Ovarian cancer is the major cause of death for women diagnosed with a gynaecological cancer in the UK. Wales has relatively worse survival rates and this appears to be due to delays in the diagnostic pathway for women with suspected early and advanced stages.

The single cancer pathway in Wales, sets out a recommended timeline for women to compete the diagnostic pathway (21 days), yet this was seldom achieved as primary care providers had too many diagnostic hurdles to navigate, leading to inevitable delays in diagnosis.

Our pilot project was designed to improve survival outcomes for women with ovarian cancer as per the National Optimal Pathway for Ovarian cancer in Wales:

• For patients with suspected early-stage ovarian cancer:

Diagnostic pathway < 28 days from point of Suspicion (PoS) and first definitive treatment < 62 days from PoS

• For patients with a suspected metastatic (advanced) ovarian cancer:

First definitive treatment < 21 days from PoS

The Ovarian one stop clinic offers the patient a same-day rapid diagnostic program.

Project Aims and Objectives:

Aim: To improve survival outcomes for women with ovarian cancer.

Objective 1: To reduce the time taken to diagnose ovarian cancer (early detection) and the time taken to optimise patients for treatment.

Objective 2: To improve on the recommended timelines as set out by the National Optimal Pathway for Ovarian cancer in Wales.

Objective 3: To provide appropriate specialist and CNS input at the first visit, enabling patient- centred care and expertise as early as possible in the management pathway.

Objective 4: To improve patient experience by giving an earlier definitive plan of management/reassurance if there is unlikely cancer.

Objective 5: To apply an enhanced version of current NICE guidance; by obtaining virtually all the required information for the MDT discussion on the same day while also providing patient-centred care.

Objective 6: To simplify diagnostic navigation for General Practitioners thus preventing inevitable delays in Ovarian cancer diagnosis.

Project Approach:

This one-stop service reduces diagnostic waiting times for women with ovarian cancer and provides appropriate specialist and Clinical nurse specialist input at the first visit. This facilitates immediate patient-centred care in the management pathway.

The flow chart model describes the pathway process from primary care assessment to the patient’s first definitive treatment. This improved approach incorporates stakeholders in primary and secondary care, nursing, radiology, administration, finance and cancer performance directors.

To improve the clinical utility of the clinic, the referral criteria was disseminated to all GP practices within Swansea Bay. A new electronic grading option on WCP (titled ovarian one-stop) got GPs to refer directly.

Project Outcomes:

A new service to facilitate early diagnosis of patients with suspected ovarian cancer was developed. Our outcomes show that patients entering this diagnostic pathway were given adequate care and support from the beginning, whilst facilitating a process to provide early diagnosis and management respectively.

Project Impact:

Our project’s predominant aim was to improve the quality of care and reduce the waiting times to reach a diagnosis for patients presenting with suspected endometrial cancer on the Single Cancer Pathway. Current Welsh Government targets aim to diagnose and start cancer treatment within 62 days of the point of suspicion (the date of primary referral). As part of the Single Cancer Pathway, NHS Wales National Optimal Pathways (NOPs) recommend as good practice that histopathology diagnosis of cancer and staging by imaging should be performed within 28 days from the point of suspicion.

Project Objectives:

1. Work with colleagues, the health board, Bevan commission and patients to co-design the new service.
2. Provide an efficient ‘one-stop’ service for patients to improve the patients’ experience and to reduce the number of hospital appointments required in order to reach a diagnosis.
3. Improve the early part of the Single Cancer Pathway – improving the diagnostic pathway by reaching a diagnosis in a more timely manner.

Project Outcomes:

To set up a new and improved ‘one stop’ PMB service in Cardiff & Vale health board in order to facilitate a timelier diagnosis of endometrial cancer and to provide reassurance quicker for those who have normal histopathology reports.

Project Impact:

Since the introduction of the one stop post-menopausal bleeding clinic, we have seen overall improvements in the time taken to reach a diagnosis (RTT) or downgrade results which are benign for patients with suspected endometrial cancer.

The feedback received from patients has been very positive. Patients prefer a ‘one stop’ approach, avoiding the need to create further delays and minimising the rneed for multiple appointments. We consistently received very positive feedback about our clinic staff, which helps to promote positive change within the department. The project has allowed us to provide timely diagnoses of endometrial cancer, reassure those who have had normal results and reduce the number of hospital visits required for patients.

National Optimal Pathways for Cancer mandate that Health Optimisation is introduced at the Point of Suspicion of cancer (PoS) (Welsh Government 2019). With over 18,000 people referred onto the Suspected Cancer Pathway (SCP) annually in Wales, it is challenging to develop an effective approach due to the high demand and limited knowledge of people’s needs on lifestyle behaviour.

Project Aims and Objectives:

Aim: To encourage people to access evidence-based health and well-being information at the PoS of cancer, enabling healthier lifestyle behavioural changes.

Objectives:

1. To understand the information that people would find useful at the PoS of cancer, focussing on the five domains of patient health optimisation (diet, smoking, physical activity, alcohol and emotional wellbeing).
2. To evaluate and critically appraise existing digital information on the five domains of patient health optimisation available to people at the PoS of cancer.
3. To design, trial and evaluate a digital Health Optimisation Self-Assessment Tool to inform and nudge people to encourage them to think about.

Project Approach:

• Using various digital platforms people were invited to complete an online questionnaire.
• A focus group was conducted and the data was analysed thematically to identify key themes.
• A digital Health Optimisation Self-Assessment Tool was developed using the findings from the questionnaire and focus groups. The tool was piloted in four GP clusters. People with an urgent suspected cancer, referred onto the SCP by their GP within the clusters, received a text containing a link to the tool, within three days, inviting them to complete the tool.

Results:

In total 50 participants responded to the questionnaire with very few receiving any information on lifestyle behaviour at the PoS (range 10-18%).

A high percentage (86%) would like to receive information in relation to lifestyle behaviour with nearly all favouring completing an online self-assessment tool (92%).

A total of 465 people were referred onto the SCP with an urgent suspected cancer, with 100% receiving the text within three days. The response rate for completion was nearly 40%. People reported that the tool was easy and simple to complete.

Project Background:

Targeted lung cancer screening has been recommended by the UK National Screening Committee.  Effective screening depends on accurate and efficient identification of the target population.

The screening process involves identifying current and ex-smokers (“ever-smokers”) in a target age range, followed by risk assessment +/- low-dose CT screening.

GP records can be used to identify ever-smokers but the completeness of this data is uncertain and updating of records can be resource-intense.

Project Aims and Objectives:

Search GP records to assess the completeness of smoking data (recorded as “tobacco codes”).

Develop a toolkit for GP practices to update missing smoking data via a text message system.

Project Approach:

Following proof-of-concept work, a toolkit was developed for the VISION360 patient administration system (used by 54% of GP practices in Wales, with the remainder using EMIS) giving step-by-step instructions for practices.

12 practices participated in the first phase of the project, assessing the completeness of smoking data and testing the toolkit.  Following an interim analysis, revisions were made to the toolkit and a streamlined version was tested by a further two practices.

Project Outcomes:

All participating practices successfully used the toolkit to update smoking records.  During the first phase of testing, use of the toolkit increased data completeness from 96.5% to 98.0% (+1.5% absolute change; 331 additional tobacco codes recorded).

The majority of feedback reported that the toolkit was easy to use.  Issues identified at the interim analysis included data errors related to manual calculation of results by users, and frustration with instructions asking to repeat previous steps.

The revised streamline version of the toolkit was successfully used by two further practices, taking practice managers an average of 30 minutes to complete (range 20-40 minutes).

Project Impact:

An improvement in data completeness of +1.5% across Wales would equate to an additional 5,934 people across Wales being eligible for targeted lung cancer screening who may otherwise have been missed.