Title: Optimising diagnosis of symptomatic cancer
Funder: Department of Health (England)

Abstract: 7.1 Aims: This programme has the overall aim of optimising the diagnosis of symptomatic cancer. It uses three cancers as examples: lung, colorectal and pancreas. 7.2 Background: Cancer care is a major part of the NHS, using 5.2% of total NHS spending. 230,000 new cancers are diagnosed in England each year with 125,000 deaths. Survival in the UK is below comparable countries, with an estimated 5,000 lives lost annually from late diagnosis.[1] Improvements in cancer diagnostics have lagged behind screening and therapeutic advances. Over 90% of cancer patients present with symptoms, usually to primary care. The factors that prompt patients to consult their doctor are ill-understood. GPs make errors, and referral guidance may mislead. Improvements in cancer diagnostics could arise from: better selection of patients to refer; liberalisation of entry to rapid access clinics; or an increase in investigations in primary care. Choosing between these requires knowledge of patient factors, the actual risk of cancer from specific symptoms, current diagnostic pathways, and patient and clinician preferences. This programme aims to identify all these parameters, and to synthesise the results to improve diagnostic pathways for cancer in the NHS. 7.3 Research plan: 7.3.1 Patient factors. Cohort study, with a nested qualitative study. Participants will be patients in two PCTs, referred with suspicion of one of the three target cancers. Using a questionnaire, and examination of their medical records we will identify symptoms, their duration, and demographic variables. Regression analyses will identify associations between initial symptoms and time to diagnosis. The qualitative study will examine the process of deciding to seek medical attention in those referred for cancer investigation. 7.3.2 Primary care factors. 10-12 case-control studies plus 3 cohort studies. Currently under-researched cancers will be selected for the case-control studies from a systematic review. We will use data from the General Practice Research Database (GPRD). The main outputs will be identifying relevant symptoms, and quantifying them as a risk figure for a patient with symptoms GPRD cohort data will be used to identify the pathways patients take between first symptom and diagnosis. The main output will be a comparison between factors associated with use of the standard pathway and those taking non-standard pathways. 7.3.3 Consumer values in design of investigative services. Questionnaire survey of general practice attenders to derive a threshold figure of cancer risk that the public believes warrants urgent investigation, including the advantages and disadvantages of investigation, plus patient-centred economic aspects. Using the data from all the earlier projects, we will address two main options for improved cancer diagnostics – increased availability of tests in primary care or liberalisation of access to secondary care clinics. These will be studied from two perspectives: firstly, in a modelling study using probabilistic cost-effectiveness analyses. This will use similar methodology to NICE guidance for new interventions, and will benchmark our findings against the current NICE figure for a gain of one quality-adjusted life year. Secondly, the results will be synthesised in a practical exercise using two PCTs to derive local diagnostic schemas and test them. 7.4 Our team includes all the main UK researchers in primary care cancer diagnostics, plus experts in qualitative methodology, health economics and modelling. We also have an NHS lead for cancer services, Improvement Foundation representation, plus strong consumer input. Six of the team are in active NHS practice; four are Prof.s. Patient involvement is considerable, both in design and future conduct of the programme. The programme has a strong management framework, with resources and responsibilities devolved to theme and project levels. It is stationed within two innovative PCTs and five leading universities. 7.5 Outputs. Theme 1 will identify features of later presentation of cancer to inform consumer awareness and general practice based interventions. Theme 2 will identify and quantify the main features of under-researched cancers for NICE in their reviews of referral guidelines. It will also identify and quantify non-standard routes to cancer diagnosis. Theme 3 will answer a key question: at what level of risk does the public believe rapid investigation is warranted? Finally, the main output of the whole programme will be the design and testing of improved investigative services for the NHS, from theoretical and practical perspectives. If successful, the programme should reduce unnecessary UK cancer deaths by the order of hundreds of patients annually. 7.6 Finances. The major cost of the programme is staffing, with small contributions for computing, travel, and consumables.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: CANCER AND NEOPLASMS