Introduction
The ThinkCancer! Study builds on an earlier piece of work – the WICKED (Wales Interventions and Cancer Knowledge about Early Diagnosis) trial which involved consulting with GP Practices throughout Wales to develop and test a series of workshops for general practice teams to improve cancer diagnosis and referral rates.
During the ThinkCancer! workshops our aim is to provide GPs and other clinical staff with updates on the latest changes to clinical guidelines and support to develop and enhance their own knowledge and skills regarding vague and ‘harder to spot’ symptoms of cancer. We work with reception teams to increase their general awareness of potential cancer symptoms and then help the whole practice to develop their own ‘Cancer Safety-Netting Plan’.
GP Practices taking part in the trial will be randomly allocated to those that have the workshops (the intervention group) and those that do not have them (the control group) to see if the ThinkCancer! workshops do help improve cancer diagnosis.
In order to assess the impact of the research study we will be reviewing anonymised data from patient records from GP practices that are taking part in the study. This will only involve patients who have recently been referred on for further tests by their GP with possible signs of cancer and will be limited to information related to the possible cancer diagnosis. We will not look at any other unrelated data.
The patient experience
Some patients may be contacted to ask if they would be willing to talk about their experiences of having tests done to investigate a possible cancer – this is completely voluntary. Patient data would only ever be seen by healthcare professionals and researchers who have signed confidentiality agreements with the NHS and all data is anonymised before leaving the GP practice.
If the GP practice is taking part in the ThinkCancer! trial patients will be contacted and given further details which also include information on how to opt out if they do not wish to take part in the study. Patients can opt out without having to give any reason and this would not affect their usual care or relationship with their GP practice. There will also be a poster in GP practices advising that the surgery is taking part in the trial with further information.
What we hope to achieve in this trial
We want to see whether the ThinkCancer! Workshops, designed to help all staff in GP practices, help to reduce the time it takes to diagnose cancers and that the workshops would be an effective use of resources if rolled out across the wider NHS.
Further information is available on the website including some experiences from patients that have taken part in the interview process from the earlier study.
Development of ThinkCancer!
In comparison with other Western countries, Wales has relatively poor cancer outcomes (The Lancet 2019) with late diagnosis being a major factor (CPGC, 2020). Evidence from the International Cancer Benchmarking Partnership has shown that GPs in Wales are less likely to refer or investigate (Rose et al., 2015) and that adherence to cancer guidelines is lower (Nicholson, Mant, Neal et al., 2016). This has a negative effect on cancer outcomes.
These deficiencies have been recognised by the Welsh NHS who earlier this year published details of a three-year Cancer Improvement Plan (Wales Cancer Network 2023), which identifies a series of measures that are being undertaken to improve the experience and outcomes for people affected by cancer. In this it is recognised that not all the deficiencies are the fault of primary care but are systemic in nature and will require additional investment and improvement in digital systems and access. However, primary care has an exceptionally important role in the early detection and treatment of cancer - a round 60% of cancers are diagnosed through primary care (Hanna 2020), and almost half (49%) of avoidable delays occur within primary care (Swann 2020).
‘ThinkCancer!’ tackles this problem by using workshops to provide GPs, associated healthcare professionals and other non-clinical staff with an update on the latest changes to clinical guidelines and to develop and enhance their own knowledge and skills regarding vague and ‘harder to spot’ symptoms of cancer. It is hoped that by doing this cancer outcomes can be improved.
Background to the ThinkCancer! Trial
The ThinkCancer! trial builds upon an upon an earlier programme of research called Wales Interventions and Cancer Knowledge about Early Diagnosis (WICKED). The overall aims of the WICKED programme were to improve the quality and consistency of primary care approaches to improve timely diagnosis of cancer. General practitioners in Wales contributed to every step of this programme of research.
The WICKED programme was developed into work packages one to five where a variety of methods were used to collect and integrate data about cancer diagnosis in primary care to produce an intervention which would form the basis of the ThinkCancer! Trial.
Work Packages 1 to 3
Work Packages 1 and 2 involved producing an online survey including a Discrete Choice Experiment (DCE) sent to all GPs in Wales. There were then twenty telephone interviews with GPs followed by focus groups held with four practice teams. d web pages,
Throughout this process various stakeholder groups were consulted, and behaviour change theory underpinned the work allowing a target behaviour to be agreed culminating in the completion of Work Package 3 - GPs thinking of and acting on clinical presentations* that could be cancer (The ThinkCancer! intervention).
Work Package 4 - The Feasibility Study
This intervention was tested on a small scale in the ThinkCancer! Feasibility Study. This helped evaluate the design of a larger Phase III study to determine whether ThinkCancer! can reduce referral times and whether it is cost effective. The feasibility study was delivered successfully and the whole-practice workshop series was clearly timely and much appreciated by general practices. The recruitment target was reached, and progression criteria indicated that a phase III trial is feasible and acceptable.
Work Package 5 – Preparation for Phase 3 trial
Lessons learnt during the feasibility study led to further refinement of the ThinkCancer! intervention in Work Package 5. Several methodological issues which were highlighted have been addressed in the phase III trial and adaptations have been made. These have further been informed by PPI input, context changes in primary care (example Continuing Professional Development (CPD) training, and comments following a peer review process.
More information about the WICKED programme can be found here .
Patient and Public Involvement (PPI)
Janice Rose has been involved throughout the WICKED programme and is a key member of the ThinkCancer! team, representing the public and patients and ensuring their voice is heard throughout the process.
“I got involved with researchers working in the field of cancer after my breast cancer diagnosis and my mum’s diagnosis of Cancer of Unknown Primary (CUP). Both happened in 2009. Since then I have worked locally, regionally and nationally with researchers representing the patient perspective in various research studies taking place and generally helping research into cancer where I can.”
“My link to the Wales Interventions and Cancer Knowledge about Early Diagnosis (WICKED) Programme came through my link to the NCRI Primary Care Group. I have worked with the researchers since the study started.”
“I am pleased to be one of the patients working with the research team looking at ways to help doctors and other staff in GP practices in Wales to help improve early cancer diagnosis for their patients. The project is very worthwhile as early diagnosis of cancer is so important for patients in terms of the outcomes after their diagnosis.”
“Having patients working with the research team allows for the voice of the patient to be listened to and considered throughout the research project. It is very important.”
Janice Rose, ThinkCancer! PPI Representative
The ThinkCancer! team is fortunate to have recently been joined by Lowri Griffiths, who brings with her a broad range of experience both as a member of the PRIME (Wales Centre for Primary and Emergency Care Research ) Centre Wales Super (Service Users for Primary and Emergency care Research) Group and from having supported family members diagnosed with cancer:
“I was offered the opportunity to get involved in the ThinkCancer! Phase III trial through the work I had been doing with the PRIME Centre Super group. I have worked in the cancer policy field for many years and my passion for this particular research project stems from a number of family members interactions with primary care and their subsequent late diagnosis, in particular – the experience my mother had when she was diagnosed with malignant melanoma and the way my aunty was diagnosed with late stage metastatic lung cancer.”
“This is my first involvement in a research project as I am a relative newcomer to the PPI world and I have been really pleased with the level of engagement with myself and Jan as the trial has been developed. It is great to see my contribution having an impact on the information that is being prepared for potential participants.”
“We have relatively poor cancer outcomes in Wales and primary care is vital to making sure we change that in the future. I am really looking forward to being able to play an active part in facilitating other people to get involved when the time is right!”
Lowri Griffiths, ThinkCancer! PPI Representative
Professor Clare Wilkinson
Professor of General Practice & Co-Chief Investigator c.wilkinson@bangor.ac.uk
Professor Richard Neal
Professor of Oncology & Professor of General Practice
R.D.Neal@leeds.ac.uk
Dr Dan Walker
Acdemic GP Trainee
d.walker@bangor.ac.uk
Dr Bethany Anthony
Health Economics
b.anthony@bangor.ac.uk
Dr Nia Goulden
Trial Statistician
n.goulden@bangor.ac.uk
Professor Rhiannon Tudor Edwards
Professor of Health Economics & Health Economic Oversight
r.t.edwards@bangor.ac.uk
Dr Alun Surgey
Academic GP
a.surgey@bangor.ac.uk
Dr Annie Hendry
Qualitative Researcher
a.hendry@bangor.ac.uk
Victory Ezeofor
Health Economics
v.ezeofor@bangor.ac.uk
Dr Rachel Evans
Trial Statistician
r.evans@bangor.ac.uk
Nic Nikolic
Admin lead
n.nikolic@bangor.ac.uk
Clio Evans
RPSO
Richard Evans
SRA
Janice Rose
PPI Representative
We would like to extend our thanks to our funders Cancer Research Wales and Cancer Research North West, and to the members of the public who support these charities, without whom our work would not be possible.
Publications
Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!
Presentations
Cancer: Doctors urged by charity to identify symptoms sooner
Cancer: Doctors urged by charity to identify symptoms sooner - BBC News
Read more about the WICKED Programme and the previous Work Packages by clicking here to read our publication in the BJGP.
*clinical presentations: symptoms, clinical signs and the context (e.g. past medical history, risk factors, previous consultations) during a primary care consultation.
For more information about this study, please contact the study team on thinkcancer@bangor.ac.uk
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ThinkCancer! Study, Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP