A series of Be Clear on Cancer awareness events were held prior to the campaign launch in Autumn 2013. These slides are from the London event on 10 September 2012 The events included: An update on the 'Blood in Pee' campaign Oct-Nov 2013 Sharing experiences from BCOC pilots A review of the impact of the BCOC campaigns Latest plans for BCOC February 20145 campaigns An opportunity for delegates to feedback on experience of campaigns and make suggestions for improvement Events were aimed at SCNs - Programme leads, Clinicians, Public Health, National NAEDI Partners - DH, Public Health England, NHS England and Charities

1. Be Clear on Cancer campaigns
for early diagnosis
Update event for ‘Blood in Pee’ national campaign –
October - November 2013
Chair: Sean Duffy, National Clinical Director for Cancer, NHS
England

2. Introduction
Welcome and setting the scene
Aims of the event
Sean Duffy, National Clinical Director for
Cancer – NHS England
1.00
The ‘Blood in Pee’ Campaign
The ‘Blood in Pee’ Campaign – part of Be Clear on Cancer
A PHE perspective on Be Clear on Cancer
National development, creative, evaluation and learning
What happens when it goes live – a voice from the pilots
Jane Allberry - DH
Prof Kevin Fenton– PHE
Yvonne Ridley - PHE
Laura McGuinness - CRUK
Suzanne Thompson and Jo Cresswell –
Northern England
1.10
1.20
1.45
What is the likely impact of the Blood in Pee national campaign? John Osmond - DH 2.05
Q&A – fresh tea and coffee available 2.20
Future plans for 2013/14 Be Clear on Cancer Campaigns Sean Duffy – NHS England 2.40
Aligning national and local delivery – new accountabilities, organisations
and ways of working
A panel with an opportunity to ask questions, chaired by Sean Duffy.
Hilary Walker – NHS IQ
Paul Roche – NHS England
Richard Roope - GP
Jane Allberry – DH
Yvonne Ridley – PHE
Laura McGuinness – CRUK
3:00
Summary of next steps and close Sean Duffy – NHS England 3.50
Agenda

3. Aims of this event
This event is intended to:
• Provide an update on the national ‘Blood in Pee’
campaign running Oct-Nov 2013, including modelling of
the estimated impact on the NHS
• Share experiences from Be Clear on Cancer ‘Blood in
Pee’ pilots
• Review the impact of the BCOC campaigns so far
• Share latest plans for BCOC February 2014 campaigns
• Be an opportunity for you to give us feedback on your
experience of the campaigns and to gather suggestions
for how these could be improved

4. Setting the scene
Cancer Reform Strategy (2007)
• Launch of National Awareness and Early Diagnosis
Initiative
Improving Outcomes: A Strategy for Cancer (2011)
• Sets out the Government’s ambition to save an
additional 5,000 lives per annum by 2014/15, through
earlier diagnosis and better access to treatment
Be Clear on Cancer Campaigns
• Launched in 2010/11
• Approach developed over time in consultation with
stakeholders and panels of experts, using research with
healthcare professionals and target audience

5. Cancer survival
• 1 year and 5 year survival rates are generally lower in
England than comparable countries in Western Europe
• Coleman et al (Lancet 2010): Up to date survival trends
show improvements in cancer survival, but the gap
between countries remains. Differences are consistent
with late diagnosis and differences in treatment
• Whether the gap in survival rates is due to differences in
stage at diagnosis or treatment, it is generally
recognised that earlier diagnosis is a major issue
• 10,000 deaths could be avoided each year in England if
our cancer survival rates matched those in the best
countries in Europe

6. Breast ~ 2000 Endometrial 250
Colorectal ~1700 Leukaemia 240
Lung ~1300 Brain 225
Kidney / Bladder ~990 Melanoma 190
Oesophagogastric ~950 Cervix 180
Ovary ~500 Oral/Larynx 170
NHL/HD 370 Pancreas 75
Myeloma 250
[NB Prostate has been excluded as survival ‘gap’ is likely to be due to
differences in PSA testing rates.]
Data derived from Abdel-Rahman et al, BJC Supplement December 2009
Avoidable deaths per annum if survival
in England matched the best in Europe

7. Rationale
• Generally the earlier the stage of cancer when it is diagnosed, the
better the chances for survival
• If kidney and bladder cancers are diagnosed at the earliest stage,
one year survival is as high as 92-97%
• At a late stage, it drops to just 25-34%
• If the number of people in England who survived bladder and kidney
cancers matched the best in Europe, around 1,000 lives could be
saved each year
• Around 16,600 people in England are diagnosed with kidney and
bladder cancer each year and 7,500 die from them

8. Achieving earlier diagnosis (1)
• Raise symptom awareness amongst the public
and patients
• Encourage prompt presentation to the GP
• Support GPs to refer on appropriately
• Ensure sufficient capacity in secondary care

9. Achieving earlier diagnosis (2)
• Focus on the biggest killers
• Funding provided through IOSC - £450million
over this Spending Review period to support
work to improve earlier diagnosis
• The importance of evaluation – we are still
learning

10. ‘Blood in pee’ campaign –
part of Be Clear on Cancer
Jane Allberry
Deputy Director Sexual Health, Screening and Early Diagnosis
Department of Health

11. Overall approach
• Campaigns – link to national priorities
• Start local, scale up to regional, go national
• What these levels of campaign involve:
- deciding focus: views of expert stakeholders etc
- determining messaging
- local activity
- adding in TV at regional level
- going national
- stakeholder engagement
- other support, e.g. shopping centre events
• ‘Blood in pee’ campaigns to date:
- 3 local pilots (2012)
- regional pilot in Tyne Tees and Borders TV regions
(Jan-March 2013)

12. Public Health England:
Perspective on Be Clear on Cancer
Professor Kevin Fenton
Director of Health and Wellbeing
Public Health England

13. Yvonne Ridley
Public Health England
Tuesday 10th September 2013, London

14. Be Clear on Cancer
Be Clear on Cancer – Campaign Roll-out

15. Blood in Urine
• Why Kidney & Bladder Cancer
• Why focus on blood in urine
• Who’s at greatest risk

16. Creative Approach
Task:
Get people who notice blood in their
pee to see their GP straight away
Insight:
Men don’t talk about their problems
whilst women are more open and
happy to discuss

17. Creative Development Research
• TV Whistle
• TV Maybe

18. TV - Whistle

19. TV - Maybe

20. Creative Work – Press ads and Posters

21. Direct Mail

22. Blood in Pee – Leaflet & Pharmacy Bag

23. National Media Roll-0ut
Oct 15th – 20th November
• TV
• Radio
• Press & Outdoor posters
• GP surgery’s
• Direct mail and Events
• PR

25. Be Clear on Cancer
‘Blood in Pee’
campaign evaluation

26. Evaluation
• We recognise there is a lot of stakeholder interest in the impact of
these campaigns
• Comprehensive evaluation of all campaigns to date has been
coordinated by Cancer Research UK (CR-UK)
• As of April 2013 National Cancer Intelligence Network (NCIN) will
lead the evaluation working with CR-UK to ensure consistency
• Evaluation metrics have been selected to reflect the different points
along the patient pathway
• Data from a range of sources: bespoke studies (eg awareness
tracker surveys, GP attendances), routine data collections (eg
diagnostic activity), commissioned datasets (cancer registry data)
• Some measures can take months to come through due to complex
nature of the data (eg cancer incidence & stage)

27. Evaluation Metrics for Be Clear on Cancer activity
Metric Broad questions we’re seeking to answer
Cancer and campaign
awareness
Are people seeing the campaign and is it raising
awareness of the signs and symptoms?
GP attendance Are we seeing more people going to their GP
with the symptoms promoted by the campaign,
and is there any shift in the profile of patients
presenting?
Urgent referrals for
suspected cancer
Are we seeing more people referred urgently for
suspected cancer, and is there any shift in the
profile of these patients?
Conversion rates Of those referred urgently for suspected cancer,
how many actually turn out to have that cancer?
Impact on investigations Are we seeing an increase in diagnostic
investigation activity, or the length of time
patients are waiting for tests?
Cancer incidence and
staging
Are we seeing an increase in the numbers of
patients diagnosed with cancer, and/or a shift
towards earlier stage disease?

28. Local and Regional ‘Blood in Pee’ Pilots
• Local pilot (i.e. no TV)
• Held in 3 pilot areas
– Avon Somerset and Wiltshire
– Nottingham
– Greater Manchester and Cheshire
• In total 18 PCT areas were covered by the pilots
• The pilots ran predominantly from January to end of March 2012
• Regional pilot (including TV and direct mail)
• Covered the previous North of England Cancer Network footprint
• 13 PCTs (17 CCGs from April 2013)
• Tyne Tees and Borders TV region
• Activity ran from 14 January to 17 March 2013

29. Are people seeing the campaign and is it
raising awareness? YES
Regional Pilot
• Knowledge that blood in pee is a definite warning of kidney/bladder
cancer increased significantly from 41% before the campaign to
65% after the campaign. This increase was noted in both men and
women
• Encouraging response to the campaign, particularly by men,
69% of men found the advertising was relevant and 51% of men
felt it told them something new
• After the campaign there was a significant increase in people saying
they would see the GP the same day if they noticed any changes to
pee or bladder habits, up from 18% to 27%

30. Are more people going to their GP with the
symptoms? YES
Local
• Avon, Somerset and Wiltshire was the only pilot to conduct formal
GP attendance analysis.
• Overall there was a higher level of attendances in 2012 compared
with 2011 for people presenting with campaign - specific symptoms
(macroscopic haematuria), but no clear increase to correspond
with the start of the campaign
Regional
• Data extraction carried out late August with results due early
Autumn

31. Purpose
• This slide set represents the interim findings from
the analysis of data from 52 GP practices.
• Data from a further 444 GP practices has been
included as a ‘control’ group to compare activity
against.
• It has been compiled specifically to provide an initial
view on whether the campaign has had an impact or
not on patient attendances.
• The study has been commissioned by NHS IQ
• The final report is due in September 2013.
31

32. To consider the impact of the ‘Be Clear on Cancer’ blood in pee
awareness campaign on patients visiting their GP with the
symptoms highlighted in the campaign.
• No clear increase in attendances for the symptom highlighted in
the campaign (macroscopic haematuria) following the launch of
the campaign, based on the week by week profile.
• Activity during the campaign in 2012/13 was 25% higher
compared with the previous year (0.18 additional visits per
practice per week), however it was 9% higher compared with the
eight weeks prior to the campaign – the same increase was
seen in practices outside the targeted area.
• Attendances for men increased by 15% within the targeted
area during the campaign compared with the eight weeks prior
to the campaign, whereas outside the area, attendances
increased by 12%.
32
Summary
Evaluation
results
Objective

33. Campaign vs control symptoms
Practices within targeted area (aged 50+)
% change in attendances from 2011/12
25%
-22%
-10% -14%
-5%
-30%
-20%
-10%
0%
10%
20%
30%
40%
Macroscopic
haematuria
Neck
pain
Shoulder
pain
Knee
pain
UTI
%changeinattendancesfrom
2011/12
Pre
Live
Post
GP attendances for the control symptoms decreased by 12% during the campaign in
2012/13, compared with the previous year.
Attendances for the control symptoms increased by 10% during 2012/13, compared with the eight
weeks prior to the campaign. Attendances for macroscopic haematuria increased by 9%.
33

34. Are we seeing more people urgently referred
for suspected cancer? YES
Local
• 26% increase in 2WW urgent referrals for suspected urological cancer within
the pilot area compared with an 18% increase in the control area
Regional
• Analysis investigated the impact of the regional campaign, by considering
the change in the number of urgent GP referrals for suspected urological
cancer, from January – April 2012 to January – April 2013
• The campaign appears to have had an impact on referrals for suspected
urological cancers, with a 28% increase in the regional pilot campaign
areas, compared to a 9% increase in the control areas
• Within the site-specific campaign areas, the increase in urological referrals
was similar for men (27%) and for women (30%)
NB* the urological cancer referral pathway covers several cancer types in addition to kidney and bladder.

35. Are we seeing an increase in diagnostic
investigation activity? YES
Local
• Cystoscopy figures for 18 PCTs covered by the local campaigns indicate a 5.9%
increase (adjusted for working days) compared with the same months in 2011
– Nottingham City PCT has a 19% increase
– Greater Manchester and Cheshire a 12% increase
– Avon, Somerset and Wiltshire a 2% reduction. Within this, some PCTs have
seen increases while others have seen decreases
• There appears to be no adverse effect on waiting times following the local pilots
Regional
• Results show strong growth in the number of cystoscopies in pilot PCTs in the period
following the campaign. However, this series is affected by some large changes in
activity for hospitals in the area (DM01 data)

36. Are we seeing an increase in numbers of
patients diagnosed?
Local
• Comparing Jan – May 2011 to Jan – May 2012
• 5.3% increase in the number of bladder or kidney cancers
diagnosed following a 2WW urgent referral for suspected urological
cancer within the pilot area
Regional
• Initial analysis expected at the end of 2013 using the Cancer Wait
Time database. This will cover the duration of the campaign and the
period after the campaign, to assess any increases in the diagnosis
of urological cancer

37. Conclusions so far
• Knowledge that ‘blood in pee’ is a definite warning of
kidney/bladder cancer increased in both men and women
• Campaign advertising seen as relevant and agreement that this
was new information
• Increases in 2WW referrals and diagnostic investigations both
locally and regionally
• From anecdotal feedback we have received throughout the two
pilots (local and regional level) we have consistently heard that the
campaign is well received by health professionals
• Need to sustain cancer awareness campaigns and other initiatives
in the longer term to bring about desired behaviour change more
widely and achieve better outcomes in cancer

38. What happens when it goes live
– voices from the regional pilot
Suzanne Thompson (Clinical Network Manager) and Jo
Cresswell (Chair of Urology Network Site Specific Group)
• What did we do?
• What did it feel like?
• A secondary care
perspective
• Finally, planning for
October

39. Clinical Engagement – What did we
do?
• Launch event & WebEx open to all stakeholders
– Modelling tool
• Education events aimed at primary care
• Briefing sessions for health champions/trainers
• Pharmacy engagement
• NECN website
• E-bulletin to all stakeholders
• Communication resource pack
• Resources: CRUK factsheets, Blood in Pee
risk assessment tool

40. What did it feel like?
• We carried out a short online survey to find out
– how well informed people were about campaigns
– the impact people felt the campaigns had on services
• To inform delivery of similar work in the future.
• Online survey developed with support of Department of
Health’s BCOC central team and Cancer Research UK
• It was sent to 606 people. 108 (approx. 18%) responded
– Acute Trust Cancer Managers, Urology NSSG
including urology nurses. It was also sent to GP
practices (Managers)

45. A secondary care perspective
• What we did to prepare for the campaign
• The impact of the campaign
• Planning for the national campaign

46. What happens after referral?
• The haematuria clinic
– Consultation
– Examination
– Urine tests
– Flexible cystoscopy
– Imaging – USS/CT scan

47. How did we prepare?
• Expected increase in workload
• Estimated from previous campaigns
• Increased haematuria clinic provision
• In advance or response to increased demand
• Unclear how many additional diagnoses
expected
• Provision of elective surgery less predictable

48. A secondary care perspective
- the impact
575
648
781
780
685
787
720
769
758
839
820
832
747
773
891
767
887
708
831
759
715
897
938
854
889
1025
1114
1022
1060
0
200
400
600
800
1000
1200
January February March April May June July August September October November December
NECN- Two Week Wait Referrals- Urology
2011 2012 2013
4875
5594
6530
6043
5890
6645
6130
6420
6404
6346
6676
5907
5895
6475
7427
6245
7853
6480
7233
6936
6289
7920
7467
6248
6550
6802
7280
7177
7786
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
January February March April May June July August September October November December
NECN- Two Week Wait Referrals- ALL
2011 2012 2013

49. A secondary care perspective
- the impact
0
50
100
150
200
250
300
350
02-Jan
09-Jan
16-Jan
23-Jan
30-Jan
06-Feb
13-Feb
20-Feb
27-Feb
05-Mar
12-Mar
19-Mar
26-Mar
02-Apr
09-Apr
16-Apr
23-Apr
30-Apr
07-May
14-May
21-May
28-May
04-Jun
11-Jun
18-Jun
25-Jun
02-Jul
09-Jul
16-Jul
23-Jul
30-Jul
06-Aug
13-Aug
20-Aug
27-Aug
03-Sep
10-Sep
17-Sep
24-Sep
01-Oct
08-Oct
15-Oct
22-Oct
29-Oct
05-Nov
12-Nov
19-Nov
26-Nov
03-Dec
10-Dec
17-Dec
24-Dec
NECN- Two Week Wait Referrals- Urology
January to December - by Week
2012 2011 2013

50. Observations
• Initial lag period with most notable increases from March
onwards
• Perception that increased referral of Visible Haematuria
(public awareness) Non-Visible Haematuria (Health Care
Professional awareness)
• Pilot coincided with difficult period for bed occupancy
(elective capacity affected)
• Key data – how did increased referrals translate into
increased diagnoses?

51. Finally, October
• Working with national partners to share
our learning
• Informing key local stakeholders
• Engaging with new partners and
developing relationships

52. Intelligence Report
Likely impact of the 2013 national Blood in Pee
awareness campaign on the NHS
Dr David Halsall, Laura Bown and Katrina Walker
Outcomes Analytical Team
NHS England
Presented by John Osmond, DH

53. From the experience of the regional pilot, we are going to predict
what might happen during the rollout of the national campaign
City Hospitals
Sunderland NHS
Foundation Trust
North Tees and
Hartlepool NHS
Foundation Trust
South Tees
Hospitals NHS
Foundation Trust
County Durham and
Darlington NHS
Foundation Trust
Gateshead Health
NHS Foundation
Trust
Newcastle upon
Tyne Hospitals
NHS Foundation
Trust
Northumbria
Healthcare NHS
Foundation Trust
The regional campaign was held in the North East from January to March
of this year

54. Incidence of kidney cancer has been rising over the past 10
years, particularly in the 20-64 age group, whereas the incidence
of bladder cancer has been decreasing over the past 10
years, except in the older age group
Source: NHS England Analysis of ONS Cancer Registrations data
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
0-19 20-64 65-74 75+ 0-19 20-64 65-74 75+
Bladder Kidney
Incidence of Bladder and Kidney Cancer in 2000 and 2010, projected to 2020
2000
2010
2020

55. 0
100
200
300
400
500
600
700
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Emergency Admissions for Bladder and Kidney Cancer in England
2012 13 2011 12 2010 11 2009 10
Emergency admissions for kidney and bladder cancer have
been falling year on year
Source: NHS England Analysis of HES (2012/13 results preliminary)

56. 0
10
20
30
40
50
60
70
80
90
100
SurvivalPercentage
One and Five Year Survival for Bladder Cancer
1 year survival 5 year survival
Survival for kidney and bladder cancer is generally
on the increase, with survival in kidney cancer
matching survival for bladder cancer in recent years
Source: NHS England Analysis of ONS data
The fall in survival for bladder
cancer is likely due to the
increasing proportion of
bladder tumours now being
coded as uncertain
0
10
20
30
40
50
60
70
80
90
100
SurvivalPercentage
One and Five Year Survival for Kidney Cancer
1 year survival 5 year survival

57. 9,170 new bladder cancer cases
8,500 new kidney cancer cases
if 1.8%/year historical growth per year continues
GP
62,000 direct access
Kidney or Bladder
Ultrasounds
28,500 direct access
Chest/Abdomen
CT scans
2WW Other Emergency
2,830 (32%) 2,120 (24%) 1,600 (18%)
New cases*
Bladder
Kidney
Other Outpatient
1,150 (13%)
1,640 (20%) 2,130 (26%) 2,050 (25%) 1,480 (18%)
What impact will the Be Clear on Cancer campaign have on
bladder and kidney cancer routes to diagnosis? Is this what
we would expect to see in 2013?
290,000 Cystoscopies
Source: NHS England Analysis of data from ONS, DiD, DM01 and *NCIN routes to diagnosis 2008

58. 9,170 new bladder cancer cases
8,500 new kidney cancer cases
if 1.8%/year historical growth per year continues
GP
2WW Other Emergency Other Outpatient
How many lives would we expect to save if we switched half of
emergency admissions to 2WW?
2WW GP - Other Emergency Other Outpatient
1 year survival – Bladder Cancer 83% 79% 36% 77%
1 year survival – Kidney Cancer 79% 80% 38% 82%
Number of patients surviving 1 year now 3,650 3,375 1,355 2,100
Number of patients surviving 1 year after
cutting emergency admissions by half
5,115 3,375 680 2,100
Difference 1465 - -675 -
790 lives could possibly be saved if emergency admissions are halved

59. A rise in ultrasounds in January, February and March and a rise in GP
referred CT scans in January and February coincided with the regional
Blood in Pee pilot – but is this significant?
Source: NHS England analysis of DiD dataset
Regional Blood
in Pee Pilot
Regional Blood
in Pee Pilot
Each trust can expect to see an extra 6 ultrasound referrals and between 6-12 extra CT
scan referrals per week during the campaign – however, it is likely that not all of these will
be for suspected urological cancer

60. Source: NHS England analysis of DM01 dataset
Each trust should expect to
see on average an extra 5
cystoscopy referrals per week
over the campaign period
Cystoscopy activity peaked in April after the campaign
finished, although this was within normal variation. Waiting lists
for the procedure increased slightly during the campaign
but, again, this was within the normal limits.

61. Despite concern over trusts not being able to cope with an
increased number of patients, the waiting times don’t seem
to have changed significantly relative to the past 2 years
Source: NHS England Analysis of DM01 dataset

62. The increase in 2WW referrals during the campaign period looks
consistent with the effect that we would have expected
Source: NHS England Analysis of Cancer Waiting Times database
Each trust should expect
on average 6 extra
referrals per week during
the campaign period

63. During the months immediately after the campaign we saw an
increase in the number of patients being treated for urological
cancer after being referred through the 2WW pathway
Source: NHS England Analysis of Cancer Waiting Times database

64. Looking at secondary care, there has been an increase in the
number of patients having a diagnostic endoscopy of the bladder
who have received a cancer diagnosis relative to trusts not
covered by the regional pilot
Source: NHS England Analysis of HES (2012/13 results preliminary)

65. We haven’t yet seen an increase in the number of operations
relating to bladder and kidney cancer although this is likely to be
due to data lags
Source: NHS England Analysis of HES (2012/13 results preliminary)

66. • In the pilot area, a 25% increase in 2WW referrals was seen over
the short term. On average, each trust should expect to see an
expect to see an extra six 2WW referrals per week.
• The consequence of this increased number of referrals did
not, however, adversely affect diagnostic waiting times. Each
trust should expect, on average, an extra 5 cystoscopy
referrals, 6 ultrasound referrals and between 6-12 CT scan
referrals each week during the campaign period.
• Given the relatively small proportion of bladder and kidney
cancers that are diagnosed via the 2WW pathway, there are
potentially significant gains to be made if patients are diverted
from the emergency route to the 2WW route, contributing to the
overall aim of saving 5,000 cancer lives.
Summary: anticipated impact of Blood in Pee campaign

67. Refreshments break

68. Sean Duffy
National Clinical Director for Cancer
NHS England
Plans for early 2014 campaigns

69. February – March 2014
• National - Breast cancer in women over 70
• Regional pilots:
– Oesophago-gastric
– Ovarian

70. Breast 70+ key message

71. Oesophago-gastric key messages

72. Ovarian key message

73. Aligning national and local
delivery – new
accountabilities, organisations
and ways of working.
A panel with an opportunity to
ask questions, chaired by Sean
Duffy

74. Summary of next steps
Sean Duffy, National Clinical
Director for Cancer, NHS England