Award Title: Realist evaluation to DEtermine Mechanisms to increase one-Year colorectal cancer (CRC) Survival in place-based health systems in England (DEMYStify)
Funder: Health Education England

Abstract: Research question 'How can place-based health systems in England increase one-year colorectal cancer (CRC) survival and tackle variations in their area?' BackgroundCRCs account for 42,000 (11%) of all new cases of cancer diagnosed annually in the UK19. Evidence shows that survival is improved if the disease is spotted early20. However less than half of cases are picked up at this stage21. Recent data for the UK shows cancer to be the leading cause of deaths that could be averted or delayed through timely, effective health care and public health interventions22. The trend in one-year CRC survival varies across local health systems with a 16% difference23 between the best and worst performing areas. There are also unexpected ('unwarranted') and unfair differences ('inequalities') in the demographics of those who survive19,20,24.Aim To understand and explain the mechanisms that contribute to increases in one-year CRC survival in specific areas in England. Objectives	Identify four case-study sites that have seen increasing or static survival trends including any demographic variation, 	Explain through targeted interviews, focus groups and analysis why these changes have occurred, 	Determine how place-based systems could act to increase one-year survival for CRC. Design, methods and timelines for delivery 'DEMYStify' is sequential explanatory research which adopts a realist perspective25. Realist methodology is theory-driven and predicated on the idea that there 'is a [social] reality that cannot be measured directly (because it is processed through our brains, language, culture etc.), but can be known indirectly'26. It focuses on unpacking and explaining the interaction between context, mechanism and outcome25 to explain the 'how' and 'why'. The study is constructed of three work packages [WP]. The first will involve developing the candidate programme theory (CPT)27 providing broad explanations about how population-level changes in one-year CRC survival happen (Yr1). WP2(Yr1) will involve quantitative analysis of trends in one-year CRC survival estimates by Upper Tier Local Authority areas. Four places demonstrating consistently static or increasing one-year CRC survival will be identified. These places will be invited to be case-study sites (Yr2+3) where document review, interviews and focus groups will be used to understand what has contributed to the trend observed. Analysis, using realist evaluation principles, will enable refinement of the CPT (Yr3). Patient, public and stakeholder involvement A PPI panel, formed at the start of this fellowship, will hold this programme of research to account. Members will be invited to collaboratively design core components including scope of focus, health system and stakeholder mapping and dissemination approaches. Views of patients will be heard by including members of well-established support groups as collaborators, lay-chair of the 'context expert group', and interviewees in case-study sites. Anticipated impact and dissemination Findings will directly benefit patients, especially 'at-risk' population groups, by informing the actions of health policy makers, healthcare leaders and third sector organisations. A range of dissemination mediums including academic papers, grey reports alongside workshops and presentations will ensure reach and impact. DEMYStify will inform future work to assess if theory developed is transferrable to other groups of cancer.

Lay Abstract: Background People with bowel cancer have different experiences and outcomes depending on where they live in England. There is a 16% gap between people surviving bowel cancer to one-year after diagnosis in the best local place compared to the worst. It is well known that early identification of bowel cancer and targeting high-risk populations will improve life expectancy. However, is not well understood why and how some local areas in England manage to deliver improvements and others do not. A National Cancer Research Institute patient member reported that there are 'so many variations in health services across the country anything to make it more consistent should be supported'. Aims My research, DEMYStify, aims to understand how different ways of working within local health services in England affect one-year bowel cancer survival. I plan to investigate what the difference is between areas that have increasing survival figures and those where the figures flatline. The purpose is to develop an understanding about how the services within local areas work together to improve bowel cancer survival and identify actions that can increase local bowel cancer survival and make outcomes more consistent across the country. Design and methods The work will begin by drafting initial ideas before looking back at earlier evidence and reports. Findings will be discussed with patient groups, clinicians and public health experts to inform the focus of the investigation. Past data about changes in survival of people with bowel cancer in England one-year after diagnosis will be analysed. From this, four local areas will be chosen as potential case-study sites. The health systems that serves those communities will be defined and will be invited to get involved. Interviews and focus groups will be conducted with key stakeholders including patient members. Information about any changes that have occurred will be gathered. There will be a strong emphasis on exploring how areas have addressed unfair differences (health inequalities) locally and the contribution this may made to changes in bowel cancer survival at one-year after diagnosis. This type of research is sometimes called mixed methods; discussions are used to try and explain trends in data. A theory development approach will be used to produce robust ideas about how and why increases in one-year bowel cancer survival are achieved. Expected outcomes and how they will be sharedIt is expected that there will be new understanding about how areas in England can work to make progress in increasing one-year bowel cancer survival. Patient groups, academics, policy and health system leaders will be able to gain insights about approaches that should be prioritised and what might be limiting progress. The research will pave the way for future work to understand if this learning is relevant to different types of cancer. As well as sharing findings in academic papers and at conferences, there will be regular and close collaboration with third sector organisations that represent patients with bowel cancer as well as lay representatives. Presentations with community groups as well as blogs, press releases and an informative report will be used to make sure the learning is shared widely and has a marked impact.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: CANCER AND NEOPLASMS