Why cancer screening needs to target the most at risk
It is a sad reality that people are dying of cancer earlier than they should in some parts of the country. People in more deprived areas are more likely to be diagnosed late and less likely to access cancer services.
Later diagnosis can be a death sentence. As cancers advance from Stage 1 (the least advanced) through to Stage 4 (the most advanced, usually incurable), survival rates drop and treatment options narrow.
Professor Christopher Nutting is President of the Royal Society of Medicine’s Oncology Section and a consultant oncologist specialising in throat cancers. He explained that the survival rate drops by 10-40 per cent, depending on the cancer, each time it progresses to the next stage. He said: “In even a relatively short period of a few months or so, a tumour could double in size, might spread to some other organ, or migrate to a more advanced stage.”
Early diagnosis
The big hope is in screening. There are three screening programmes in England: for bowel, breast and cervical cancer. Between them, they prevent 8,700 deaths a year, according to the NHS.
They work because they generally catch cancers at an earlier stage, often before a patient experiences any symptoms.
But the number of people taking up the opportunity of screening varies. Participation in all three of the cancer screening programmes is lower among more ethnically diverse communities, deprived groups, vulnerable people, such as those with learning disabilities, and people with severe mental illness. Tellingly, people in the most deprived groups are 50 per cent more likely to have their cancer diagnosed via an emergency route, such as a visit to A&E. This usually means symptoms are present and the cancer is more advanced.
This is more than a coincidence. Access to screening services is often worse in areas with the greatest need, on top of which are layered physical, communication, cultural and social barriers.
Barriers
Time is a major factor for people in deprived areas, according to Professor Maggie Rae, Trustee of the Royal Society of Medicine and President of its Epidemiology and Public Health Section. She said: “Disadvantaged people are too busy, perhaps working two jobs, trying to put food on the table, with no time to go to the doctor because they don’t get time off work to go for appointments.”
On top of that, Cancer Research UK found that people in the most deprived communities were less likely to recognise many potential cancer symptoms than those from the least-deprived groups. Indeed, they were only half as likely to recognise an unexplained lump or a mole that has changed appearance as possible signs of cancer.
The barriers are often compounded for people with certain other conditions, such as deafness, autism or a mental illness. These can make visiting a hospital difficult, says Dr Rebecca Maxwell of the Royal Society of Medicine’s Emergency Medicine Section. She has been involved in initiatives to make hospital more accessible for these groups. She said: “It's busy, it's noisy, there's lots of lights on, so, for certain groups of people who have got other conditions, that is the completely wrong environment.” Relatively simple interventions, such as having quiet cubicles where people can wait in a less stimulating atmosphere, are making a difference, she said, but these are not widespread.
All of this adds up to a situation in which the people who are at higher risk are less likely to participate in the screening. This is something healthcare leaders want to change.
Ambitions
The NHS Long Term Plan sets out ambitious targets for cancer diagnosis. It pledges that, by 2028, three-quarters of cancer cases will be diagnosed at Stages 1 and 2, up from 50 per cent now, and 55,000 more people each year will survive cancer beyond five years.
Early diagnosis is central to these plans and this, in turn, hinges on improving the uptake of screening.
To be successful, the NHS believes a multi-system approach is needed. Part of its approach is to reorganise healthcare management in England. In July 2022, 42 Integrated Care Systems were created in the country to “plan and deliver joined up health and care services”.
There is a significant role for primary care in this effort – not only in channelling more people into screening programmes but also improving referral for suspected cancer. Some cancers are more difficult than others to spot. Of the cancers that are most diagnosed via emergency routes, bowel and pancreatic cancer are deep inside the body, whereas lung cancer can be mistaken for a chest infection or a smoker’s cough.
There also needs to be investment in new approaches. The NHS-Galleri trial is exploring whether a blood test could help to detect cancer early, alongside screening. The idea is to sequence genetic codes to try to determine whether somebody is predisposed to cancer. The early results are promising and, unlike previous initiatives, the trial cohort is weighted towards the most at-risk groups.
Holistic approach
Of course, while improved screening would undoubtedly save many lives, it would not be a panacea. Once diagnosed, people need to access follow-on treatment in time and this is not happening as much as it should.
Royal Society of Medicine member Professor Chris Bentley has worked at board level in the NHS for 22 years and is an expert on health inequalities. He points out that the best clinical care plan in the world can still fail if the patient is unable to make the appointments and focus on their healthcare interventions because of other overwhelming stresses in their life. He advocates for holistic care plans, such as those offered by Macmillan Cancer Support. He said: “They've got what they call Joining the Dots programmes, which allow them to draw together targeted inputs from other partners, to help address issues such as food and fuel scarcity, income and debt, and housing insecurity.
“If we want to get the best outcomes and narrow the inequality gap, we’re going to have to think seriously about how these sorts of inputs can be resourced.”
It is all too easy for healthcare interventions to become only about numbers and money. But it is always worth stepping back to remember the real people at the centre of this. Not just the people whose deaths could be avoided but the behavioural psychology and real-world pressures that can have a huge impact on the success or failure of initiatives. The evidence so far is that availability of cancer screening programmes is not enough; we need to identify and dismantle any barriers standing in the way. With fewer gaps in their knowledge and understanding, and fewer barriers to practically accessing help, the hope is that more of the public will act.
The Royal Society of Medicine has launched a major multi-year programme to tackle health inequalities and is holding a flagship conference on 11 January 2023, in partnership with NHS England. Professor Rae will be speaking at the conference.
This is the fifth in a series of features in support of the RSM’s Tackling Inequalities programme. Each examines health inequalities through the lens of different RSM sections. This article focused on early cancer diagnosis and featured the Emergency Medicine, Epidemiology and Public Health, and Oncology Sections. Thank you to all contributors.
You can join the conversation on social media using the hashtag #tacklinginequalities. If you have a suggestion for a future feature or wish to contribute, please email media@rsm.ac.uk.