Trial Aims to Improve Early Cancer Diagnosis in Primary Care
Funded by Cancer Research Wales, in collaboration with North West Cancer Research, an ambitious new clinical trial is set to commence across Wales and the North West of England, seeking to transform primary care practices into centres of excellence for diagnosing cancer. The ThinkCancer! trial will test an innovative training and awareness intervention that will change the ways in which GPs think about cancer and improve processes to ensure more lives can be saved through earlier cancer diagnosis.
Wales is among the worst performing countries in Europe when it comes to cancer outcomes, which equates to hundreds of extra lives being lost every year. Key to addressing this concerning situation is improving the early diagnosis of cancer, since it is well-known that the earlier cancer is detected, the easier it is to treat, manage and cure. At Cancer Research Wales, we are investing significant amounts into researching new methods of diagnosing cancers, including several different blood tests that have the potential to make a real difference for patients.
However, improving cancer diagnosis is not just about developing new tests and equipment – ensuring that patients can access these tests in a timely manner is equally as important. Over 60% of cancer patients will initially visit their GP, meaning that primary care has a vital, yet often difficult role, to play in suspecting cancer amongst the common symptoms that present for the more prevalent less serious conditions. As well the challenge of getting the right tests for the right patients at the right time.
Cancer Research Wales previously funded a study, led by Professor Clare Wilkinson of the North Wales Centre for Primary Care Research at Bangor University, which looked into the knowledge, attitudes and referral behaviour of GPs towards suspected cancer, as well as safety net processes in surgeries.
The study, known as WICKED (Wales Interventions and Cancer Knowledge about Early Diagnosis), provided some important insights into the difficulties facing GPs when it comes to cancer. Although, primary care does a fairly good job with respect to suspicion of cancer and referral of suspected cases for some common cancers - as demonstrated by the International Cancer Benchmarking Project – the initial study detected some worrying trends with definite room for improvement to bring all primary care up to best practice with more efficient processes and ways of working to ensure more consistency and equity of care across Wales.
This will become more critical as primary care comes under increasing pressure due to a variety of reasons, not least workforce issues and access to diagnostics. Latest available data show that regions of highest deprivation which carry the greatest cancer burden in Wales have the least number of GPs, practice nurses and admin staff per head of population compared to the rest of Wales. Therefore, it is essential that robust, resilient and coherent ways of working are adopted, not only in these areas, but across all of Wales.
Notably, there was a wide variation in the use of NICE NG12 guidelines and in the confidence of GPs to recognise and act upon different symptoms, with many reporting they did not feel confident dealing with so-called vague symptoms (such as unexplained weight loss or fatigue). The NG12 guidelines were introduced in 2015 and contained a vastly expanded list of new symptoms and their patterns of presentation that GPs should consider for numerous cancer types. The finding that not all GPs use these but rather rely on experience and ‘gut feeling’ is worrying. This is further compounded in that only 1 in 3 of the GPs surveyed reported using available decision support tools to inform their actions.
Based on their findings, the team behind the WICKED study worked with primary care to co-produce an intervention to try and address some of the issues they uncovered, specifically tailored to the areas where GPs felt they needed support.
Yr Athro Clare Wilkinson, Prif Ymchwilydd
“General practices in the UK are already very good at picking up cancer symptoms and signs, but given the variability we have found, we hope this work can contribute to bringing all up to the highest standards. This is the first trial to concentrate on the whole practice team, aiming for speedy and accurate referrals with extra safety netting to avoid errors.”
The intervention, named ThinkCancer!, consisted of a series of workshops, which collectively provided guidance and cancer awareness training, as well as assistance with setting up safety netting procedures to prevent patients with vague symptoms from “falling through the cracks”. Unlike most primary care interventions, ThinkCancer! involved the whole staff of each practice, such as admin and nursing staff and practice managers as well as receptionists, rather than just the GPs alone, to promote a holistic approach. This move was welcomed by GPs as they sought to foster an open-door policy where staff felt confident in raising concerns about patients with worrying symptoms who make initial enquiries with the surgery.
As part of their work, the team ran a feasibility randomised trial of the ThinkCancer! intervention with 19 GP practices across Wales to assess the practicalities of their ideas and to gauge the responses of those who took part. There was overwhelmingly positive feedback about the workshops and a number of practices immediately implemented the safety netting plans drawn up during the sessions. The team were able to adapt successfully to the Covid-19 pandemic through the use of online resources.
Following on from this successful initial work, Cancer Research Wales, in collaboration with North West Cancer Research is now funding the team to test ThinkCancer! in a large-scale Phase III clinical trial, which will provide definitive evidence about the effectiveness of the intervention. The trial will involve the delivery of the workshops to GP practices across Wales and the Northwest of England – these practices will be compared to similar ones who did not receive the training.The success of ThinkCancer! will be measured using key metrics, such as the time taken for patients to be referred to secondary care, increased clinical knowledge of possible cancer symptoms through continual training and awareness of hot topics as they emerge, accuracy of referrals, and impact of improved safety netting processes, amongst others.
The findings of the WICKED study around the behaviours and attitudes of GPs with regards to cancer contributed towards a series of recommendations about primary care that were made to the Welsh Government Cross Party Group on Cancer in 2020. It is hoped that the ThinkCancer! clinical trial will similarly be able to deliver strong evidence of its effectiveness in improving cancer diagnosis in primary care, which can encourage Welsh Government to deliver a national rollout to benefit all cancer patients across Wales.