'Know 4 sure' campaign: Information for GPs

Campaign materials

'Know 4 sure' briefing sheets and marketing materials (e.g. leaflets and posters) are available on the resources and tools page.

Download campaign materials

The ‘Know 4 sure’ cancer symptoms campaign pilots took place in five areas in England from 14 January to mid-March 2013.

If your practice is within one of these areas, you may have seen more patients coming to see you with one of the four key cancer symptoms highlighted in the campaign. Over the last two years we have been working with local NHS teams and Cancer Networks around the country on early diagnosis of cancer pilots. There are a range of questions that we have heard GPs ask in relation to running activities to promote awareness of the signs and symptoms of cancer.

If you have a question about Be Clear on Cancer that isn’t answered here, please contact partnerships@phe.gov.uk.

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What is different about this campaign?

Following several tumour-specific cancer awareness campaigns, Be Clear on Cancer has become a well-recognised brand. Therefore, it is timely to pilot a more general cancer symptoms approach that will work with them. ‘Know 4 sure’ is the headline for this new Be Clear on Cancer campaign – it will be used in all the adverts and materials.

Why run this cancer symptoms campaign?

Around 268,000 people are diagnosed with cancer in England each year - more than 236,000 are aged 50 and over [1]. Outcomes in Britain are worse than those in some European countries and it is estimated that 10,000 deaths could be avoided each year if cancer survival matched the best in Europe [2].

But, awareness of signs and symptoms of cancer is low and we know that people can delay going to see their GP for a number of reasons.

With more than 200 types of cancer, the Department of Health can’t continue to produce individual campaigns. So, for the first time, this campaign will focus on four key symptoms that are indicators for a number of cancers,  including less common ones.


1. Source: All cancers excluding non-melanoma skin  cancer (C00-C97 excl. C44). Data were provided by the Office for National  Statistics on request, June 2012. Similar data can be found here: http://www.ons.gov.uk/ons/search/index.html?newquery=cancer+registrations

2. Note: Estimates based on  figures provided in Abdel-Rahman et al (2009)

Why now?

Approximately 10,000 deaths from cancer in England could be  avoided every year if our cancer survival rates matched the European  best. The Department of Health’s Improving Outcomes – A Strategy for Cancer sets out how it  will seek to achieve the ambition to prevent 5,000 deaths from cancer per year  by 2014/2015, bringing survival rates in England up to the average for Europe. The Government’s strategy for cancer includes a range of actions to improve  cancer outcomes, including:

  • reducing the incidence of cancers which are preventable by lifestyle changes;
  • improving access to screening for all groups and introduce new screening  programmes where there is evidence they will save lives and are recommended by the UK National Screening Committee;
  • achieving earlier diagnosis of cancer, to increase the scope for successful treatment – diagnosis of cancer at a later stage is generally agreed to be the single most important reason for the lower survival rates in England;
  • achieving earlier diagnosis of cancer, to increase the scope for successful treatment and making sure that all patients have access to the best possible  care and support.

The Be Clear on Cancer campaign is one of a number of actions to achieve earlier diagnosis by specifically seeking to improve public awareness of cancer symptoms and encouraging earlier presentation.

Find out more about the background to the campaign.

What background information is there on Be Clear on Cancer?

Be Clear on Cancer is the overarching brand for a programme of work, which aims to improve early diagnosis of cancer by raising awareness of symptoms and making it easier for people to  discuss them with their GP. Each campaign is tested locally to see how people  respond and what impact it has on their behaviour. The results inform whether the campaign is taken forward more widely.

In early 2011, the Department of  Health ran the successful regional Be Clear on Cancer bowel cancer pilot – the  first test of the Be Clear on Cancer campaign. Lung cancer then became the focus  of a regional pilot in the Midlands, running from 10 October to 13 November  2011. In addition, a number of local teams ran Be Clear on Cancer activities for breast, bowel and lung cancer in 2010/11.

From January to March 2012, the Department of Health ran the first national Be Clear on Cancer campaign to raise awareness of bowel cancer signs and  symptoms. Eighteen local projects also ran activities to raise awareness of the  symptom of blood in urine (for bladder and kidney cancers), breast cancer in  women over 70, and oesophago-gastric cancer; and in May 2012 the lung cancer  campaign rolled out nationally.

Over the next year, the programme of work will continue to develop. The national bowel campaign has been repeated and local pilots in three areas of  England are piloting the impact of using different approaches to sustain the national bowel activity until March 2013. These three pilots cover North London  and North East London; North West England; and Yorkshire TV region.

Regional pilot campaigns will run for ‘blood in pee’ in the North of England and for breast cancer in women over 70 in the Central TV area from 14 January to mid-March 2013. Smaller scale pilots to test the new campaigns focusing on ovarian cancer and ‘Know 4 sure’ cancer symptoms will be taking place too.

What is the key message for the public?

The message for the public is:

'Know 4 sure'

When it comes to cancer, there are 4 key signs to look out for:
1.  Unexplained blood that doesn’t come from an obvious injury.
2. An unexplained  lump.
3. Unexplained weight loss, which feels significant to you.
4. Any type of unexplained pain that doesn’t go away.

Chances are it’s nothing serious, but finding it early makes it more  treatable. So if you notice any of these signs, tell your doctor.

Why focus on these four symptoms of cancer?

The agency M&C Saatchi presented a range of possible campaign approaches to an expert panel, which included GPs and secondary care clinicians, who  were asked by the Department of Health to assist in advising on the basic design of the campaign and the key public messages to be used.

A campaign that highlighted a limited number of possible cancer symptoms was  agreed to be the optimal approach for a non-tumour specific campaign. Four main  symptoms of cancer were identified based on clinical predictors of cancer and  research into the most commonly reported symptoms by cancer  patients [1].

This approach was tested alongside other potential alternatives with a sample  of GPs and the target audience in two phases of qualitative research. The  outcome of this qualitative research confirmed that the cancer symptoms approach  would be the most effective choice to take to pilot.


1. Hippisley-Cox J, Coupland C. Symptoms and risk factors to identify women with suspected cancer in primay  care: derivation and validation of an algorithm. British Journal of General Practice 2013;(in press)

Who is the campaign aimed at?

Almost 9 in 10 cancers in England are diagnosed in people aged 50 and over. So, the campaign is targeting this age group, as well as their key influencers, such as friends and family.

Do people think they need to have all four symptoms?

No. The campaign was tested with the target audience during the two phases of qualitative research - people understood that they don’t need to experience all of the symptoms featured in the campaign. They also understood that the numbering does not rank the symptoms in order of seriousness or importance.

Overall, the target audience felt the campaign message was clear and found  ‘Know 4 sure’ an engaging way to introduce the subject of cancer.

Which cancers is the campaign targeting?

The campaign is aimed at covering a number of cancers, including less common ones, which can’t be achieved through the tumour-specific campaigns that have run so far. Work has been done to look at the most likely cancers that may present with the four key symptoms highlighted in the campaign message.

What about people presenting with other conditions?

Although the messages in this campaign focus on persistent, new or unexplained  symptoms, some patients that come and see you may prove not to have cancer. But  they may still need treatment for something else. For example, during a previous  lung cancer campaign in Leeds, some patients presenting with relevant symptoms  were diagnosed with other respiratory conditions.

Why is there no mention of screening in the advertising or leaflets?

The Be Clear on Cancer campaign targets patients with symptoms, so screening  is not mentioned in the posters and adverts – the Department of Health wants to  keep the message simple and direct. The campaign leaflet was tested with GPs and  the target audience, and both felt information on healthy lifestyles was more  relevant than screening information.

But the campaign is an ideal opportunity to encourage people to take part in screening programmes as appropriate.

Where will the ‘Know 4 sure’ cancer symptoms campaign appear?

Local Cancer Networks are working with the Department of Health to develop  activities aimed at reaching people in your community. Activities have varied  across the pilots - all included advertising, for example in  local press  and radio, and some included community-based work, such as local events.  These ran from 14 January to mid-March 2013.

The pilot campaigns ran in the following Cancer Network areas: North  East London and North Central London; Lancashire and South Cumbria, and Greater  Manchester and Cheshire; and Central South Coast.

Activities and adverts highlight the main message for the public featuring  the four key symptoms of cancer.  But the campaign leaflet also includes other  possible symptoms of cancer. The aim is to encourage more people with these  symptoms to go and see their GP earlier.

Will general practices in the target areas be overwhelmed with people?

The honest answer is that we don’t know exactly how many people will respond  to the advertising and promotion – this campaign approach is different to the  previous campaigns, which have focused on specific tumour types. This is why the Department of Health is initially piloting the 'Know 4 sure' cancer symptoms  campaign on a relatively small scale: to assess the impact on primary and  secondary care, and test the feasibility of this approach.

We expect that you will see more people coming to your practice with symptoms  as a result of ‘Know 4 sure’ campaign activities, but experience of previous Be  Clear on Cancer campaigns suggest that you’re unlikely to be overwhelmed.

The national Be Clear on Cancer bowel campaign, which ran from January to  March 2012, included TV advertising and the increase in people presenting to  their GP equated to an increase of one patient with relevant symptoms per practice every two weeks.

It may take a few weeks for you to notice the impact of the campaign and any  additional patients requesting appointments though. The 2011 regional bowel  cancer pilot showed a peak four weeks into the campaign.

We have been criticised for making too many referrals in the past, is it any  different now?

Early diagnosis of cancer is a very high priority  for the Government. That is why Improving Outcomes: A Strategy for Cancer, published in  January 2011, put an emphasis on improved GP access to key diagnostic tests to  support the diagnosis of a number of cancers. The strategy is backed by over  £750 million, including more than £450 million to support early diagnosis of  cancer.

The NHS Constitution includes the right to see a specialist within two weeks or urgent referral, where cancer is suspected, or for the NHS to take all  reasonable steps to offer a range of alternative providers where this is not  possible. Recent statistics show that 95.4% of patients were seen by a  specialist within two weeks.

The Department of Health put additional funding into Primary Care Trust  baselines to meet the cost of any additional treatment resulting from work to  improve earlier diagnosis. Alongside National Cancer Action Teams and Cancer  Networks, they have been working with local NHS teams to estimate any potential  impact.

The Department of Health has recently published  ‘Direct access to diagnostic tests for cancer: best practice  referral pathways for general practitioners’. It provides information on  direct referral by GPs to specific diagnostic tests for the assessment of  particular symptoms where cancer may be suspected but the urgent GP referral  (two-week wait) process is not applicable .

Will we overwhelm local services with this campaign and supporting activity?

The Department of Health initially piloted the ‘Know 4 sure’ cancer  symptoms campaign on a small scale so that it could assess the extent of its impact on local services.

Cancer Networks in the pilot areas worked closely with NHS Trusts across  their regions to prepare for the campaign. They have learned from the experiences of the previous Be Clear on Cancer campaigns and liaising with the Department of Health. They continued to work with their local clinical leads  to monitor the capacity needs of their regions throughout the nine-week  campaign.

We have learned from the other Be Clear on Cancer campaigns that the impact  on diagnostic testing is very dependent on the existing capacity within the NHS  for specific diagnostic tests.

The £450 million allocated to support early diagnosis over this spending  review period also includes additional funding in NHS baselines, including  enabling better GP access to key diagnostic tests and more testing in secondary  care.

Do activities of this kind cause unnecessary anxiety?

Be Clear on Cancer materials promote the potential benefits of early presentation and reassure people that the symptom is unlikely to be cancer, but  that it’s best to get it checked. The tone is balanced, practical and reassuring.

There was overwhelming support from the public following the first national  bowel cancer campaign in January 2012. More than 9 out of 10 people (92%) and  89% of GPs said it is important for the Government to be communicating these  kinds of messages.

What are the cancer statistics for my area?

You can find out more about the cancer statistics in your area using Public Health England's National General Practice Profiles.

Learn more about GP practice and local data

What do I need to do as a GP in the pilot area?

GPs have a pivotal role as the gatekeepers to investigation and referral, but  the task is a difficult one as the number of new diagnoses encountered each year  is typically very small.

We know from routes to diagnosis work conducted by Public Health England that 24% of all  cancer patients present as emergencies. So there is a clear role for GPs in the  early diagnosis of cancer.

We hope you will see an increase in the number of people presenting with  symptoms and continue to use your clinical judgement and refer for investigation  as appropriate.

So as a GP in the pilot region:

Be mindful. This campaign may prompt people who’ve  previously ignored symptoms to come and see you. They may worry they’re wasting  your time, not think their symptoms are serious, or not find it easy to  communicate their symptoms. Be prepared for more patients wanting to see you  about possible symptoms and keep a look out for those most at risk – they may be  coming to see you about other things or it might be an opportunity for further  assessment.

Encourage your colleagues to prepare for  and support the campaign. Practice nurses, receptionists and practice  managers all have an important role to play in this campaign.

There’s a separate  briefing sheet for practice teams.  Ensure  everyone is aware of the campaign, so they can support it.

Download the briefing sheet for practice teams

We have provided some questions and answers specifically for practice teams  on this site and are making additional materials available to your practice  teams to support them in preparing for the campaign, including planning for  increases in the number of people visiting their GP or ringing for test results.  Your local Cancer Network can also provide you with additional support.

Make the most of available support.  There is lots of information to support you with the diagnosis of  cancer, including the NICE referral guidelines for suspected cancer. Continue to use your clinical  judgement - not every patient who presents to their GP with these symptoms will  need to be referred using an urgent two-week referral. Standard outpatient  referral and/or straight-to-test referrals may also be appropriate for some  patients. Or it may be appropriate to initially carry out tests or monitor  patients in primary care.

Other useful resources include:

Get more useful resources and tools

Is there a briefing sheet for this campaign?

Download briefing sheet for pharmacy teams

Download briefing sheet for practice teams

Download briefing sheet for GPs

Where can I get more information on the Be Clear on Cancer campaigns?

For more information about Be Clear on Cancer, or if you have any queries, please contact partnerships@phe.gov.uk.


All cancers excluding non-melanoma skin cancer (C00-C97 excl. C44). Data were provided by  the Office for National Statistics on request, September 2012. Similar data can  be found here: http://www.ons.gov.uk/ons/search/index.html?newquery=cancer+registrations

Be Clear on Cancer statement

Be Clear on Cancer  is a cancer awareness campaign led by Public Health England, working in partnership with the Department of Health and NHS England. This page contains links to documents that we hope you find useful. Please note however that the views or opinions expressed within those links are not necessarily those of Cancer Research UK.

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