Cancer outcomes in England are poor when compared with the rest of Europe and elderly cancer patients also survive less well in this country. The main gap on a national basis is present in one year survival, suggesting late stage diagnosis, and there is a broad consensus that the priority for reducing premature mortality from cancer is to improve the stage of diagnosis of cancers. Delivering early diagnosis is likely to be dependent on a package of measures across public health and the NHS (including both directly commissioned and CCG commissioned services) aimed at:
- Effective population screening (for prevention of some cancers as well as early detection);
- Raising awareness of symptoms to promote earlier presentation of patients with potential symptoms of cancer in general practice;
- Earlier and more accurate diagnosis of the symptoms of cancer by GPs; and
- Ensuring timely access to diagnostics.
In the following section of the resource we have made an assumption about the cumulative effect of a range of measures designed to promote prevention and early diagnosis, rather than seeking to apportion benefits to specific interventions/actions.
Prevention and early diagnosis
For early diagnosis of cancer, the relative assessment of priorities and benefits is based on a number of assumptions about the drivers of premature mortality and the interventions which are most likely to impact on reducing premature mortality, rather than an assessment of the relative benefits of a range of clinical interventions. Whilst there is strong evidence about the impact of earlier diagnosis on reducing premature mortality, the assessment of benefits is based on analytical modelling of the impact of diagnosing a proportion of cancers at stage 1 or 2 which would otherwise, without concerted effort to deliver earlier diagnosis, have been diagnosed at stage 3 or 4.
While earlier diagnosis should be cost-effective, it does not appear to be cost-saving. It requires large increases in testing and in direct treatment costs. Treating patients for a middle stage cancer with curative intent is generally more costly than a very early stage of the disease or palliative treatment for late stage cancers. The modelling indicates that the cost per life-year saved is in the range of £2,000-£6,000 for the three cancers included in this analysis (i.e. colorectal, breast, and lung).
- 4.1 Cancer prevention
- 4.2 Effective population screening
- 4.3 Promoting symptom awareness
- 4.4 Ensure effective planning of diagnostics capacity to support early diagnosis
- 4.5 Monitor variation in referral and diagnosis rates amongst local practices and work with local GPs to understand the reasons behind variance
Issue: Evidence suggests that an effective mortality reduction strategy for cancer should have a strong prevention and health promotion focus.
Suggested action: A prevention strategy should seek to address the key risk factors for cancer:
- Smoking – A lifetime of smoking raises the lifetime risk of lung cancer 50 times and it also contributes to bladder, pancreas and a number of other cancers.
- Infection with the Human Papillomavirus is associated with cancers of the head and neck, oral cancers, and cancers of the anogenital tract, in particular cervical cancer. Vaccination of young girls and regular screening can prevent many of these cervical cancers developing.
- Obesity is associated with bowel cancer, breast cancer in post-menopausal women, endometrial, kidney, and oesophageal cancers. Physical activity is associated with reduced risk of cancers of the colon and breast and has been linked to reduced risk of endometrial, lung, and prostate cancers.
A healthy diet and reducing alcohol consumption will also assist in reducing the risk of some cancers.
Issue: NHS England will commission screening services under a Section 7a agreement with the Department of Health. However, there is currently low uptake of screening amongst certain groups:
- Breast, cervical and bowel cancer screening programmes all show higher participation in more affluent areas.
- For cervical cancer, ethnicity is the most important predictor of participation.
- Men are less likely to accept an invitation to participate in bowel cancer screening than women, even though they are at higher risk.
- People who have other health problems are less likely to participate in cancer screening, in particular there is concern that people with learning disabilities or mental health problems are not accessing screening.
Suggested action: To maximise the impact of screening, commissioners could:
- Work with GPs and their patient populations to ensure that they are aware of cancer screening programmes.
- In particular, commissioners may wish to focus on increasing access to services for currently under-represented groups, such as people with learning disability, people with a serious mental illness and people from certain ethnic groups, as well as communities in more deprived areas, through more targeted approaches to reaching these groups (such as seeking to ensure that screening is delivered locally).
Issue: Public Health England is continuing to run ‘Be Clear on Cancer’ symptom awareness campaigns, which are aimed at raising public awareness of the symptoms of cancer and have been running at national, regional and local levels since 2011. The campaigns are designed to tackle late presentation of patients with possible cancer symptoms and thereby to promote earlier diagnosis of cancer.
Suggested action: Commissioners could consider working with local authorities and health and wellbeing boards to coordinate local work to support the cancer awareness campaigns, including raising awareness amongst local professionals and factoring in the impact of the campaigns into local plans.
Issue: Delivering early diagnosis will, in part, be dependent on ensuring adequate capacity within diagnostics services.
Suggested action: A key consideration for CCGs seeking to deliver earlier diagnosis of cancer is assessing the demand for and planning to deliver increased capacity for diagnostic tests for cancer, whilst also seeking an improvement in access to tests from primary care to minimise the extra burden on secondary care clinicians. Particular consideration should be given to ensuring adequate endoscopy capacity, as the roll-out of bowel scope screening is likely to result in localised pressures on existing capacity.
Issue: There are significant variations in the patterns of GP referrals and outcome rates in relation to the diagnosis of cancer.
Suggested action: Commissioners and area teams may wish to consider undertaking an analysis of referral patterns and outcomes at practice level and working with those practices which appear to have poorer outcomes to understand why there is variance. Commissioners and area teams may wish to focus symptom awareness raising activity on those practices and to identify opportunities for working with local strategic clinical networks, to disseminate learning and provide support for practices with poorer outcomes.