What is a cancer care review?
A cancer care review (CCR) is a supportive conversation between a person with cancer-related needs and a healthcare professional, usually in the primary care setting.1 People with a cancer diagnosis experience poor quality of life in both physical and mental health domains, many decades after their diagnosis.2 CCRs were embedded into the GP contracts (in NHS England) in 2003. They provide an opportunity for patients to discuss their experience of cancer and identify unmet needs.1 This article aims to provide English primary care clinicians with a guide to conduct CCRs based on patient perspectives, current research evidence, clinical experience, and policy.
The UK cancer care landscape
Providing cancer care is important given that over 3 million people are living with or after cancer in the UK, which will increase to 4 million by 2030.3 Personalised cancer care aims to empower this growing population and tailor the care to their needs.4 Personalised care for cancer is being delivered through health and wellbeing information support events, holistic needs assessment (HNA) with a personalised care and support plan (PCSP), end of treatment summaries (EOTS) (Figure 1), and CCRs in primary care. The first three interventions are currently largely delivered in secondary care but outputs from the HNA and EOTs are valuable for primary care teams to provide continuity of care. CCRs now involve an early offer of support within 3 months of diagnosis followed by a comprehensive review within 12 months post-diagnosis in order to support a personalised approach.5
Figure 1. Personalised cancer care within the English healthcare system and financial incentives. MDT = multidisciplinary team. QOF = Quality and Outcomes Framework.
Primary care has a role to co-produce new models of care that support people living with and beyond cancer.6,7 This may include adopting the principles of personalised care and considering the needs of those with multimorbidity.6,8 In order to see the person beyond their illness, a shift in both organisational and clinician perspective is needed, as well as changes in processes.6
Evidence base supporting CCRs
A 2021 scoping review identified limited evidence for CCRs and some negative patient experiences from the early 2010s.9 Despite this, it is difficult to demonstrate the impact of single consultations within complex cancer journeys. A 2017 Macmillan-funded Scottish project highlighted high patient satisfaction when 13 trained general practice nurses delivered 246 CCRs with adequate time for care delivery.10 Financial incentive data (Quality and Outcomes Framework [QOF]) provides no measure of CCR quality. High completion rates contrast with findings of a national cancer survey (National Cancer Patient Experience Survey [NCPES])11 in England where only 20% of people with cancer surveyed recalled having a CCR, suggesting there is need for further understanding of this large discrepancy including qualitative analysis.
Preparation
Preparing for the CCR will improve both effectiveness and quality of the review. Macmillan’s Practical Implementation Guide for Cancer Care Reviews12 sets out key practice-level steps to improve the quality of the intervention, patient identification, and correct CCR coding.
Given current workforce challenges, QOF guidelines emphasise that clinical elements of CCR should involve GPs, general practice nurses, or allied health professionals, supported by non-clinicians such as social prescribers and cancer care coordinators with proper training and supervision.13
Contact within 3 months of the cancer diagnosis (QOF code: CAN005)
A proactive offer of support from the GP practice helps remind patients that they can come to primary care when they need to.
Clinicians should check diagnosis, tumour site, staging of the cancer, and coding in clinical notes before contacting the person by their preferred modality, for example, text message. There are example letters on the Macmillan website (Figure 2). In the message or consultation, it is important to acknowledge the diagnosis, offer an opportunity to discuss their diagnosis, and provide information about support services. Use of existing templates (for example, Macmillan cancer care review template) will ensure correct coding.
Figure 2. Cancer care review (CCR) professional resources. eHNA = electronic holistic needs assessment. QOF = Quality and Outcomes Framework.
CCR within 12 months of the cancer diagnosis (QOF code: CAN004)
Clinicians should prepare for the consultation by gauging the needs of patients using a simple pre–CCR questionnaire (Box 1). The questionnaires can be shared with patients using the practice’s suite of tools, such as SMS (for example, AccuRx Florey), email, or a paper-based concerns checklist prior to consultation (Figure 2), or a direct link to Macmillan’s electronic holistic needs assessment.
| The authors asked three patient and public representatives who have a lived experience of cancer about their expectations for cancer care reviews and this is what they said: |
Prior to the consultation
Allocate a little longer for appointments to allow time for questions and discussion, ideally a double appointment. Read up on the clinical background and about the patient before the consultation. Be aware of local and national cancer support services or support groups. Be aware that people from ethnic minority backgrounds may have different ways of managing health and illnesses, for example, ethnic minorities may seek support from family and community prior to seeking help from health care.14
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During the consultation
Avoid jargon. Acknowledge the life-changing impact of a cancer diagnosis and do not underestimate the importance of compassion. Maximise continuity by having one or two clinicians to follow the person on their cancer journey so they do not need to keep re-telling their story to different professionals, which can be tiring. Provide links to local and national cancer support services or support groups.
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End of the consultation
Ensure patients are clear about follow-up plans with their cancer team and who to contact if they are unsure, for example, care navigator or specialist nurse at oncology service, or practice nurse at GP practice. Summarise the appointment content, possibly through text or writing including useful contacts at the practice, but ideally a care plan.
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Box 1. What do patients want from cancer care reviews?
Ideally, CCRs should be offered in more than 10-minute appointment slots. Macmillan recommends 30 minutes, which may be challenging for primary care to deliver. A feasible solution may be a follow-up appointment and/or referring to other primary care team members such as a social prescriber or cancer care coordinator, if available. Patients should be offered the opportunity to bring a family member, carer, or an advocate to the CCR consultation for support, if appropriate.
Prior to the appointment, clinicians should review existing documentation such as a treatment summary (EOTS) and HNA care plan (PCSP) (Figure 1), or recent hospital clinic letters. The consultation can be conducted face-to-face or remotely (telephone or video) in line with patient preference and communication needs. The CCR conversation usually covers the cancer diagnosis and treatment, the treatment consequences (short to long term), medication reviews, physical activity advice, referring to relevant colleagues (for example, mental health or physiotherapy), and signposting to local support services.
Using an existing cancer care template (for example, Macmillan or Ardens) can help structure consultations and will ensure that correct coding is applied. After the CCR, clinicians should provide a PCSP, a tenet of personalised care, which can be provided through a printout of the consultation or through My Care Plan (Figure 2). Alternatively, this could be circulated through text messages along with information on local support services.
Conclusion
Cancer care reviews have the potential to support patients with unmet need to get support that they need and to live more enabled lives in the community. Primary care has an important role in offering and delivering these reviews consistently and in a meaningful way. It is the authors’ view that the future of a personalised care approach lies in integrating cancer care into long-term condition reviews in primary care, but this is not supported through the existing primary care funding model, which focuses on managing conditions separately.15 Innovation and new models of care can be piloted in primary care to maximise the holistic approach to care.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
Dipesh P Gopal is a GP and School for Primary Care Research Primary Care Clinicians Career Progression Fellow, supported by the Department of Health and Social Care and the National Institute for Health and Care Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
- © British Journal of General Practice 2024
