Overview
Screening plays a crucial role in identifying cancer at its earliest stages, often before symptoms appear, when it is most treatable. Early detection significantly improves treatment outcomes and increases survival rates. By catching cancer early, interventions can be less invasive, less costly, and more effective, allowing individuals to maintain a higher quality of life.
Cancer screening programs in NSW have significantly improved health outcomes by enabling early detection and reducing cancer mortality. The BreastScreen NSW program detects around 75% of early-stage breast cancers, contributing to a 98% five-year survival rate for early diagnoses. Bowel cancer, which accounted for 10.3% of all cancer diagnoses in NSW in 2020 and causes more deaths than prostate, breast, or melanoma cancers, has a 90% survival rate when detected early through the National Bowel Cancer Screening Program. The Cervical Screening Program has also reduced cervical cancer incidence and mortality, with early detection offering a 75–80% survival rate.
The newly implemented National Lung Cancer Screening Program targets individuals at high risk, primarily people aged 50–70 with a history of heavy smoking. This program aims to detect lung cancer at an earlier, more treatable stage using low-dose CT scans. Early detection through lung cancer screening has been shown to reduce mortality by up to 20%, offering a significant opportunity to improve outcomes for one of the deadliest cancer types.
Together, these programs enhance survival rates, improve quality of life, and reduce healthcare costs across NSW.
As the first point of contact for many patients, primary care practitioners are uniquely positioned to influence screening behaviours, educate patients about the importance of regular screening, and identify those at risk. General practice involvement is crucial in ensuring that patients are guided through appropriate screening pathways, receive timely follow-ups, and access early interventions. Promoting cancer screening in general practice has the potential to reduce the burden of cancer, improve patient outcomes, and save lives. Your commitment to integrating cancer screening into routine care can make a significant difference in the fight against cancer.
In this toolkit, you’ll find quality improvement activity ideas, resources, and information to assist your practice in prioritising cancer screening as part of comprehensive primary health care.
Foundations of Quality Improvement
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Foundation of Quality ImprovementViewHide
The foundation of quality improvement outlines what quality improvement (QI) is, why undertake QI and what are the key components of QI.
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Model for Improvement (MFI) TemplateViewHide
This MFI template has been adapted from the Institute of Healthcare Innovation to develop, test, and implement changes in general practices participating in Southwestern Sydney PHN’s Quality Improvement in Primary Care Program (QIPC).
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MFI WalkthroughViewHide
This is a step-by-step instruction to guide you on how to complete the MFI.
Quality Improvement Activities
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Data CleansingViewHide
Data cleansing involves identifying and correcting errors, inconsistencies, or missing information in a data record. It ensures high-quality data that will enable a clinician to provide optimal care. Family history is one of the non-modifiable risk factors for many health issues. Knowing whether a patient has a family history of any type of cancer enables the clinician to provide the most suitable prevention education and offer screening. There are estimates that 20% of the nation’s cancer disease burden comes from smoking and it is the biggest preventable cause of cancer. The following QI activities can assist you in updating and improving your patient’s medical records.
Cancer Screening – Improve family history/smoking status recording
Clinical guide for Best Practice Software- How and where to document- Data cleansing
Clinical guide for Medical Director Software- How and where to document- Data cleansing
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MBSViewHide
Cancer is one of the most common and preventable diseases in Australia. Early detection can save lives. The below QI activities and walkthroughs can assist clinicians to monitor patient’s overall health by completing health assessments for those in a specific age range or ethnicity. It is not only a chance to sustain the practice’s level of quality care but also increases practice revenue and long-term growth.
Cancer Screening – Patients eligible for 45-49 health assessment
Clinical guide for Medical Director software – How and where to document – Health Assessments
Clinical guide for Best Practice software – How and where to document – Health Assessments
Cancer Screening – Patients eligible for indigenous health assessment
Clinical guide for Best Practice software – How and where to document – Health Assessments
Clinical guide for Medical Director software – How and where to document – Health Assessments
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Cervical ScreeningViewHide
The cervical screening program targets women aged 25 to 74, with screenings recommended every five years. The QI activities outlined below will assist you in identifying patients who are due or overdue for the test based on their medical record in your practice. The walkthroughs provide a step-by-step guide to narrowing down your patient list and extracting data using POLAR.
Cancer Screening – Improve cervical screening rate
POLAR Walkthrough – Non urgent patients overdue for cervical screening
POLAR Walkthrough – Identifying patients due for urgent cancer screening
Clinical guide for Medical Director software – How and where to document- Pathology
Clinical guide for Best Practice software – How and where to document – Pathology
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Breast ScreeningViewHide
Breast screening is the most effective way to improve breast cancer survival and is currently free for women aged 40 and above, with or without a referral. The QI activities below will help you identify the patient cohort most in need of screening, while the walkthroughs will guide you in extracting the most relevant data from POLAR reports. Additional useful links are provided in the sample MFI for more detailed information.
Cancer Screening – Improve breast screening rate
POLAR Walkthrough – Non urgent patients overdue for breast screening
POLAR Walkthrough – Non urgent first nations people due for breast screening
POLAR Walkthrough – Identifying patients due for urgent cancer screening
Clinical guide for Medical Director software – How and where to add – Radiology
Clinical guide for Best Practice software – How and where to add – Radiology
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Bowel ScreeningViewHide
Bowel screening is a government-funded test available to Australians aged 45 to 74. Bowel cancer is the second leading cause of cancer-related deaths, making early detection crucial. Actively identifying eligible patients to promote participation in bowel screening programs can be an excellent starting point to boost screening rates. Use the sample MFI below to start your own and walkthroughs will guide you on how to get your initial data from POLAR and track progress along the way. Useful links are also available in the plan for your reference.
Cancer Screening – Improve bowel screening rate
POLAR Walkthrough – Non urgent patients due for bowel screening with a history of polyposis
POLAR Walkthrough – Identifying patients due for urgent cancer screening
Clinical guide for Medical Director software – How and where to add – Pathology
Clinical guide for Best Practice software – How and where to add – Pathology
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Lung ScreeningViewHide
The National Lung Cancer Screening Program (NLCSP) offers low-dose CT screening to individuals at high risk of lung cancer, aiming to detect disease at an earlier, more treatable stage. As primary care plays a critical role in identifying and referring eligible patients, general practice is central to the program’s success.
Investing in quality improvement within general practice helps streamline patient identification, enhance risk assessment, and support effective communication and follow-up. Strengthening these processes not only improves screening uptake and outcomes but also supports more equitable care across populations.
The following QI activities are designed to support clinicians in identifying patients who meet the National Lung Cancer Screening Program (NLCSP) eligibility criteria for screening (50-70 years old with a smoking history). Using POLAR, the step-by-step walkthrough will guide you through refining your patient list based on key criteria—such as age, smoking history, and extracting relevant data from your practice records.
Cancer Screening – Identifying Patients aged 50-70 with a smoking history
POLAR Walkthrough – Identify patients aged 50-70 with smoking history
Clinical guide for Medical Director Software – How and where to document – Data cleansing
Clinical Guide for Best Practice software – How and where to document – Data cleansing
Tips & Tricks
Private Bookmark
It is not always easy to remember what filters have been applied to obtain the required patient cohort, especially when using multiple filters.
The Private Bookmark function is available on all POLAR reports. By creating your bookmark, a single click from the bookmark list will allow you to retrieve all previously applied filters needed for the patient cohort.
To learn how to set up a private bookmark Click here
Correct documentation
For POLAR to extract the most accurate data, it is important each item is correctly documented in the patient’s file. Data mapping of each tab is available in the Help menu to guide clinicians in documenting care items in the correct place in their clinic’s medical software.
Helpful Resources
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Clinical ResourcesViewHide
South Western Sydney PHN | Benefits of using QIPC cancer screening module in POLAR
South Western Sydney PHN | Order FREE cancer screening educational flipcharts for your organisation
Cancer Institute NSW | Primary Care Cancer Control Quality Improvement Toolkit
Cancer Institute NSW | Toolkit for the Aboriginal health workforce
Cancer Institute NSW | Resources for health professionals caring for teens and young adults
National Cancer Screening Register | Healthcare Provider Portal
Cancer Australia | National Cancer Control Indicators
Can We | LGBTQ+ Inclusion Toolkit
Australian Government Department of Health and Aged Care | Cervical screening Provider Information
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Patient ResourcesViewHide
National Cancer Screening Register | Participant Portal
Cancer Institute NSW | Support for adolescents and young adults with cancer
Our Mob and Cancer | Cancer in Aboriginal and Torres Strait Islander People
Breast Cancer Network Australia | My Journey
Australian Government Department of Health and Aged Care | BreastScreen Australia Program
Australian Government Department of Health and Aged Care | National Bowel Cancer Screening Program
Australian Government Department of Health and Aged Care | Cervical Cancer Screening Program
Own it | It’s your cervical screening test
Information and Support
Please email enquiries to CQIsupport@swsphn.com.au for further information or support with the toolkit.