Accelerate, Coordinate, Evaluate Programme: a new approach to cancer diagnosis

Cancer survival in England falls short of the best in the world. It is estimated that if the NHS is successful in implementing the initiatives and ambitions outlined in the 2015 cancer strategy, up to 30 000 more patients per year will survive cancer for 10 years or more by 2020. Of these, almost 11 000 will be through earlier diagnosis.¹ To achieve the system-wide changes needed to support earlier and faster diagnosis for patients, evidence will be critical.

A key objective of the ACE (Accelerate, Coordinate, Evaluate) Programme (www.cruk.org/ace) is to provide evidence to support development of new diagnostic pathways. ACE was initiated in June 2014 as a 3-year NHS England initiative, supported by Cancer Research UK and Macmillan Cancer Support, with a team made up of staff from the three organisations. The programme aims to address the NHS outcome of ‘preventing people from dying prematurely’, as well as improving overall patient experience along the diagnostic pathway.

Through funding from ACE, as well as from local NHS organisations, a number of projects are running across England trialling new approaches and pathways to diagnosis. Of these, ACE supports many projects looking at the important role GPs and other primary care health professionals have in recognising symptoms of cancer and referring patients who need further investigation. By evaluating these local approaches, ACE will present a national body of evidence to inform cancer commissioning.

EXPLORING INNOVATIVE APPROACHES TO CANCER DIAGNOSIS

The first wave of the programme, launched in 2015, is made up of around 60 projects across England, split into eight thematic ‘clusters’ to help facilitate peer learning and evidence gathering. Each cluster contains a number of projects, each exploring a different concept within a theme. For example, one cluster is considering new approaches for patients that GPs find most difficult to place on a specific pathway, particularly those who present with vague but concerning symptoms. Innovative ideas being tested include a new electronic referral system from GPs to radiologists enabling triage advice on the most suitable imaging for a patient with suspected cancer.

Another cluster explores effective ways to remove barriers to screening for a range of vulnerable groups, including patients with sensory impairment and/or learning difficulties and those from minority ethnic groups.

Each approach will be subject to evaluation supported by the Department of Health Policy Research Units. Interim reports have been published from the ‘pharmacy and other primary care’ cluster, which explores an enhanced role for non-GP primary care professionals in early diagnosis of cancer. Two projects consider whether community pharmacies could help diagnose cancer earlier, given their accessibility, opening hours and familiarity with the local population.² As mentioned in a blog³ looking at the direct referral of patients with suspected cancer by community pharmacists, there are a number of reasons why a patient may visit their local pharmacy rather than their GP. For some people this could be because they aren’t registered with a GP, while others may be reluctant to make an appointment for fear of wasting the GP’s time.

Another cluster report looks at the role community pharmacies can play in early diagnosis, as well as outlining the skills and knowledge pharmacy staff need to perform such activities, and how to organise training.⁴ Referral for suspected cancer through other primary care routes has the potential to reach a greater proportion of patients at a higher risk of cancer, as well as possibly reducing pressure on overburdened GP practices.

INCREASING SCREENING UPTAKE FOR PEOPLE WANTING TO TAKE PART

Aiming to improve survival rates of patients through earlier diagnosis of bowel cancer, Luton CCG began trialling a new role for practices in improving National Bowel Screening Programme uptake.

Luton has a cancer survival rate below the national average and is implementing a number of initiatives to improve early detection and reduce late diagnosis. In 2013–2014, the bowel screening uptake across Luton CCG was 49.8%;⁵ well below the national average of around 58%.⁶ Trend analysis showed that only one practice achieved the national average, with uptake across the practices ranging from 11.9% to 61.6%.

Managed by Mark Morton, commissioning manager for Luton CCG, the project focuses on non-responders to the bowel screening invitation (as opposed to people actively declining). Patients are contacted by phone by practice staff and are offered additional information relating to the benefits of engaging with the national programme and ordering a replacement pack if they wish to participate. This model, allowing practices to order a replacement pack directly from the screening hub, should help GPs engage with patients within the target range who may be at higher risk of bowel cancer. Crucial to reaching patients in areas of high ethnic diversity, the practice can also request information in the patient’s preferred language on the request form.

It is hoped that the approach of direct contact from GP practices will enable patients to make an informed choice about whether to engage with the programme. Anecdotal evidence suggests that many national health messages are missed by ethnic populations who are unable to read English; this project aims to enable GP practices to communicate with patients in their own language and engage with them either by phone or when the patient comes into the practice.

The project provides an enhanced payment for practices contacting the patient and ordering the replacement kit where agreed, and a further payment is made if the patient completes and returns the kit. Evaluation of the project is expected this year and will also support consideration of alternative options to improve screening uptake.

STREAMLINING PATIENT DIAGNOSTIC PATHWAYS VIA MULTIDISCIPLINARY DIAGNOSTIC CENTRES

The second wave of the programme plans to pilot new ‘one-stop’ diagnostic pathways for patients with non-specific but concerning symptoms; an approach incorporating a Multidisciplinary Diagnostic Centre (MDC).⁷ As recommended in the Independent Cancer Taskforce report, published in July 2015,⁸ the pilots aim to test how feasible the pathway will be for the NHS in England.

Figure 1.

How Multidisciplinary Diagnostic Centres could improve early cancer diagnosis. Reproduced with permission from Cancer Research UK.

In the current system, patients who display non-specific but concerning symptoms such as weight loss or abdominal pains, which could be indicative of cancer, don’t have an effective and direct referral pathway. This causes difficulties for GPs and other primary care professionals in knowing which route to send the patient, leading to delays in diagnosis and potentially poorer outcomes.

Denmark, which has a similar health system to the UK, where GPs act as gatekeepers, set up MDC-based pathways to ensure patients have the appropriate tests quickly. This new pathway allows GPs to refer to one centre where a patient’s symptoms are accessed by a number of specialists. Where possible, all testing is made on the same day.

A pilot study showed that 16.2% of all patients referred through this Danish pathway because of non-specific serious symptoms had cancer.⁹ The GP’s gut feeling was a common clinical finding that was a strong predictor of cancer.

The projects that form Wave 2 will trial the same concept through slightly different approaches to each other. While some projects are looking at GP referrals only to the MDC, others are also considering self-referrals and referral of patients who present at accident and emergency departments, where there is a suspicion that the patient may have cancer. The delivery will also differ between the projects, from radiology-led approaches to physician-led. In order to build a clearer picture of how the approach might work in England, the projects cover a geographical range from large urban areas to rural settings.

A paper published in 2015 shows that 50% of the UK population will receive a cancer diagnosis in their lifetime.¹⁰ This puts an increasing strain on primary care who play a pivotal role in ensuring patients with suspected cancer receive appropriate referrals. ACE will contribute to the evidence base to inform commissioners and national policy makers about effective approaches to diagnosing patients earlier and, importantly, how to ensure GPs and other healthcare professionals are adequately supported in making decisions about patient care.

The first wave of ACE outputs this year will include reports with key findings, case studies, and resources developed to assist primary care health professionals in improving patient flow and experience. To sign up to receive outputs when they become available or if you have any further questions please contact ACE at ACEteam@cancer.org.uk.

Provenance

Commissioned; not externally peer reviewed.