Cancer Care Review (CCR)


What is a Cancer Care Review

With increasing numbers of patients surviving their Cancer diagnosis, primary care has an important role in supporting people to live well with and beyond cancer. The Cancer Care Review (CCR) is a conversation between a patient and their GP or Practice Nurse about their cancer journey. It is essential to personalised care  and it is an opportunity for patients to;

  • Talk about their cancer experience and concerns.
  • Understand what support is available in their community.
  • Receive the information they need to begin supported self-management.

After a cancer diagnosis, people may have lots of appointments and support from their hospital team. However, the GP surgery team is also there to help. This short video explains the purpose of the Cancer Care Reviews that take place 3 and 12 months after diagnosis.

What are the requirements for QOF

In recognising the important role that primary care plays to support people after a cancer diagnosis, changes have been made to the Quality and Outcomes Framework (QOF) cancer requirements.

The introduction of the new and updated indicators for cancer aims to increase the personalisation of cancer care and the timing of the cancer care review. The changes focus on key times of need, when patients may feel vulnerable including:

  • At the time of a patient’s diagnosis (within 3 months).
  • After a patient has received acute treatment (within 12 months).

The QOF also specifies that practices should use Macmillan’s national, integrated electronic CCR template to support a well-structured review.

QOF indicators

Points Achievement thresholds
CAN004. The percentage of patients with cancer, diagnosed within the preceding 24 months, who have a patient Cancer Care Review using a structured template recorded as occurring within 12 months of the date of diagnosis. 6 50-90%
CAN005. The percentage of patients with cancer, diagnosed within the preceding 12 months, who have had the opportunity for a discussion and been informed of the support available from primary care, within 3 months of diagnosis. 2 70-90%


Supporting Patients at Diagnosis

Below is a suggested process map (from Cancer Diagnosis) which can be followed by the GP practice.

Download diagram here.

On receiving a letter or Serious Diagnosis form, it is good practice to make an initial phone call to the patient.  GP practices should proactively provide patients with the opportunity for a discussion to make them aware of the support available from their GP and wider practice team. This is to facilitate early and supportive conversations and ensure patients are aware of what help is available.

This can be done via phone call or you may also choose to send a letter to advise patients about the help that is available. We have created a sample letter including links to support from Macmillan which can be personalised to your GP practice.

NCA new diagnosis letter

NCA Patient Cancer Care Review leaflet (November 2022) – this leaflet for patients explains what a Cancer Care Review is and when should it happen

How to Prepare for a Cancer Care Review

Primary Care teams now need to offer a patient the Cancer Care Review any time within 12 months of diagnosis. We suggest setting a recall at 8 months, so it can potentially coincide with the end of their cancer treatment.

Patients may be invited to make an appointment for their Cancer Care Review by sending a letter in the post. We have created a sample invitation letter which can be personalised to your GP practice.

NCA Cancer Care Review invite letter

You should send patients information either with the invitation or in the days prior to their appointment to help them better identify the issues that are important to them. A copy of the MacMillan concerns checklist can be sent for the patient to complete and return. Practices may also utilise digital questionnaires and Florey Surveys which can be sent to the patient by SMS before their Cancer Care Review.

Macmillan concerns checklist

What should a Cancer Care Review Include

The Cancer Care Review should be a dedicated appointment. It is a holistic conversation that covers clinical, practical, emotional, psychological and financial (where appropriate) aspects of the person’s cancer care. Practices should use Macmillan’s national, integrated electronic Cancer Care Review template within their Primary Care IT system to support a well-structured review.

A suggested structure for a Cancer Care Review could include:

  • Discussing their diagnosis, treatment and potential consequences (physical, emotional, social, practical).
  • Reviewing medication.
  • Finding out about the person’s support network and checking if they themselves are a carer.
  • Agreeing a date for the next review, or agreeing that another will happen at certain points of transition in their care e.g. the end of their treatment.
  • Giving the patient the opportunity to raise anything else they wish to discuss.

MacMillan have collated their 10 top tips for carrying out an effective Cancer Care Review.

Macmillan Primary Care 10 top tips for carrying out an effective Cancer Care Review

Electronic Cancer Care Review Templates

Evidence found that use of a structured template alongside quality improvement activities for holistic cancer care reviews enabled higher quality personalised care conversations to occur. The template can be used as an aide memoire when carrying out a CCR. It also includes supporting information which can be shared with the patient as well as providing a helpful coded record of topics discussed.

The Macmillan CCR template is available on all major IT systems and guidance on how to access and integrate them is below.

Macmillan CCR template guidance

Involving Social Prescribers

People living with cancer have varied needs and cancer can affect all aspects of their life, from relationships to work or finance. Cancer can have a huge emotional impact on the individual and those around them. All patients should be considered for a referral to a social prescriber as part of the cancer care review. As individual needs vary, some people may not require a referral, others may only need limited contact with the social prescriber however for others, more regular contact and review/follow up might be necessary.

The aim of social prescribing models is to help people live their lives as well as possible, with a focus on supporting them to take control of and to improve their health, wellbeing and social welfare.

They actively support people to focus on what matters to them, and help to build confidence and resilience to enable self-management as appropriate. These roles often support people to navigate care between professionals and to access support for their holistic needs.

For more information on the role that Social Prescribers can play in supporting people living with cancer and how Primary Care Networks can get the best out of these roles, please download the MacMillan resources below.

MacMillan Social Prescribing for Cancer Patients

MacMillan Top Tips – Social Prescribing

Useful Resources



Download PowerPoint presentation slides from the session above here.