Lung cancer is the second most common cancer in men and women after prostate and breast cancer, respectively. With such high prevalence in the UK it has become essential that the general population is made aware of the risk.
Lung cancer is more prevalent in the elderly, with 80 per cent of cases occurring in patients over the age of 60. Currently, males make up 55 per cent of newly diagnosed cases but, since young females are smoking increasingly, this may change.
Some groups are at increased risk of getting lung cancer but there are profound and modifiable risk factors. There is strong correlation between smoking and environmental tobacco smoke and lung cancer. Other links have been formed with environmental exposure to asbestos, haloethers, polycyclic aromatic hydrocarbons, nickel and arsenic. There are also possible links involving diet, genetic factors and the presence of underlying benign forms of parenchymal lung disease, including chronic obstructive pulmonary disease and pulmonary fibrosis.
In the past, lung cancer was pretty much a death sentence. In 2012 just under £200m was spent on lung cancer research. With advances in chemotherapy, according to Macmillan, one-year survival rates have risen to 29 per cent in men and 33 per cent in women in 2005–09.
Five-year survival rates are depressing at 7 per cent for women and 5 per cent for men. Nonetheless the key to giving people the best chance of survival is early detection and diagnosis.
Early diagnosis also results in a shorter treatment period, which is particularly significant for the NHS since one year of treatment costs just under £25,000 according to National Institute for Health and Care Excellence guidance, and there are 42,000 new cases every year.
Given the emphasis on early diagnosis and referral, the community pharmacy team is ideally placed to help.
What we did
In keeping with the agenda set out by our local clinical commissioning groups, Manor Pharmacy Group ran a lung cancer campaign for four weeks in summer 2013. We made it our priority to raise awareness about lung cancer. We worked synergistically with the NHS lung cancer campaign to maximise the outcome of our efforts.
On the principle of “making every contact count” we involved the entire pharmacy team in the campaign, thereby increasing the opportunity for our campaign to be communicated to the public. Elements of the so-called “Swiss cheese model” were implemented: if the opportunity to share information was missed by counter staff then it could be provided by the dispensing staff or pharmacist or via the promotional material we produced in house.
All seven Hertfordshire branches of Manor Pharmacy became points of reference for the public in gaining information about lung cancer. We wanted people to know the symptoms, the facts and, most importantly, when to consult their GP.
To ensure we achieved our objective it was essential that each member of the pharmacy team was communicating the same clear consistent message and that the counter staff were confident in what they were presenting to the public. For this reason, training packs were sent to each pharmacy containing up-to-date literature about lung cancer. The packs contained NHS posters and leaflets along with our own Manor Pharmacy Group produced information sheets. We also produced a PowerPoint presentation containing information on the signs and symptoms of lung cancer, when to go and see the GP, lung cancer myths and facts, early detection survival rates, risk factors and additional points of reference if people wanted more information.
Our intentionally non-targeted approach made sure as many people as possible left the pharmacy having engaged in a dialogue with the pharmacy staff. Instructions were also given on targeting specific groups, such as people buying cough remedies, the elderly, patients involved in medicines use reviews or smoking cessation, and patients who were waiting for medicines to be dispensed.
Three key points were communicated to each patient every time the topic was raised:
- A cough that has lasted for three or more weeks
- Non-smokers can get lung cancer
- Early detection equals increased survival rate
We wanted to keep the points concise to aid the patient in the recollection of that knowledge. We supplemented these verbal cues by using the aforementioned training packs and PowerPoint presentation.
Our primary goal was to engage in a dialogue with patients. If we were unsuccessful in raising a dialogue, we would rely on our support material such as the PowerPoint presentations, posters and leaflets. Data collected were only from the dialogues we engaged in. Despite handing out awareness material we cannot be certain that people read it.
What we found
During the one-month campaign we actively counselled 133 people, of whom 55 per cent were female.
With the increased incidence of lung cancer in the over 60 population, we were particularly encouraged that more than 60 per cent of the people engaged by our campaign were from that age group. The next highest group (19 per cent) were aged 50 to 59 years.
We found our most successful entry into raising awareness was by talking to people who were receiving or waiting for dispensed medicines (80 per cent). The next most productive method was by the pharmacist conducting smoking cessation or an MUR (8 per cent). Other ways included talking to patients buying medicines, cough medicines in particular. Some patients raised the issue themselves after viewing or receiving our promotional material.
Of the 133 people we talked to, six (5 per cent) were referred to their GP.
What happened next
In terms of raising awareness the campaign was a great success. Over 90 per cent of the people we spoke to had little knowledge of the information we were promoting about lung cancer.
Health and Social Care Information Centre figures show that there were 11,495 community pharmacies in England in March 2013. We were able to educate 124 people in seven of our branches. If we were to extrapolate this figure to a nationwide campaign, this equates to about 1.5 million people being made aware primarily through conversations with pharmacy staff. Running campaigns such as ours allows us to make clear to the government, other healthcare professionals and the public our value to them.
The use of non-targeted approaches helped inform a larger number of people. We took a non-targeted approach to the sexes but women were more willing to be counselled. It appears to be socially ingrained in men not to talk about their health; this presented a hurdle and many counselling opportunities were missed because of this. Given the notorious health inequality in men, it is vital that community pharmacies are persistent in talking to them about their health. Perhaps we need to upskill our counselling ability in this area.
The fact that dispensing and selling medicines, medicines use reviews and smoking cessation were the most effective ways of reaching people highlights the importance of involving the entire pharmacy team in the campaign and not focusing on one aspect of the pharmacy alone when seeking to raise awareness.
With regard to targeted approaches, we took a particular interest in patients who bought cough medicines because cough is one of the most prevalent early warning signs of lung cancer. Perhaps disappointingly, counselling only resulted from the purchase of a cough medicine on 4 per cent of occasions. If this campaign were to be run during winter there may be more counselling opportunities owing to increased sales of cough medicines.
We also took targeted approaches with the elderly and patients who smoked but we were diligent in ensuring non-smokers also received the message that they were at risk of lung cancer.
Dialogue about lung cancer was prompted by 3 per cent of customers having seen the promotional material. Although only a small percentage, it was still a valuable tool. It is worth noting that we cannot account for those people who saw the promotional material and shared the information with others.
Despite only 5 per cent of patients and customers being referred to a GP, this critically reinforces the need for these kinds of campaigns to take place. T his small percentage equates to six lives potentially being saved by early detection and thousands of pounds being saved by the NHS in treatment and staffing costs.
By actively engaging in dialogue, we were able to communicate effectively with a diverse local population. Allowing each branch to work autonomously meant they were able to implement the best-suited strategies for their local populations, build greater rapport and encourage active engagement with the campaign.
The community pharmacy team is the first point of contact for most patient ailments. We find ourselves in a unique position to help improve the public’s health. We knew the counter staff would play a vital role, but we were encouraged by the active role played by the dispensing staff and pharmacists. They had the opportunity to reinforce counselling points while giving out dispensed medicines and during MURs. This reinforced the already well established communication infrastructure between the pharmacist and GP.
The most important thing we learnt from this campaign is the lack of awareness among the general public. If community pharmacies can generate more awareness, we have a greater opportunity to reach and educate the public.
This campaign was not only beneficial for our patients but also for the Manor Pharmacy Group. Every member of the team was involved: counter staff, pharmacy manager, dispensing staff, preregistration trainees, summer placement students and the pharmacist. Together we extended our own knowledge about lung cancer and improved our team and patient communication skills. By working together we were able to use individuals’ strengths to support and enhance the campaign.
Conclusion
This campaign has been effective, as demonstrated by the awareness raised and the GP referrals generated. Knowledge about early signs and symptoms of lung cancer can be the determining factor between life and death.
Such campaigns should be run several times a year, directed by clinical commissioning groups. They are simple to implement and are effective in addressing public health issues. They also help to educate and reinforce the knowledge of members of the pharmacy team, thus increasing their ability to provide excellent patient-centered care. We have demonstrated the importance of providing sufficient training material to ensure efficient delivery of information from the pharmacy to the public.
Lack of knowledge among the public consistently results in people seeking medical advice at a late stage or not at all. Community pharmacy teams are on the front line. We must take responsibility for this shortcoming and ensure knowledge is shared.
As part of the NHS outcomes framework (2013–14) NICE has articulated a number of public health outcomes indicators, for example. “Domain 1: Preventing people from dying prematurely”.
Cancer tsar Mike Richards refers to the “size of the prize” in the early detection of cancers as having the potential to save 15,000 lives a year. The NHS “Call to action: commissioning for prevention” suggests that the UK lag behind many other countries in preventive strategies and early detection of several cancers, and early detection of lung cancer is specifically listed as a target. Pharmacy clearly has a crucial, life-saving role to play.
ACKNOWLEDGEMENTS We acknowledge the contribution of the summer placement students, preregistration trainees, pharmacists and staff at Manor Pharmacy Group.Â
