Objectives To assess the impact of a 7-week public bowel cancer awareness campaign pilot by reviewing the number of 2-week referrals from general practitioners (GPs) to hospital, endoscopic procedures and new cancers diagnosed throughout the five acute hospitals in The Peninsular Cancer Network, UK.
Design A retrospective before and after study.
Setting The Peninsula Cancer Network in the South West of England, UK.
Main outcome measures For the period July 2010–July 2011, data were collected on the number of 2-week referrals, number of endoscopic procedures performed and number of new cancers diagnosed. The average for the 6 months before the campaign was compared with the immediate 3 months and then the fourth to sixth months following the campaign. Student's t test was used to compare the means of the three groups.
Results There was a statistically significant increase in the number of 2-week referrals from GPs to hospital in the 3 months following the campaign but this effect disappeared after that. There was no statistical increase in the number of endoscopic procedures or new cancers diagnosed following the awareness campaign.
Conclusions The pilot ‘Be Clear on Cancer’ awareness campaign had a significant effect on the number of patients being referred from GPs to hospital; however, the effect was short lived and had returned to baseline by 3 months. The campaign had no effect on the number of new cancers diagnosed, which was the stated underlying aim of the pilot.
- PUBLIC HEALTH
Statistics from Altmetric.com
Bowel cancer is the third most common cancer in the UK with an annual incidence of 39 991 and a total mortality of 15 908 (2008). As part of its ‘Improving Outcomes: A Strategy for Cancer’ programme, the Department of Health piloted a ‘Be Clear on Bowel Cancer’ public awareness campaign in the Peninsular Cancer Network and the East of England Strategic Health Authority.1
The Be Clear on Bowel Cancer Pilot 2011
The pilot was run in the Peninsular Caner Network and the East of England Strategic Health Authority. The campaign consisted of a social marketing campaign using regional television, radio and print media (see figure 1) and face-to-face events. It was conducted from early January 2011 for 7 weeks. The total cost was £1 590 000. As figure 1 shows, the public were informed to seek medical attention if they had 3 weeks of symptoms. In the UK, the current guidelines as set by the National Institute for Health and Clinical Excellence2 state that referral is only indicated after 6 weeks of symptoms. This guideline was not changed during the pilot.
The Peninsula Cancer Network
The Peninsula Cancer Network brings together all organisations involved in the provision of care for cancer patients both inside and outside of the National Health Service (NHS) for the two English counties, Devon and Cornwall. Nearly 1.7 million people live in this region which has a land area of 4000 square miles. Five acute hospitals serve this region and there are 20 Network groups including the colorectal network involved in this study. There are approximately 1300 colorectal cancers diagnosed and 500 deaths per year (2007 figures).
In the past, media campaigns have been used in other areas of medicine to increase awareness and affect behaviour. Attempts to increase the public's awareness of stroke in Canada demonstrated that one can increase awareness and may increase emergency department presentations with paid television campaign.3 ,4 However, they showed that short campaigns had little effect and that continuous advertising may be required to build and sustain public awareness. A further study from Europe has demonstrated increased knowledge, if not hospital presentation, resulting from mass media efforts.5 There is mixed evidence showing a clear benefit to the public of health awareness campaigns.6
The stated underlying aim of the ‘Be Clear on Bowel Cancer’ pilot was to diagnose cancers earlier and therefore reduce the mortality of bowel cancer bringing it in line with the best countries in the world.7 The pilot study has already been analysed internally within the Department of Health and the initial study demonstrated an approximate 50% increase in general practitioner (GP) attendance, 2-week referrals and endoscopy.8
This study evaluates the ‘Be Clear on Bowel Cancer’ pilot in more detail by specifically looking at the effect on the number of cancers diagnosed within the Peninsula Cancer Network.
Data were collected for the five hospitals in the Peninsular Cancer Network whose populations made up the vast majority of the likely recipients of the information of the campaign. These hospitals were: North Devon Healthcare NHS Trust, Royal Devon and Exeter NHS Foundation Trust, Plymouth Hospitals NHS Trust, Royal Cornwall Hospitals NHS Trust and South Devon Healthcare NHS Foundation Trust. Data on three variables were collected: the number of 2-week referrals from GPs to hospital, the number of new cancers diagnosed and the combined number of endoscopies (flexible sigmoidoscopies and colonoscopies).
Cancer referrals in NHS England
Patients with bowel related symptoms present to their GPs. If the symptoms fit the ‘2-week referral’ criteria (these are: rectal bleeding or change in bowel habit for 6 weeks or more aged 60 or over, both rectal bleeding and change in bowel habit over 40 years, or unexplained iron deficiency anaemia, or abdominal or rectal mass), the GP will fax the referral to the acute hospital which will see the patient (either in clinic or endoscopy) within 2 weeks. If they are found to have a cancer they are termed ‘31-day decision to treat’, and these patients will have a definitive management plan within 31 days of referral. Patients will have their treatment started within 62 days of the first referral.2
The data on 2-week referrals and new cancer diagnosis were gathered from the Open Exeter database. Data are inputted into this system from all acute hospitals on a monthly basis. As well as the ‘2-week referral’ data, it also includes the '31-day decision to treat’ data, which is discussed in the box above and correlates exactly to the number of new cancer diagnosed. The number of endoscopic procedures was provided by the South West Strategic Health Authority.
As this was an evaluation of a previously run public health pilot, the ethics committee was not consulted as there were no implications for patients as the campaign had already been conducted.
The three metrics were gathered from July 2010 to July 2011. This allowed baseline data to be calculated for 6 months before the start of the campaign, which could then be used to compare the levels for 6 months afterwards. This was split into two 3-month periods to assess the immediate effect and longer lasting effect of the campaign.
Three sets of data were created for each metric: the mean for the 6 months preceding the campaign, the mean for the 3 months immediately after the campaign and then the 3 months following that (ie, months 4–6 after). Student t test was used to compare the means for these groups across the three metrics: number of referrals, number of endoscopies performed and number of new cancers diagnosed. The t test used was unpaired and two-tailed. In addition, the data were displayed graphically.
Figures 2⇓–4 show the raw data for the 13-month time period.Table 1 shows the effect of the campaign for the first 3 months after the start. There was a statistical increase in the number of 2-week referrals but no increase in the number of new cancers diagnosed. There was an increase in the number of endoscopies performed but this did not reach statistical significance. Exactly a third of the endoscopic tests were flexible sigmoidoscopies and two-thirds were colonoscopies.
Table 2 shows the effect of the campaign for the second 3-month period following the campaign (months 4–6). The initial effect on 2-week referrals had returned to baseline during this period and again there was no statistical effect on the number of cancers diagnosed or on endoscopies performed.
This study has shown that the ‘Be Clear on Bowel Cancer’ pilot study in the Peninsular Cancer Network did not increase the number of cancers detected in the period during and after the pilot campaign. It did statistically increase the number of referrals being made from GPs to hospitals immediately after the campaign but this effect stopped after 3 months. The number of endoscopic procedures being performed did increase for 1 month only but this effect was not statistically significant.
It can be assumed that the increase in referral from GP to hospital increased immediately after the campaign as a result of more patients presenting to the GPs. Although the campaign informs patients to present with 3 weeks of symptoms, the national guidelines to GPs is to refer if the patient has 6 weeks of symptoms. This puts the GPs in a difficult position as the patients are anxious and expect investigation; so, there is little the GPs can do except refer using the ‘2-week’ pathway. It must be remembered that endoscopic procedures—colonoscopy and flexible sigmoidoscopy—are invasive and there is risk to the patient (1 in 1000 risk of perforation9) as well as cost to the healthcare system.
Strengths and weaknesses of the study
As the campaign was carried out in one region of the country, it is not clear that the findings would be transferable to national or international level as the socio-economic make up of the population will be different.
It is possible that the campaign may have resulted in more non-malignant polyps being detected and removed. The data on this were unavailable as they are not collected as routine. For future evaluations, it would be useful to know this.
No control group was used. It is possible that some other factor increased the number of ‘2-week referrals’ but given the temporal relationship with the start of the pilot study that seems unlikely.
A strength of the study is the numbers involved: during the study period, 20 035 endoscopies were performed and 1320 colorectal cancers were diagnosed in five separate NHS trusts.
Comparison with other studies
Public awareness campaigns to promote awareness of disease and health behaviour have a long history and have achieved, at best, mixed results. The relative effectiveness of the diverse approaches used to promote preventive activities is unknown and policymakers attempting to improve preventative care have little definitive information on which to base decisions.10 Attempts have been made to increase awareness of colorectal cancer in the past. One study demonstrated the effect of using a celebrity (Katie Couric) to raise the profile and this resulted in a significant increase in the uptake of colonoscopy and the effect lasted up to 9 months; other studies have reinforced the effect of celebrity.11 ,12 Locally, to the Peninsular Cancer Network, there has been a small increase in awareness in younger people following the death of a football player from bowel cancer.13 Further campaigns in America have shown that public awareness is increased with colorectal awareness campaigns.11 Screening for colorectal cancer suffers from a low-uptake but several studies have shown that large-scale mass media campaigns increased screening uptake.14–17
Behaviour and referral patterns have been evaluated for other cancer types. A study from the 1980s in the UK showed the effect of media campaigns on early diagnosis of malignant melanoma, although the initial rise in referrals after the first media hit was not reproduced later.18 Breast cancer is arguably the most known and understood cancer by the public. An interesting paper analysing the National Breast Cancer Awareness Month (NBCAM) in America showed that the NBCAM increased the numbers of diagnoses in the month following the campaign only when public knowledge of the disease was low; after 1995 when breast cancer advocacy was expanding into a nationwide movement there was no effect of the NBCAMs.19
Avenues for further work
There is good evidence that the UK national bowel cancer screening programme saves lives; however, the uptake of the programme is currently between 40% and 60%.20 Public awareness programmes aimed to increase screening uptake have worked in the past and perhaps this would be a better area to address than the symptomatic population with three or more weeks of symptoms.21
The results of this pilot demonstrate that the awareness campaign did not achieve the underlying stated aim of the Department of Health's strategy for improving outcomes in cancer, namely, diagnosing cancers earlier in the disease process thereby reducing mortality. The national ‘Be Clear on Bowel Cancer’ public awareness campaign has already begun and if it demonstrates the same effect as the pilot it could be questioned whether this form of awareness programme is effective, as well as repeating the lesson that pilot studies should be fully evaluated before being rolled out nationally. The National Bowel Screening Programme is strongly evidence based and it may be that a programme to increase screening uptake would be more effective and there is evidence that this would work.21
Changing behaviour is only useful if it improves public health. Public health interventions are notoriously lacking a good evidence base and we believe that pilot studies should be evaluated fully before translating into policy.22
The ‘Be Clear on Bowel Cancer’ awareness pilot did not result in more cancers being detected.
The number of ‘2-week’ referrals from GPs to hospital increased significantly for the first few months but this returned to baseline after 3 months.
Public health campaign pilots should be thoroughly evaluated before being rolled out as national campaigns.
Current research questions
Will the same effect as the pilot showed be seen in the national programme?
Will raising awareness of bowel cancer result in a long term reduction in mortality?
How can we increase bowel cancer screening uptake?
Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet 2010;376:1261–71.
Schroy PC III, Glick JT, Robinson PA, et al. Has the surge in media attention increased public awareness about colorectal cancer and screening? J Community Health 2008;33:1–9.
Cram P, Fendrick AM, Inadomi J, et al. The impact of a celebrity promotional campaign on the use of colon cancer screening: the Katie Couric effect. Arch Intern Med 2003;163:1601–5.
McGarrity TJ, Long PA, Peiffer LP. Results of a repeat television-advertised mass screening program for colorectal cancer using fecal occult blood tests. Am J Gastroenterol 1990;85:266–70.
Logan RF, Patnick J, Nickerson C, et al. Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut 2012;61:1439–46.
Contributors RB and MJM cleaned and analysed the data, drafted and revised the paper. IRD devised the study, gathered the data and revised the paper. He is the guarantor. SJM, CO, MTC, PJA and ASG represent the colorectal MDTs that gathered the data and revised the paper.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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