Diagnosing and treating cancer cost £6bn per year, a disease that will affect one in three of us during our lifetime. Despite year-on-year improvements in cancer treatment the UK still trails other OECD counties for cancer outcomes. Better prevention, screening and early detection were identified in the 2011 NHS Cancer Outcome Strategy as ways to reduce the growth in incidence of cancer and improve one and five year survival. from diagnosis. Bowel cancer detection and treatment has improved but still lags when compared with other developed nations. A major program of bowel cancer screening has been rolled out in England with the aim of detecting and removing pre-cancerous polyps. A national advertising campaign has been used to raise awareness of cancer symptoms to encourage patients not to delay in contacting their doctor when they have “blood in their poo”. A hybrid model has been developed to link through from the early patient behavioural aspects of cancer detection through to outcomes. The hybrid approaches uses a discrete event simulation to represent the pre-cancerous stages through to initial contact points with the NHS and then onto to diagnosis and staging by the multi multidisciplinary teams (MDT). From the stage of diagnosis a probabilistic pathways model was used to predict annual costs and mortality for up to 10 years after initial diagnosis. This approach permitted developing a total lifetime cost measure for patients with a cancer diagnosis and the ability to test out how this might change with different policy options. Early modeling results have assisted the better understanding of the medium and long term implications of policies on bowel cancer and have helped set priorities to improve outcomes

1. Modelling your way out of the poo
Forecasting costs and outcomes of bowel cancer
David Halsall, John Osmond and
Laura Bown
NHS England Analytical
Services

2. Background to the problem
So what is the problem with bowel cancer?
• 325,000 people diagnosed with cancer in the UK in 2010,
half of them will die of the disease. A third of people will
develop cancer in their lifetime
• There has been a 35% increase in incidence since 1970s,
largely related to lifestyle and improvements in other
conditions e.g. heart disease.
• Bowel cancer survival is poor compared to other countries
which is largely down to late presentation.
• Current polices to address this poor performance are based
around screening and better awareness.
• We want to model how current policies will feed through to
the better outcomes and estimate how much it will cost over
a 5 -10 year period.

3. Background of cancer
One in three of us will get cancer in our lifetime
One in three people can expect to have a
cancer diagnosis at some time in their life.
This cancer incidence rate is average for
north Europe, higher than western Europe
and lower than the US and Canada
For many cancers having a healthy lifestyle
can reduce the risk of getting the disease.
Tobacco, being over weight, low fruit & veg & alcohol
are known risk factors for cancer. Most of lung
cancers and half of bowel cancers could be
preventable by lifestyle
New cases of cancer 2000 & 2010 by age
60,000
Lung 13%
Breast 15%
Colorectum 13%
Prostate 13%
New cases of cancer
40,000
30,000
2010
2000
50,000
Male =
Female =
20,000
10,000
0-19
Four cancer types are responsible for half of new
cases reported each year. Leukaemia, brain,
melanoma, ovary, uterus lymphoma & pancreas
make up the next most frequent sites. There are a
further 20 sites of rarer cancers.
20-64
65-74
75+
Lifestyle choices and improved treatment for
cardiovascular conditions is leading to an increase in
the incidence of cancer. Soon over 2 million people will
have had a cancer diagnosis.

4. Background of cancer
Cancer survival is improving but England is still lagging by
international comparisons
Over the past 30 years the chances of surviving five
years after diagnosis has doubled for breast and bowel
cancer. Some cancers, such as lung, are particularly
hard to treat and progress has been much slower.
Colorectal cancer, five-year relative
survival rate by sex, 2004-09 (or nearest period)
Five year cancer survival
Despite this improvement England and the UK have
lagged behind comparator countries but current
strategies aim to halve the difference between England
and the average of Australia, New Zealand Canada.
Health at a Glance 2011: OECD Indicators

5. Background of cancer
Biology of cancer – slow start & explosive finish
Generic
Stage 1
Stage 2
Stage 3
Stage 4
(Bowel)
(Duke A)
(Duke B)
(Duke C)
(Duke D)
Symptoms and the first
opportunity for imaging
diagnosis
Cut off point for curative
treatment
If you die of cancer
you will have around
1kg of cancer cells in
your body

6. Why are UK cancer outcomes poor
Why is cancer survival poor in the UK?
• Why is survival poor in in the UK?
The excess of very early deaths the UK suggests late
diagnosis plays a major part of the story
Why is survival poordiagnosedUK?
in the as emergency
• Around 25% of cancers are
admission in A&E. Many of these patients may only live for
a couple of weeks after first diagnosis
• It is likely that late presentation by patients, late
investigation and/or onward referral and suboptimal primary
treatment all play a part in the explanation. But the sooner
treatment is started the better the outcome
Colon cancer: all-ages, one-year net
•
survival by stage of first diganosis
A
B
C
D
98.3%
90.8%
78.1%
36.7%
Colon cancer: all-ages, one-year net survival* (NS, %) by stage at diagnosis ECRIC cancer registry
Patients diagnosed during 2006 in the cancer registries included in the ICBP analyses

7. Cancer screening
Cancer screening can spot cancers before symptoms
become apparent.
• Breast and cervical cancer have well established
screening programmes.
• Lung cancer screening may be beneficial for
those who smoke
• Bowel cancer screening was first piloted in 2000
and has rolled out in waves and now offers
screening every two years to all men and women
aged 60 to 69.
• The NHS is now also rolling out bowel scope
screening to all men and women aged 55 to
remove polyps before they become cancerous
• There are no other major cancers which are
routinely screened for.

8. An abnormal bowel cancer screening test
can lead to the detection of pre-cancerous polyps or
cancer at an earlier stage
Removal of pre-cancerous polyps
can lead to a reduction of
cancer incidence
Dukes stage at
diagnosis
A
B
C
D
Unknown
8
Screendetected
%
27.9
22.7
25.7
6.3
17.4
Crude 1 year survival
96%
Nonparticipant
%
10.4
23.5
26.7
21.0
18.4
77%
Morris et at BJC (2012) 107 757-764

9. Why are UK cancer outcomes poor
Promptly diagnosing cancer is key to good
outcomes in non-screened patients
Delays in the patient presenting with symptoms
• Most patients present to their GP with symptoms – and most present quite
quickly
• Some patients present symptoms late or never. These patients frequently
report that they were unaware their symptoms could be serious.
• People in the UK (rather than patients) frequently report that they would be
worried about wasting their GPs time.
Delays in diagnosis
• Most patients with cancer are referred promptly by GPs (one or two visits only)
down the rapid access 2 week wait route.
• Some are only referred after multiple visits.
• There are large variations in use of direct access diagnostic tests, such as
chest x-ray between general practices.
• There are large variations in the use (and accuracy of use) of urgent referral
2WW routes

10. Early detection of cancer
The Be Clear on Cancer advertising
campaign targets those with symptoms

11. Cost of treating bowel cancer
The lifetime cost of bowel cancer is heavily dependent on
complications and the treatment of secondary cancers
11
Stage of diagnosis
D
C
B
A
Produced by Monitor Company Group, L.P.
for Macmillan cancer support 2012

12. Modelling the problem
The aim is to increase the proportion of cancers diagnosed at stages A & B
which will improve outcomes but may not reduce costs in the short term
Survival – 1 to 5 years
Screening
12K
Duke A
Stage of
diagnosis
at
MDT*
Total costs
Population
GP
Other
Emergency
Duke B
22K
Duke C
24K
Duke D
2WW
10K
30%
20%
Modelled with discrete
event simulation
* Multi-disciplinary team
10%
0%
Duke Duke Duke Duke
A
B
C
D
Colon cancer 2006 ECRIC
Modelled with Excel based
Stocks and Flow simulation

13. Modelling the problem
Part 1: Pre First MDT
Screening
3%
A&E
23%
Cancer
96%
76%
Symptoms
GP
Routine
Death
Urgent
1%
1%
Symptoms
Death
National Cancer Intelligence Network, Routes to Diagnosis
MDT

14. Modelling the problem
What is microsimulation?
Microsimulation models operate at individual unit level, e.g
vehicles on a road, suitcases in an airport. NHS patients can
be modelled in the same way.
Each unit has its own unique set of characteristics. Rules and
probabilities control the movement of these units through the
model. Rules and probabilities can then be changed to assess
the impact of policy interventions.
Example: Pharmacy
Arrival
Queue
Served
Exit

15. Modelling the problem
The microsimulation model
The model is split into two parts – a microsimulation of the pathway up until
first MDT which gives results of stage of diagnosis. These results are then
linked to costs and survival data

16. Modelling the problem
Post first MDT treatment pathway
1 – 5 year survival
treatment with curative intent
Stage A
Minor
Surgery
Stage B
treatment with palliative intent
RadioTherapy
MDT
Major
Surgery
Stage C
Stage D
Symptoms ChemoTherapy
ChemoTherapy

17. Modelling the problem
With in the modelling solution it has been assumed that
cancer survival will continue to improve independent of
funding
Percentage of cases surveing one year
100
Dukes D
80
60
Dukes C
40
20
0
17
Probability of surviving one year by Duke stage used in model
Dukes A
Dukes C
1971-1975 1976-1980 1981-1985 1986-1990 1991-1995 1996-2000 2001-2005 2006-2010 2011-2015 2016-2020 2021-2025
Assumed probability living more than 1 year by cancer stage over time.

18. Results
The Baseline case shows costs and the number of
in-year deaths both rising
Dukes A
New cases
died
2013
2,995
488
2018
3,252
469
2023
3,510
403
Dukes B
New cases
died
7,336
1,180
7,967
1,140
8,599
1,049
New PC cases
22,986
24,964
26,942
Died
7,033
7,267
7,444
in-year
EME/unstaged cost (£m)
7,462
338
8,104
364
8,746
389
Baseline symptom based bowel cancer
model output
30,000
500
25,000
450
20,000
400
5,000
0
Died in year
300
10,000
New PC cases
350
15,000
Costs
250
2013
2018
2023
Dukes D
New cases
died
5,309
3,650
5,766
3,980
6,222
4,276
Baseline stage of diagnosis
Base line symptom based presentation
2013
2018
2023
Dukes C
New cases died
7,346
1,716
7,979
1,678
8,611
1,716
30%
20%
10%
0%
This shows in the baseline
case in-year deaths from
symptom presentations
rising but at a slower
rate than new cases or cost

19. Results
The model can predict what will happen over time if we
stage shift the distribution of first diagnosis from D to C
2013
2018
2023
Dukes A
New cases
died
0
0
0
0
0
0
Dukes B
New cases
died
0
0
0
0
0
0
Dukes C
New cases
died
0
0
500
86
1,000
178
Dukes D
New cases
died
0
0
-500
-325
-1,000
-664
live "saved" Cost (£M)
-238
-486
0
1
2
Stage of diagnosis
Assume 100 patients a year
Are shifted from D to C over 10 years
Number of additional cases
above baseline. An additional
100/year cases are shifted
down one stage from Duke’s
D to C by 2023.
This will save 484 lives at an
additional cost of £2m / year
above baseline.

20. Results
The model can predict what will happen over time if we shift
100 patients from each stage down by one stage.
Net change over baseline
2013
2018
2023
Dukes A
New cases
died
0
0
500
35
1,000
83
Dukes B
New cases
died
0
0
0
0
0
0
Dukes C
New cases
died
0
0
0
0
0
0
30%
25%
20%
Baseline
15%
100/year shift up
10%
5%
0%
Duke A
Baseline
Shifted
10%
13%
Duke B
24%
24%
Duke C
24%
24%
Duke D Unstaged
17%
15%
25%
25%
Assume 100 patients a year are shifted D >C>B>A
Dukes D
New cases
died
0
0
-500
-325
-1,000
-664
live "saved" Cost (£M)
-325
-664
0
0
1
Number of additional cases
above baseline. 100/year
cases are shifted down one
Stage from Duke’s D to C to
B to A by 2023.
This will save 664 lives at an
additional cost of £1m / year
Above baseline .

21. Summary and Next Steps
• Coarse modelling to demonstrate principle.
• Benefit: 200/300 lives saved per year via earlier diagnosis
by 2018
• 6% of the 5000 lives saved per year required across all
cancers in mortality call to action.
• Cost: Small increase of £1m/£2m per year
• Add appropriate level of detail and repeat in microsimulation.

22. Questions?