Awareness campaigns improve diagnosis, but at what cost?
Authors: Hannah Cagney
Journal: The Lancet Respiratory Medicine (2016)

“Been coughing for 3 weeks or getting out of breath easily? Tell your doctor.” This message could soon be plastered across general practice noticeboards throughout England. Public Health England (PHE), together with National Health Service (NHS) England and the Department of Health, has launched its yearly drive to improve public awareness of respiratory symptoms that could suggest lung cancer, lung disease, or heart disease. The campaign, Be Clear on Cancer, aims to improve diagnosis not only of lung cancer, but also of chronic obstructive pulmonary disease (COPD) and coronary heart disease; together, these three disorders cause more than 100 000 deaths per year in England. The campaign is based on awareness of two symptoms: a persistent cough, lasting more than 3 weeks, and breathlessness, a new focus introduced to the campaign this year. The campaign runs from July 14 to October 16, 2016, and includes television advertisements, face-to-face events in venues such as shopping centres, and celebrity champions. NHS Wales is also running a Be Clear on Cancer campaign focusing on persistent cough as a symptom of lung cancer. Meanwhile, the British Lung Foundation charity is promoting a year-long campaign, Listen to Your Lungs, throughout 2016–17 to raise awareness of breathlessness as a symptom of respiratory disease. However, the addition of breathlessness to Be Clear on Cancer has fuelled worries of unintended consequences such as increased general practitioner (GP) workload, costs, and patient anxiety—potentially exceeding the benefits of increased diagnoses. The vague wording of the breathlessness component—“If you get out of breath doing things you used to be able to do, tell your doctor”—might be open to misinterpretation or misunderstanding by the public. Underdiagnosis of respiratory disease is a serious issue in the UK. “The Be Clear on Cancer campaigns have been rolled out because we are lagging behind the rest of Europe in regards to cancer survival outcomes, and it's the late diagnosis of cancer that is considered one of the primary reasons for this lower survival rate in England”, says Sara Kayat, a GP in south London's Balham Park Surgery, who feels the new campaign's message is broadly useful. After the 2012 National Lung Cancer PHE campaign, urgent referrals from general practice for assessment of potential cancer symptoms (referred to as 2-week wait referrals) increased by 32% during the 8 weeks of the campaign compared with the same period in 2011. About 700 more people were diagnosed with lung cancer, with 400 more people having their cancer diagnosed at an early stage, and 300 additional patients receiving surgery as a first treatment for lung cancer. But Paul Little, Professor of Primary Care Research at the University of Southampton (Southampton, UK), comments that the impacts of the PHE campaigns in previous years have not been systematically assessed. “Clearly more cancers were detected, but what was not measured was the extra work that we saw: a lot of people being nervous about coughs that were simply due to a chest infection, due to the simple fact that 3 weeks is the average duration of a cough for the chest infections that we see”, he says. “PHE can say ‘we caught more cancers’, but at what cost, could the particular guidance have been a little more evidence-based, and the impact more fully evaluated?” A regional pilot of the breathlessness component of the PHE campaign, which ran from February to March of this year in the East of England, noted increased awareness of breathlessness as a symptom of lung disease (from 50% to 60%) and heart disease (from 42% to 52%). But investigators of the pilot admitted that “the direct impact of the campaign was challenging to assess from the clinical metrics”. Full evaluation reports of the 2013 and 2014 campaigns, as well as clinical evaluation of the regional pilot (eg, using echocardiograms and referrals to psychological therapy to measure diagnostic activity, treatment, and adverse effects of the campaign) have yet to be published. Without a solid understanding of the campaign's effects, its costs and benefits are difficult to judge. According to analysis of the 2012 campaign, GP visits for persistent cough increased by 62% in the campaign period compared with in 2011. This increase could be viewed as modest, equivalent to only an extra three consultations per practice per week. But across the country, it represents hundreds of thousands more GP visits. This comes at a time of scarce resources and increasing demands on primary care; an analysis published in The Lancet this year showed a substantial increase of 16% in GP workload between 2007 and 2014. Despite the potential drawbacks of PHE's campaign, breathlessness remains a serious symptom that is important to identify, says Kayat. “Whilst some aspects of these campaigns can be construed as onerous, as they often generate an increase in potentially unnecessary attendances and patient anxiety, I do think this specific campaign on breathlessness is one of the more pertinent”, she says, noting that breathlessness campaign might be more likely to identify clinically significant pathology compared with previous targets of Be Clear on Cancer—for example, blood in stool as a symptom of bowel cancer, which isn't a very specific symptom of serious illness. “At present people often attribute breathlessness to a natural part of ageing or general lack of fitness, or even lifestyle. But this campaign highlights that long-term breathlessness is not a normal occurrence.” Little remains sceptical that PHE have chosen the best approach. “I applaud the idea, but before campaigns are run in the public domain, the rationale for the particular guidance needs to be closely argued and well justified”, he says. “If we had a health service where GPs weren't retiring [en masse] and practices weren't falling over, fine, but the last thing practices need at the moment is something that isn't fully thought through, that will create more work, and that we don't know whether it's going to achieve anything.” The controversy highlights the complexity of attempting to change public knowledge and attitudes about health conditions. If you want to run an effective public awareness campaign, simply putting information out there will not always work, warns Stephan Dombrowski, a health psychology researcher at the University of Stirling (Stirling, Scotland, UK). “Campaigns are often based on the simplistic assumption that informing people about a symptom and the link to a specific condition leads them to seek help as recommended. This assumes that people pay attention to the campaign, understand the campaign correctly, remember the campaign, retrieve the information from memory when they are faced with the relevant symptoms, and then act on this information. Those are a lot of assumptions.” Dombrowski points to the Act FAST stroke campaign (based on symptoms of facial weakness, arm weakness, or slurred speech) as an example of careful design. “The symptom of facial weakness on one side is very specific to stroke, and telling people to call 999 when they see this symptom is likely to have a positive impact”, he says. “The symptoms of severe headache or visual disturbances might also be indicative of stroke, but they are not included in the current campaign because they are not very stroke-specific, and might create undue worry in people who have these symptoms”. He continues, “I think that public health awareness campaigns can play a vital part to prompt some people to seek help when needed, but just raising awareness on its own is unlikely to lead to favourable long-term outcomes. These campaigns need to be supplemented by relevant support services and programmes to help people translate awareness into behaviour at the appropriate point in time.” One example could be the British Lung Foundation's awareness campaign, which links to an online breathlessness questionnaire, designed to assist individuals in understanding the potential causes of their breathlessness, screen for those with potentially serious symptoms needing medical attention, and offer advice and support about healthy living or psychological contributors to breathlessness.