Title: The SPOtting Cancer among Comorbidities (SPOCC) programme. Supporting clinical decision making in patients with symptoms of cancer and pre-existing conditions.
Funder: Department of Health and Social Care

Abstract: Research question How can patient and health professional decision making in patients with symptoms of cancer and with pre-existing conditions be optimized for reducing diagnostic delay? Background Cancer accounts for 35% of avoidable deaths in England and Wales. Concurrent health conditions are associated with reduced cancer survival, partly attributable to delayed diagnosis. There is sparse information on which comorbidities have an impact for which cancers, the mechanisms and points in the diagnostic pathway and that impact is manifest. This lack of information does not allow workable interventions to be delivered. Our recent review identified a number of priority areas for research which we will address in this programme of work to further produce specific interventions. Aims and Objectives We aim to optimise patient and health professional decision making in general practice patients with symptoms of possible cancer and with pre-existing conditions. Objectives include: quantification of the impact of pre-existing conditions on timely presentation, investigation and diagnosis to understand the source of any disparities; quantification of the predictive value of symptoms of cancer in these patients; the development and piloting of an intervention aimed at reducing diagnostic delay in cancer diagnosis for these patients; and the economic exploration of the likely range of the interventions effectiveness and cost-effectiveness. Methods Six inter-related work-packages (WP). WP1(Years 1-2): Investigation of the impact of comorbidities on the diagnostic process using linked data from primary care (CPRD), National Cancer Registration and Analysis Service (NCRAS), Hospital Episode Statistics, and Cancer Patient Experience Survey. WP2(Y1-Y3): Investigation of patient, GP and nurse experiences and perceptions of decision making for cancer symptoms in the presence of pre-existing conditions through interviews with 60-80 patients, 15 GPs and 15 nurses analysed using a critical realist perspective. WP3(Y2-Y3): Quantification of the impact of comorbidity on patient help-seeking and healthcare provider's attitudes on investigations through online vignette studies with 6000 patients, 800 GPs and 800 nurses. WP4(Y2-Y3): Quantification of risk of selected cancers in symptomatic patients with pre-existing conditions through case-control studies using linked CPRD and NCRAS data. WP5(Y3-Y5): Development of an intervention for improving timeliness of investigation of patients with co-morbidities and symptoms of cancer based on MRC Framework for Complex Interventions and Intervention Mapping, and feasibility testing in 8 GP practices (240 patients). WP6(Y4-Y5): Development of a decision analytic model to explore the cost-effectiveness of the intervention and to extrapolate early diagnosis to the longer-term. Anticipated Impact and Dissemination We anticipate the findings will change UK clinical guidelines, improve referral to secondary care and directly impact patient survival. Findings should help to reduce the estimated 10,000 lives lost every year through late diagnosis and directly support the NHS target of 75% of cancers being diagnosed at early stage by 2028. Dissemination activities aim to reach patients with long term conditions, those involved in their clinical care, charities, academics, policy makers, and the public and will include co-produced plain language evidence summaries, a stakeholder event, academic publications, conference presentations and dissemination through website, blogs, social media, and our multiple and extensive networks.

Lay abstract: Current recommendations for investigating possible cancer do not take into account the presence of other long term conditions, such as obesity or diabetes. There are multiple reasons that may make it harder to spot possible cancer in these patients and lead to delays in diagnosis and worse survival rates. For example thinking the cancer symptoms are just the pre-existing condition, or ongoing symptoms masking cancer symptoms. However there is relatively little research on these issues. This research will help us improve cancer diagnosis in people with other long term health conditions. We want to improve existing recommendations for investigating possible cancers that take into account other health conditions, and develop and test a new approach to spotting possible cancers in people with long term health conditions Over 5 years, we will carry out 6 linked research studies. 1. Using existing data from general practice and The National Cancer Registration and Analysis Service, we will identify which health conditions are associated with delayed cancer diagnosis. 2. We will Interview both patients with pre-existing conditions and GPs to understand their experience and views of spotting possible cancer symptoms in the presence of pre-existing medical conditions. 3. Using a survey which will include imaginary situations, we will try and understand how patients, GP s and nurses respond to and make decisions about possible cancer symptoms in the presence of other conditions. 4. We will use existing data on symptom reporting and cancer diagnosis to estimate the risk of possible cancer for patients with different conditions and symptoms to develop risk assessment tools. These tools could improve how cancer is diagnosed in patients with pre-existing medical conditions. 5. With the help of the knowledge gained in the studies 1 to 4, and collaborating with patient and clinicians, we will develop and test a new approach aimed at reducing the delay in diagnosing cancer in patients with pre-existing conditions. 6. We will look at the cost of this new approach and its &ldquo;value for money&rdquo; in terms of improving cancer diagnosis and care of patients. Patient and public involvement Patients have been involved in the development of this programme of work and will continue to be involved throughout. We will establish a patient advisory group with experience of cancer and other long term conditions. This advisory group will meet at key stages in the programme and help to make key decisions, including the design of studies and the analysis and interpretation of data. Dissemination Alongside academic publications and conference presentations, we will co-create, with patients and clinicians, targeted plain language summaries to ensure findings reach all relevant stakeholders, including charities, policy makers and patient groups. Further dissemination will include: website, blogs/social media and an engagement event.

Research activity codes: 4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES
Health categories: CANCER AND NEOPLASMS