Summary

Be Clear on Cancer was created to support earlier diagnosis and improve cancer survival rates. Subsequently the Department of Health, along with key stakeholders, has been delivering a programme of campaigns to raise public awareness of cancer symptoms.

Television advertisements, radio, press and face-to-face events have been used to focus on lung and bowel cancer at a national level; kidney/bladder and breast cancer in women over 70 at a regional level; and ovarian, oesophago-gastric and Know4sure – highlighting 4 key symptoms of many different cancers – locally.

All the campaigns are rigorously evaluated and results show that awareness of the signs and symptoms of cancer is raised, more people visit their GP, there has been an increase in urgent referrals and a shift towards earlier diagnosis. 

Challenge

Despite improvements in survival and mortality in recent decades, cancer outcomes in England remain poor when compared with the best outcomes in Europe. In January 2011, Improving Outcomes: A Strategy for Cancer set out the ambition to prevent 5,000 deaths from cancer per year by 2014/15. This would improve survival rates in England to the point where they would match the average for Europe. Diagnosing cancer at a later stage is generally agreed to be one of the key reasons for the lower survival rates in England.  

The challenge was therefore to find a method of delivering information to the public, raising their awareness of symptoms and encouraging more people to see their GP earlier, to increase the possibility of timely and therefore successful treatment. 

Cancer Research UK was appointed in 2011 to help develop the evaluation framework and co-ordinate data flows. An expert advisory group, including representatives from a wide range of specialties helped guide the evaluation. The individual campaigns are subject to comprehensive evaluation, including quantitative, qualitative and bespoke elements, with data reflecting key points along the patient pathway. This includes symptom awareness, attendances at primary care, urgent referrals and diagnostic investigations, as well as critical outcome measures.

Objectives

The over-arching aim of Be Clear on Cancer (BCOC) was to raise awareness of key symptoms and encourage people to see their GP earlier. The campaigns were aimed at men and women who are over the age of 50, the age group most likely to be diagnosed, and those from lower socio-economic groups, as these people are more likely to delay visiting their GP.

To select which tumour sites should be targeted, priority was given to the cancers with the largest number of potentially avoidable deaths. These included breast cancer (particularly among older women not invited for screening), bowel and lung cancers. Each campaign was first rolled out in small test area so we could assess the impact. 

The Department of Health (DH) worked closely with local cancer networks and clinicians to ensure that they were prepared and that people visiting their GP as a result of our materials received an appropriate response. Once this local pilot ran smoothly the DH would upscale to a regional pilot with heavier-weight media, including TV advertising. Only when it had robust evidence that the campaign was having the required impact on symptom awareness and visits to GPs would the DH agree to roll-out nationally.

Solution

Deploying a pilot, evaluate and roll-out approach ensured the best use of public money and NHS resources. The DH created a clear brand for this initiative that was crucial to its success. The consistent tone of a ‘good doctor’ in advertisements was clear and authoritative, empathetic and approachable. The language used was straightforward, for example ‘blood in poo,’ not ‘blood in stools.’ Using everyday language removed the embarrassment of people not knowing what to say to their GP.

Roadshows took place in everyday accessible venues, including shopping centres and football grounds, and we engaged community champions to roll out messages to harder to reach groups, including the very elderly, and ethnic minority groups where there may be lower levels of literacy and limited understanding of English. A range of resources were also piloted for people with disabilities.

By identifying a clearly identifiable symptom and a memorable time period, the DH provided the reassurance people needed that a visit to the docter was warranted. Using real GPs in the advertisements provided further reassurance that docters really wanted to be approached. This is  the first mainstream campaign in England where people have been actively encouraged to visit their GP and has overcome the reticence some people have in seeing their doctor.

Results

Headline findings from the campaigns include the following results: 

National bowel cancer (Jan-March 2012)

• 15 per cent increase in awareness of blood in stools 
• 37.3 per cent increase in attendances of men and 21.9% of women reporting campaign related symptoms 
• 40 per cent increase in two week wait referrals; higher increases for men compared with women 

National lung cancer (May-June 2012)

• 9 per cent increase in spontaneous awareness of cough/hoarseness
• 32 per cent increase in two week wait referrals; higher increases for men compared with women

Regional lung cancer (Oct-Nov 2011)

• Statistically significant increase in the proportion of small cell lung cancers stages as ‘limited’ and a positive trend towards earlier stage of diagnosis of non-small cell lung cancers in pilot trusts
• 14 per cent increase in cases diagnosed (excluding mesothelioma) in the pilot area 

Local oesophago-gastric cancer (April-July 2012)

• 16 per cent increase in prompted awareness of the symptom difficulty swallowing 
• 20 per cent increase in oesophageal cancers diagnosed following a two week wait referral for suspected upper gastrointestinal cancer in the pilot area.

Evaluation

Reports are prepared on the individual streams of local, regional and national activity to guide the future direction of Be Clear on Cancer and to provide feedback on the extent to which our ambition of saving lives is being met. These reports are being shared online as they become available.

The team also send regular update emails to all campaign stakeholders, including cancer network directors and the National Awareness and Early Diagnosis Initiative (NAEDI) implementation leaders so that they are aware of any results or learnings as soon as they become available to share. This is essential to ensure the continued engagement of our local partners in the campaigns.

The NAEDI forum was set up as a coalition of charities with an interest in the early diagnosis of cancer and therefore became a key route for sharing information about the campaigns. It is also a valuable feedback source on the campaigns and the ‘on the ground’ reaction to them.

Charities, such as the British Lung Foundation and Macmillan Cancer Support, have subsequently adapted the messages and materials developed as a part of Be Clear on Cancer, and reflect them in their own work to raise awareness of the importance of early diagnosis.

Impact

The DH has encouraged local teams to use the Be Clear on Cancer materials and to run their own awareness campaigns. There is an informative area about the campaigns on the Cancer Research UK website. 

These resources were taken up by several cancer networks in 2012/13, such as Avon Somerset and Wiltshire Cancer Network, which used its own funds to support regional Be Clear On Cancer activity.

During the Breast Cancer in Women campaign, in over 70 local pilots in the North Trent Cancer Network area, the BCOC key messages were used alongside a locally developed, tailored information pack for local volunteers and community groups. In rural Northumberland and Cumbria, teams took BCOC into more isolated locations, even during winter, using a branded Land Rover.

As part of the oesophago-gastric campaign, three cancer networks collaborated to develop a bespoke online training tool for pharmacists and pharmacy technicians, which was hosted on the British Oncology Pharmacy Association website. Although it was led by local teams it applied the BCOC key messages and learnings.