{"slug":"protocol-upgrade","tag":"protocol-upgrade","variants":["protocol-upgrade"],"description":"Changes to how existing care is delivered rather than new treatments, graded by whether they are proven and unevenly used, promising, or untested.","count":40,"kinds":{"idea":40},"related":[{"slug":"upgrade-proven-unevenly-used","tag":"upgrade:proven-unevenly-used","shared":25},{"slug":"upgrade-promising","tag":"upgrade:promising","shared":15},{"slug":"precision","tag":"precision","shared":9},{"slug":"breast","tag":"breast","shared":5},{"slug":"colorectal-evidence","tag":"colorectal-evidence","shared":1}],"records":[{"id":"idea-crc-exercise-as-a-funded-treatment","kind":"idea","name":"Fund structured exercise after colon cancer surgery as a treatment, because a randomised trial says it works as well as a drug","route":"/ideas/idea-crc-exercise-as-a-funded-treatment/","tldr":"A three-year supervised exercise programme after chemotherapy cut recurrence and death by roughly a third in 889 patients, an effect the size of adjuvant chemotherapy. No health system has a funding line for it."},{"id":"idea-bio2-prehabilitation-standard","kind":"idea","name":"Four weeks of training and nutrition before major cancer surgery, as standard","route":"/ideas/idea-bio2-prehabilitation-standard/","tldr":"Getting fitter and better nourished before an operation reduces complications and speeds recovery. It is cheap, but only a few hospitals do it."},{"id":"idea-prev-omit-radiotherapy-low-risk-breast-default","kind":"idea","name":"Make skipping radiotherapy the default for very low-risk breast cancer","route":"/ideas/idea-prev-omit-radiotherapy-low-risk-breast-default/","tldr":"Trials show older women with the lowest-risk breast cancers gain almost nothing from radiotherapy after lumpectomy. Yet most still get it. Track and reward omission."},{"id":"idea-tr1-justify-every-exclusion","kind":"idea","name":"Default-inclusive eligibility: sponsors must justify every exclusion criterion","route":"/ideas/idea-tr1-justify-every-exclusion/","tldr":"Trials should let people in unless there is a scientific or safety reason to keep them out. Every exclusion rule would need a written reason, reviewed like the rest of the protocol."},{"id":"idea-tr1-pre-emptive-pharmacogenomic-testing","kind":"idea","name":"Test DPYD, UGT1A1 and TPMT/NUDT15 before the first dose, everywhere","route":"/ideas/idea-tr1-pre-emptive-pharmacogenomic-testing/","tldr":"A cheap gene test for DPYD, UGT1A1 and TPMT or NUDT15 before fluoropyrimidines, irinotecan or thiopurines identifies people at risk of severe or fatal toxicity so their dose can be lowered. The EMA has recommended DPD testing since 2020; US uptake remains partial."},{"id":"idea-acc-reflex-genomic-profiling-at-diagnosis","kind":"idea","name":"Pathologists order genomic profiling automatically at diagnosis of advanced cancer","route":"/ideas/idea-acc-reflex-genomic-profiling-at-diagnosis/","tldr":"A substantial share of patients with advanced non-small-cell lung cancer start first-line treatment before their biomarker results arrive, or without full testing, and so miss targeted therapy. Letting the pathologist order the full genomic panel the moment a cancer of a defined type and stage is confirmed shortens time to result and makes testing complete."},{"id":"idea-acc-electronic-pro-monitoring-standard","kind":"idea","name":"Weekly electronic symptom reporting as a standard of care during systemic therapy","route":"/ideas/idea-acc-electronic-pro-monitoring-standard/","tldr":"Patients on cancer treatment who report their symptoms every week through an app or phone line, with nurses acting on alerts, feel better and go to the emergency department less. Two early trials also found longer survival, but the largest trial, designed to test survival, found no difference. The quality-of-life benefit is reason enough to make it routine and paid for."},{"id":"idea-acc-embedded-decision-aids","kind":"idea","name":"Decision aids built into the record for every preference-sensitive cancer choice","route":"/ideas/idea-acc-embedded-decision-aids/","tldr":"Choices like mastectomy versus lumpectomy, or whether to have chemotherapy after surgery, depend on what matters to the patient. Good decision aids exist but are rarely used; building them into the clinic workflow would change that."},{"id":"idea-acc-financial-toxicity-screening-at-diagnosis","kind":"idea","name":"Screen every patient for financial hardship at diagnosis and connect them to help","route":"/ideas/idea-acc-financial-toxicity-screening-at-diagnosis/","tldr":"Cancer often ruins families financially, and money worries make people skip treatment. Ask about finances at the first visit, as routinely as asking about allergies, and route people to assistance."},{"id":"idea-acc-default-fertility-preservation-referral","kind":"idea","name":"Default fertility preservation referral for every patient under 40 before treatment","route":"/ideas/idea-acc-default-fertility-preservation-referral/","tldr":"Fewer than half of patients starting treatment that can damage fertility have a documented fertility discussion or referral, with worse rates for women, minorities and patients outside academic centres. An order-set trigger that refers every patient under 40 to reproductive medicine unless they actively decline would make the conversation routine and timely."},{"id":"idea-acc-risk-stratified-follow-up","kind":"idea","name":"Risk-stratified follow-up: low-risk survivors to primary care with fast re-entry","route":"/ideas/idea-acc-risk-stratified-follow-up/","tldr":"Not every survivor needs to see an oncologist every six months for years. Sort people by recurrence risk, send low-risk survivors back to their family doctor with a clear plan, and guarantee rapid return if something changes."},{"id":"idea-acc-automatic-early-palliative-triggers","kind":"idea","name":"Automatic palliative care referral triggered by diagnosis, not by decline","route":"/ideas/idea-acc-automatic-early-palliative-triggers/","tldr":"Palliative care given from the start of treatment for advanced cancer improves quality of life and may extend it. Instead of waiting for an oncologist to remember, the system should refer automatically when the diagnosis is recorded."},{"id":"idea-acc-single-fraction-palliative-radiotherapy-default","kind":"idea","name":"Single-fraction radiotherapy as the default for painful bone metastases","route":"/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/","tldr":"Randomised trials and meta-analyses show a single 8 Gy radiotherapy session relieves pain from uncomplicated bone metastases as well as ten sessions, with a higher retreatment rate, yet habit and per-fraction payment keep most patients on the longer course. Making one session the default, with an opt-out justification and payment neutrality, would spare patients trips and free machines."},{"id":"idea-acc-geriatric-assessment-by-default","kind":"idea","name":"Geriatric assessment by default for every patient over 70 starting cancer treatment","route":"/ideas/idea-acc-geriatric-assessment-by-default/","tldr":"A short structured check of memory, mobility, nutrition and medicines before treatment cuts serious side effects in older patients without reducing benefit. It should be automatic, not optional."},{"id":"idea-moon-recorded-consultations","kind":"idea","name":"Recorded, AI-summarised consultations given to patients by default","route":"/ideas/idea-moon-recorded-consultations/","tldr":"Every cancer consultation is recorded with consent and the patient receives the audio plus a checked written summary of what was said and decided."},{"id":"idea-moon-question-prompt-lists","kind":"idea","name":"Question prompt lists sent to patients before every major consultation","route":"/ideas/idea-moon-question-prompt-lists/","tldr":"Before a results or treatment-planning appointment, patients receive a list of good questions to ask, tailored to their situation, and can tick the ones they want covered."},{"id":"idea-moon-olanzapine-antiemetic-everywhere","kind":"idea","name":"Low-dose olanzapine and generic antiemetic bundles in every guideline and formulary","route":"/ideas/idea-moon-olanzapine-antiemetic-everywhere/","tldr":"A cheap, old antipsychotic at a low dose is one of the best anti-sickness drugs for chemotherapy. Make sure every cancer unit in the world uses it."},{"id":"idea-moon-hair-preservation-for-all","kind":"idea","name":"Fund scalp cooling and hair-preserving measures for every alopecia-inducing regimen","route":"/ideas/idea-moon-hair-preservation-for-all/","tldr":"Losing hair is one of the most distressing side-effects of chemotherapy and can often be prevented with a cooling cap. Make it routinely available and paid for."},{"id":"idea-pu-breath-hold-left-breast-routine","kind":"idea","name":"Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer","route":"/ideas/idea-pu-breath-hold-left-breast-routine/","tldr":"Taking and holding a deep breath during each beam moves the heart away from the treated breast and roughly halves the dose it receives. England's national guideline has recommended it for left-sided breast cancer since 2018, yet surveys in Germany, Austria, Switzerland, Australia and the United States found it applied to a fraction of the people who could have it."},{"id":"idea-pu-breath-hold-visual-feedback","kind":"idea","name":"Let the patient see their own breath-hold on a screen or in video glasses","route":"/ideas/idea-pu-breath-hold-visual-feedback/","tldr":"During breath-hold radiotherapy a camera or sensor measures how deep the breath is, but often only the radiographers see the trace. Showing it to the patient, on a screen or in video glasses with a target band to stay inside, made holds steadier and more repeatable in the clinical comparisons OnCo found, though none has yet measured whether it changes side effects."},{"id":"idea-pu-breath-hold-coaching-before-planning","kind":"idea","name":"Breath-hold coaching and home practice a week before the planning scan, in the patient's own language","route":"/ideas/idea-pu-breath-hold-coaching-before-planning/","tldr":"Breath-hold is usually taught on the day of the planning scan. Two hospital series found that teaching it at least five days earlier, with practice at home, went with lower heart doses and shorter set-up times, and a survey of American radiation oncologists found interpreters were present at fewer than one in three first treatments for people who do not speak English."},{"id":"idea-pu-five-fraction-breast-default","kind":"idea","name":"One week of breast radiotherapy in five treatments as the default after surgery","route":"/ideas/idea-pu-five-fraction-breast-default/","tldr":"A trial of 4,000 people showed that five treatments over one week control breast cancer as well as three weeks, and England's national guideline has offered it as standard since 2023 when the lymph nodes are not treated. In United States hospitals, ten treatments or fewer were used for 11.4 per cent of women with early breast cancer after breast-conserving surgery in 2020 and 2021."},{"id":"idea-pu-prostate-hypofractionation-default","kind":"idea","name":"Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy","route":"/ideas/idea-pu-prostate-hypofractionation-default/","tldr":"Randomised trials showed that 20 treatments over four weeks, and for many men five, control localised prostate cancer as well as 37 to 39, and England's national guideline has offered the four-week course since 2019. In New South Wales its use rose from 5.2 to 40.3 per cent of men between 2014 and 2018, and an international survey found it used less for high-risk disease."},{"id":"idea-pu-rectal-spacer-prostate","kind":"idea","name":"An absorbable gel or balloon between prostate and rectum before radiotherapy, used under audit","route":"/ideas/idea-pu-rectal-spacer-prostate/","tldr":"A spacer injected between the prostate and the rectum pushes the bowel out of the high-dose area for a few months and then dissolves. Randomised trials found fewer bowel side effects, but the procedure carries its own rare serious complications, and England's guidance allows it only with special arrangements for consent and audit."},{"id":"idea-pu-pelvic-filling-protocol","kind":"idea","name":"A measured drink of water before pelvic radiotherapy, and bowel preparation kept to what trials support","route":"/ideas/idea-pu-pelvic-filling-protocol/","tldr":"The bladder and rectum change size from day to day and move the prostate with them. A randomised trial found that drinking about half a litre of water before each treatment kept the bladder more consistent than drinking a litre, and small trials of anti-wind medicines before prostate radiotherapy found no effect."},{"id":"idea-pu-open-face-masks","kind":"idea","name":"Open-face immobilisation masks for brain and head and neck radiotherapy where surface guidance can check the position","route":"/ideas/idea-pu-open-face-masks/","tldr":"Radiotherapy to the head usually means a moulded plastic mask clipped to the table over the whole face. In a randomised comparison in 29 people with brain tumours, a mask with the face cut out caused much less discomfort and anxiety with the same accuracy, and 27 of them preferred it."},{"id":"idea-pu-mask-anxiety-screening","kind":"idea","name":"Ask about mask anxiety at every head and neck radiotherapy visit, and offer music and guided relaxation","route":"/ideas/idea-pu-mask-anxiety-screening/","tldr":"About a quarter of people having radiotherapy for head and neck cancer say the mask makes them anxious, and radiographers do not reliably notice who. A randomised trial of 208 people in India found that music and a guided relaxation exercise during the first five sessions lowered mask anxiety scores."},{"id":"idea-pu-radiotherapy-walkthrough-before-planning","kind":"idea","name":"Show people the radiotherapy room and the treatment before the planning appointment, using virtual reality or a guided visit","route":"/ideas/idea-pu-radiotherapy-walkthrough-before-planning/","tldr":"A randomised trial of 196 women about to have breast radiotherapy found that explaining the treatment with a virtual-reality walkthrough lowered anxiety and improved understanding compared with the usual explanation. A review of 15 education studies found that leaflets and brief talks made little difference, and more intensive, staff-led preparation did."},{"id":"idea-pu-tattoo-free-set-up","kind":"idea","name":"Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink","route":"/ideas/idea-pu-tattoo-free-set-up/","tldr":"Most people having breast radiotherapy are given small permanent ink dots to line them up on the couch. In a United Kingdom survey of 204 people afterwards, half rated the impact of those tattoos as negative, and surface cameras or ultraviolet ink line people up as accurately without leaving a visible mark."},{"id":"idea-pu-washing-and-deodorant-during-radiotherapy","kind":"idea","name":"Tell people having radiotherapy that they can wash the treated skin and use deodorant","route":"/ideas/idea-pu-washing-and-deodorant-during-radiotherapy/","tldr":"Old advice told people not to wash the treated area or use deodorant during radiotherapy. Pooled randomised trials found that washing, with or without soap, reduced severe skin reactions, and that deodorant made no difference to them, so neither ban is supported."},{"id":"idea-pu-enhanced-recovery-with-measured-compliance","kind":"idea","name":"Enhanced recovery after cancer surgery, with each element's compliance measured and fed back","route":"/ideas/idea-pu-enhanced-recovery-with-measured-compliance/","tldr":"Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements."},{"id":"idea-pu-shorter-fasting-before-surgery","kind":"idea","name":"Clear drinks until two hours before an operation, rather than nothing from midnight","route":"/ideas/idea-pu-shorter-fasting-before-surgery/","tldr":"Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids."},{"id":"idea-pu-extended-clot-prevention-after-surgery","kind":"idea","name":"Four weeks of blood-clot prevention after major abdominal or pelvic cancer surgery","route":"/ideas/idea-pu-extended-clot-prevention-after-surgery/","tldr":"Blood clots after a major operation for bowel, gynaecological or other abdominal cancer often appear after discharge. Extending preventive blood thinners to four weeks roughly halved clots in pooled trials without more major bleeding, and professional societies recommend it, yet among 23,527 older Americans having bowel cancer surgery in 2016 and 2017, 4.7 per cent received it."},{"id":"idea-upgrade-oral-anticancer-medicine-adherence-programme","kind":"idea","name":"A structured support programme for everyone taking cancer tablets at home","route":"/ideas/idea-upgrade-oral-anticancer-medicine-adherence-programme/","tldr":"More cancer treatment now comes as tablets taken at home, where nobody sees missed doses or side effects building up. A nursing guideline recommends a structured programme: a check at the start of who may struggle, teaching, follow-up calls from the team, and coaching. The trials behind it are small and mixed, so this is promising rather than settled."},{"id":"idea-upgrade-hand-foot-cooling-compression-during-taxanes","kind":"idea","name":"Frozen gloves or tight surgical gloves offered during every weekly taxane infusion","route":"/ideas/idea-upgrade-hand-foot-cooling-compression-during-taxanes/","tldr":"Cooling the hands and feet, or squeezing them in tight surgical gloves, during paclitaxel infusions narrows blood vessels while the drug level peaks. In one randomised trial, moderate or worse nerve damage in the treated hand fell from 50 to 29 per cent with cooling; a larger trial of frozen gloves and socks missed its main target but found less numbness."},{"id":"idea-upgrade-oral-cryotherapy-with-bolus-chemotherapy","kind":"idea","name":"Ice chips in the chair for every bolus fluorouracil and high-dose melphalan infusion","route":"/ideas/idea-upgrade-oral-cryotherapy-with-bolus-chemotherapy/","tldr":"Holding ice chips in the mouth for half an hour around a quick injection of fluorouracil, or high-dose melphalan before a stem cell transplant, cools the mouth while the drug level peaks. A review of 14 trials found it prevents mouth ulcers in about one in four people given fluorouracil, and a guideline recommends it. How often it is offered is not measured."},{"id":"idea-upgrade-clot-risk-score-and-preventive-anticoagulation","kind":"idea","name":"A blood clot risk score at the start of chemotherapy, with preventive anticoagulation offered to those at higher risk","route":"/ideas/idea-upgrade-clot-risk-score-and-preventive-anticoagulation/","tldr":"People with cancer get blood clots more often than others. A score built from the cancer type and routine blood tests picks out those at higher risk, and in two placebo-controlled trials a low-dose blood-thinning tablet reduced clots but caused more bleeding. United States guidance says it may be offered; surveys in the Netherlands and China found most specialists do not use the score."},{"id":"idea-upgrade-hepatitis-b-testing-before-systemic-treatment","kind":"idea","name":"Hepatitis B blood tests before anyone starts systemic cancer treatment, with antiviral tablets for those who need them","route":"/ideas/idea-upgrade-hepatitis-b-testing-before-systemic-treatment/","tldr":"Hepatitis B can lie quiet for decades and flare when cancer treatment weakens the immune system, sometimes fatally. An American Society of Clinical Oncology opinion says everyone starting systemic cancer treatment should be tested first, and antiviral tablets prevent most flares. Across 29 studies, 57 per cent of patients were tested before chemotherapy."},{"id":"idea-upgrade-stop-smoking-treatment-at-diagnosis","kind":"idea","name":"Stop-smoking treatment offered to every person who smokes at a cancer diagnosis, as part of cancer care","route":"/ideas/idea-upgrade-stop-smoking-treatment-at-diagnosis/","tldr":"Quitting smoking around a lung cancer diagnosis is linked to longer survival, and in a randomised trial of people newly diagnosed with cancer, longer counselling with free medicine raised the six-month quit rate from about one in five to one in three. In a survey of 762 accredited United States cancer programmes, 17.6 per cent regularly prescribed stop-smoking medicine."},{"id":"idea-upgrade-nutrition-risk-screening-at-treatment-start","kind":"idea","name":"Nutrition risk screening when cancer treatment starts, with a dietitian plan for everyone who screens positive","route":"/ideas/idea-upgrade-nutrition-risk-screening-at-treatment-start/","tldr":"Weight loss and poor eating during cancer treatment are common and often missed. A European guideline strongly recommends checking intake and weight from diagnosis, and in a randomised trial of hospital patients with cancer at nutritional risk, tailored nutrition support lowered 30-day deaths from 19.9 to 14.1 per cent. Of 100 Italian centres surveyed, 31 assessed every patient."}]}