. An evaluation of the impact of large scale interventions to raise public awareness of a lung cancer symptom. Br J Cancer, 2014 [Epub ahead of print] doi: /bjc