What is a Cancer Care Review?


A 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 helps 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.

What are the QOF requirements?

Changes to the QOF requirements 2021/22

In recognising the important role that primary care plays to support people after a cancer diagnosis, changes have been made to 2021/22 Quality and Outcomes Framework (QOF) cancer requirements.

The changes focus on key times of need, when patients may feel vulnerable. These include:

  • 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. Find out how to access the CCR templates in your primary care IT system.

2021/22 QOF indicators

We have included the QOF indicators related to CCRs below.

Indicator 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 (NICE 2020 menu ID: NM205) 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 (based on NM204) 2 70-90%
You can read the full QOF 2021/22 specifications on the NHS website.

Supporting patients after a cancer diagnosis

A cancer diagnosis can be a difficult time for patients. As recognised with the introduction of the CAN005 indicator, primary care professionals are now required to reach out to patients who have received a diagnosis.

We recommend getting in touch with your patients in the following ways:

  • A telephone call or virtual consultation

    Primary care teams may choose to reach out with a telephone call or virtual consultation after they learn of a patient’s diagnosis. This gives the patient an opportunity to discuss their concerns and express what support they may need. You can also use this time to signpost patients to local support or let them know all the ways we can support them

  • Sending a letter

    Your practice may already have a robust process for contacting patients after a new cancer diagnosis. This is a helpful way to let patients know you are there for them. You may also choose to send a letter to advise patients about the help that is available. We have created a sample letter which can be personalised to include links to support from Macmillan and the option to include local services.

  • Sending a text message

    We worked with accuRx to create an SMS text message template you can send to patients. The SMS signposts patients to trusted information and support after a cancer diagnosis. To use the SMS template, search for the template title ‘Macmillan Support Services’ or find it via this pathway in your accuRx system: Clinical > Useful services.

Supporting patients after a cancer diagnosis is the first QOF requirement for primary care professionals. We have more information about supporting patients from diagnosis.

How to prepare for a Cancer Care Review

After you have reached out to your patient following a diagnosis, it can be helpful to give them time to prepare for a CCR conversation. Primary Care teams now need to offer a patient the CCR within 12 months so it can coincide with the end of their cancer treatment. We recommend getting in touch with patients by:

  • Sending an invitation by letter

    You may decide to invite the patient for a CCR by sending a letter in the post. This helps patients to understand the purpose of the review and consider any issues they would like to discuss. A copy of a Concerns checklist can be sent with the letter to help them prepare. Download the CCR invitation sample letter.

  • Sending a digital questionnaire

    We have developed a Cancer Care Review Patient Questionnaire as a Florey Survey in accuRx which is now live and accessible to all accuRx users. The questionnaire can be sent to the patient via an SMS text message before their CCR. It’s quick and easy to complete on a smartphone, and helps the patient and physician prepare for the CCR conversation by highlighting the most important concerns. AccuRx has created a step by step guide on using Florey Surveys, the Macmillan Cancer Care Review Questionnaire Florey can be found under the ‘Partnered’ list when selecting a Florey template.

What should a Cancer Care Review include?


An effective CCR conversation should aim to discuss:

  • the patient’s diagnosis
  • the cancer treatment and its possible consequences
  • the patient’s prescription entitlements (and a Medication Review)
  • the patient and carers’ information needs
  • physical activity advice and signposting to local support services
  • signposting to Macmillan and other organisations.

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. More information on this can be found in our evaluation: Evaluating the impact of a Cancer Care Review Template in Primary Care (PDF).

We have listed our 10 top tips for effective Cancer Care Reviews.

You can also access electronic templates to support the CCR conversation below.

Electronic Cancer Care Review templates

The Quality Outcomes Framework (QOF) specifies the use of Macmillan’s national integrated template to guide the CCR conversation. This ensures the patient’s holistic needs are identified and considered.

We have developed electronic CCR templates on all major GP IT systems:

  • INPS Vision

    To access the CCR template in INPS Vision: In the Vision+ Consultation Manager, select the arrow on the right-hand side of the + icon and select ‘clinical templates’.

  • TPP SystmOne

    To access the CCR template in the TPP SystmOne: System > Resource Library > type 'macmillan' as the key search term and look for 'Macmillan Cancer Care Review Template 2019'.

  • EMIS

    To access the CCR template in EMIS, follow this pathway: EMIS Library > EMIS Protocols > Third Sector Partnerships > Macmillan/Cancer Support > Macmillan Cancer templates.

We have also produced an Personalised Care Quality Improvement toolkit to support the template. It contains searches to help practices demonstrate and monitor quality improvements to CCRs.

Want help to access the template or searches on your system? Please email macdocs@macmillan.org.uk.

Training courses for Primary Care

We offer training courses to support healthcare professionals with CCRs.

Find out more about learning and development courses for healthcare professionals.

Involving Social Prescribers

Social prescribers and link workers are well placed to work alongside primary care professionals, where they can identify and signpost patients to information and local support services.

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, download the following PDFs: