Healthcare Leader looks at developments in early cancer diagnosis and prevention, and what those working in the field hope for in the 10 Year Health Plan and National Cancer Plan. Kathy Oxtoby reports
Cancer affects one in two people during their lifetime, and ‘record numbers’ of people are being diagnosed and treated in the UK, according to the Department of Health and Social Care (DHSC).
Published data shows that more than 3.1 million people were investigated for suspected cancer and 355,935 people received their first cancer treatment in the previous 12 months.
Cancer survival in the UK is at ‘the highest it has ever been and 10-year survival for all cancers combined has doubled since the early 1970s’, DHSC says. ‘However, survival and mortality rates are worse than in many other comparable countries and this has to change.’
It is often quoted that England, and indeed the UK, perform worse than other OECD countries in terms of cancer diagnosis and mortality. Research by the Organisation for Economic Co-operation and Development (OECD), for example, reveals that the UK ranked 31 out of 43 countries for five-year survival from lung cancer, and 26th for colon cancer.
There is no one simple answer as to why this might be. However, compared to peer countries, the UK has certain behavioural factors, such as relatively high excess alcohol consumption, and relatively high levels of obesity, says Sarah Arnold, a senior policy lead at The King’s Fund.
‘The UK should focus more on preventing cancer in the first place’, although there have been some positive developments, such as the reduction in smoking prevalence, she says.
Research has also highlighted how in the UK, ‘there seems to be a public hesitancy in consulting your doctor’, she says. While a better understanding of the reasons why people may not go to their GP is needed, this could be due to a lack of recognition of cancer symptoms, fear of getting a diagnosis, or because people know someone with cancer who has had a negative experience in the NHS, says Ms Arnold. ‘And there is a socioeconomic gradient to all this, because those from more deprived areas are less likely to contact their GP about issues, more likely get sicker and access services later. For example, accident and emergency (A&E) attendances are nearly twice as high in the most deprived groups, and emergency admissions 68% higher, and when they are diagnosed, people living in poverty are more likely to die younger.’
Delayed diagnosis
Holly Norman, head of health systems engagement at Cancer Research UK (CRUK), says it appears that in the UK, people tend to be diagnosed when their cancers have progressed further, more than in other comparable countries.
‘Some of the biggest delays that we see in people getting their cancer diagnosis actually happen before they’ve necessarily “hit” the health service,’ she says. ‘The two big ways people get diagnosed with cancer is following a consultation with their GP and then a referral, and the other is through a screening programme. It’s probable that we have room for improvement in both of those areas – so people coming forward with their symptoms earlier and being referred, earlier, and also having the best possible modern screening services with the best possible number of people choosing to take up screening.’
‘Late diagnosis is a key driver for poor outcomes,’ says Kathy Nelson, head of cancer network for NHS Bedfordshire, Luton and Milton Keynes (BLMK) Integrated Care Board (ICB).
‘We know that the earlier people are diagnosed with cancer, the more likely they are able to have treatments with curative intent or less invasive/lengthy treatments.’
This link was clearly identified in the Luton Cancer Outcomes study – award winning work carried out by the ICB to understand the different factors behind the poor cancer outcomes in the area.
The study also highlighted a number of other factors such as awareness and willingness to talk about cancer signs and symptoms, and access to treatments – as the cancer centre is located some way from where patients live which means additional travel costs and time. And people also living in deprivation had other concerns about family and work responsibilities that meant ‘health didn’t always come first’, she says.
Screening uptake is a contributing factor when it comes to explaining why England is frequently cited as underperforming in cancer diagnosis and mortality outcomes compared to other OECD countries, says Claire Brennan, programme manager, Early Diagnosis and Timely Presentation, the East Midlands Cancer Alliance (EMCA).
‘Uptake of cancer screening – particularly for bowel and cervical cancers – remains suboptimal, with significant variation across regions and demographic groups,’ says Ms Brennan.
EMCA has responded to these disparities by submitting a funding application to the Small Business Research Initiative (SBRI) to support interventions aimed at increasing cervical screening participation.
EMCA is also funding ICBs to implement targeted projects aimed at improving bowel and breast screening uptake, particularly in under-screened populations. ‘There is a notable difference in screening participation between practices serving the most and least deprived communities,’ says Ms Brennan.
Public understanding of cancer symptoms and associated help-seeking behaviours remains ‘inconsistent, particularly within underserved populations’, she says. In the East Midlands, early-stage diagnosis rates differ by socioeconomic status – 54% in the most deprived areas compared to 57.6% in the least deprived. There is also a gender disparity, with women being 16% more likely than men to receive an early-stage diagnosis.
Economic impact
The impact of cancer comes at a heavy cost to the economy. The OECD report Tackling the impact of cancer on health, the economy and society estimates the economic impacts of cancer around the world. Cancer could add £14.4bn to the UK’s health spending every year until 2050, according to the OECD’s modelling.
Overall, the UK is projected to lose the equivalent of 170,000 full-time workers to cancer each year between 2023 and 2050.
The OECD estimates that, without action, the UK’s health expenditure on cancer will increase by 52% per capita by 2050. But the impact of cancer goes much further than figures can convey.
Cancer ‘isn’t just about numbers or performance targets, it’s about people’, says Ms Nelson. ‘Just hearing the news someone has got a cancer diagnosis can change their whole life.’
That diagnosis can impact on their family, their work, and there may be long term effects of treatment. ‘It’s important we diagnose people quickly, but just as important that patients know that health professionals understand that there’s a lot more going on for them than just being told they have a cancer diagnosis. This can impact treatment decision making and therefore treatment times.
‘We want to treat them in a timely way, but there are other factors that we need to consider like the effect on work, finances, how their family feel about it, and for some people, their mortality.’ Other countries like Netherlands and Sweden have patient navigation and MDT structures that minimise these delays.
Much more needs to be done to help manage the rising incidence of cancer – forecast by CRUK to be half a million new cases each year by 2040 – to bring down waiting lists and improve outcomes.
The government is ‘taking action’ through a National Cancer Plan for England. This plan will ‘take forward the reforms to be set out by the 10 Year Health Plan and our approach to cancer will be based on the shifts set out in it’, DHSC says.
DHSC launched a call for evidence in February, which includes questions on early diagnosis as well as prevention, access, treatment, living with and beyond cancer, and research and development. The evidence gathered will inform the National Cancer Plan for England, due to be published later this year.
Early diagnosis, screening and detection
Early diagnosis ‘remains critical for improving survival and is a priority for the NHS’, says DHSC. ‘Record improvements to early diagnosis have been led by the NHS’s early diagnosis programme.’
Screening is a ‘very powerful tool’ for early detection, says Ms Norman. For breast and bowel, ‘about 90% of the cancers found in the screening programmes are found at an early stage’, she says. ‘It’s a very important part of achieving what we want to see in terms of people being diagnosed earlier when they have better treatment options.’
Three current screening programmes are breast, bowel and cervical. And now there is also targeted lung cancer screening – an ‘exciting change’, which is in the process of being rolled out across the country, specifically for people who meet certain criteria, including having a smoking history, says Ms Norman.
According to DHSC, the programme has diagnosed more than 5,000 lung cancers, three-quarters of which are at an early stage.
‘We know that lung screening is changing the stage that lung cancers are diagnosed at, and that has significant implications for how treatable and how survivable lung cancer can be,’ says Ms Norman.
Each Cancer Alliance is working with NHS England to roll out this screening programme according to a local roll out strategy. With the 10 Year Health Plan and the National Cancer Plan, CRUK is calling for that roll out to be ‘completed rapidly and that the lung screening programme is put onto a sustainable footing alongside the other screening programmes as quickly as possible’, says Ms Norman.
Bowel cancer screening uptake has been increasing across the UK since the introduction of the Faecal Immunochemical Test (FIT). The most recent data shows that yearly uptake was 70% in England for 2022-23.
While FIT is helping to improve bowel cancer screening uptake, uptake is still lower than other cancer screening programmes and inequalities in uptake still exist.
A development with FIT is that the NHS is testing in early adopter sites, what happens when the threshold set by the health system that triggers a further investigation is lowered. It is anticipated this will pick up more cancers, and probably more cancers at an early stage. ‘This is another exciting development, and we’re keen to see the results,’ says Ms Norman.
She says there is an ‘important need for investment in the digital infrastructure that supports the screening programmes’. Currently the programmes ‘run very old IT and upgrading that IT will allow potentially more innovation to be introduced into the screening programmes’.
It would also allow some basic improvements, like being able to send text messages, and to integrate screening data with other data sets to be able to target interventions more. ‘That investment in the digital structure could unlock some real improvements in screening and allow screening to make a bigger contribution towards early diagnosis,’ she says.
It is important for ICBs to look at inequalities in uptake of screening. ‘We know there are barriers people face,’ says Ms Norman. There are lower participation rates among people with disabilities and learning disabilities, for example. ‘We would like to see those inequalities understood more, and in the Cancer Plan, support and commitment to measures that help address those kinds of inequalities.’
ICBs should be working with their Cancer Alliances, which will have ‘a good sense of what some of the challenges are in their local services’, she says.
Early detection is ‘mission critical to improving patient experience and mortality. It is different from early diagnosis as it is a proactive approach to diagnosing cancer’, says Ms Nelson. She believes ‘this starts with people and communities, and there needs to be more focus on prevention and secondary prevention’.
There is an ‘emerging shift in the distinction in policy between early diagnosis and early detection, and I would like to see more of this in the 10 Year Plan’, says Ms Nelson.
She explains early detection work historically focused on screening, ‘but now we have other programmes of work England wide, such as GP and patient education, case finding opportunities, use of innovation and community engagement that are all now recognised elements of early detection approaches to support improved cancer outcomes.’
There is an opportunity in the 10 Year Health Plan to have ‘a more joined-up approach to case finding and community readiness to talk about cancer or act on signs and symptoms’, she says.
In Luton, the ICB partnered with GPs, council and faith leaders to run a project to raise awareness of prostate cancer risk both in the black community and in primary care at the same time. ‘This was a successful approach which led to a significant number of men being diagnosed with prostate cancer who had no idea of their risk,’ says Ms Nelson.
‘In BLMK, we have an ambition to reduce the variation in early stage diagnosis in our area, but recognising as a whole we have very good early diagnosis rates when compared to other areas. We have achieved this through a systematic early diagnosis strategy over a long period of time. Some of these benefits are not realised over a short period of time but can take years before they show up in the data.’
Across the East Midlands, efforts are underway to strengthen early detection and screening capabilities.
Currently, 84% of lower gastrointestinal referrals are accompanied by a FIT test, enhancing early detection in bowel cancer, says Ms Brennan.
The Nottingham and Nottinghamshire Lung Cancer Screening Programme is operational across three sites, with four additional sites expected to launch in 2024/25. To date, the programme has identified over 300 lung cancers.
With pancreatic cancer case-finding, five Primary Care Networks (PCNs) are piloting proactive identification of high-risk individuals using diabetes and unexplained weight loss as indicators.
The region is expanding direct access to CT scanning and self-request chest X-ray services, enhancing diagnostic capacity and accessibility.
The capsule sponge, a novel surveillance method for patients with Barrett’s Oesophagus – a precursor to oesophageal cancer – is being deployed in two systems, with plans for broader adoption in 2025/26, says Ms Brennan.
ICBs are ‘actively developing culturally and contextually appropriate engagement materials and outreach events to improve screening participation in seldom-heard communities’, she says.
EMCA is participating in a project targeting cervical screening non-responders via SMS reminders, focusing on the most deprived areas across the East Midlands with the lowest uptake.
As highlighted in the Lord Darzi report to the health secretary, the focus on early diagnosis and prevention must be central to any future cancer strategy, says Ms Brennan.
‘For the forthcoming 10-year Cancer Plan, key areas of focus should include scaling effective screening and case-finding models, addressing inequalities in access and outcomes, and enhancing public awareness and symptom recognition. Other areas should include strengthening primary care’s role in early detection and investing in diagnostic infrastructure and workforce.
‘ICBs should play a proactive role in these efforts, leveraging local insights to design and implement tailored interventions that meet the needs of diverse communities,’ says Ms Brennan.
HPV vaccine and cancer vaccine trials
As well as early detection and screening, vaccinations are now an established part of the armoury of cancer prevention.
The HPV vaccine ‘aims to stop people getting some types of high-risk HPV. These high-risk types of HPV are linked to some cancers’, says Dr Louise Soanes, chief nurse at Teenage Cancer Trust.
The vaccine is given through one injection for young people under 25.
For women in their 20s who were offered the HPV vaccine at 12 to 13 years old, the vaccine has reduced cervical cancer rates by 90%, the charity says.
There are two main HPV vaccination programmes in the UK – in schools, and at sexual health clinics for men who have sex with men.
The HPV vaccine has ‘been around for a while’, and is an area where ICBs potentially could have a role, says Ms Norman. The vaccine rates dropped off in schools during Covid, and have not returned to the same level of the vaccine uptake prior to the pandemic.
She says there is a role for ICBs to look at what some of the drivers are in their local communities for why parents might be choosing for their children not to take up the vaccine, or what other barriers there might be, working with services and communities ‘to try and make sure we increase the coverage of the vaccine’.
Cancer vaccines, she says, ‘are much newer technology’ which were supercharged by research done for the COVID vaccine, then translated into giving a boost to cancer vaccines’ work.
There are a number of clinical trials in the UK for cancer vaccines, some of which are being funded by CRUK. ‘But at the moment, cancer vaccines are only available to patients in the UK if they are participating in a clinical trial,’ she says.
It is important to make sure ‘we have the right investment in ongoing research, and a good strategy for bringing the innovations from research into services where the evidence says we’re ready’.
‘Offering personalised treatments is key to shifting the dial on cancer outcomes,’ says Ms Nelson. ‘I believe preventative tools are a cornerstone for early diagnosis. We need to link HPV vaccination uptake rates with cervical screening uptake. Across the country, improving the uptake rates for HPV in boys and girls has been a challenge for ICBs and public health teams.’
She says BLMK is below the national average for vaccination uptake. ‘More education in schools about the wider impacts of the vaccine would be helpful. A stronger recognition of the link between screening uptake and HPV uptake may help us to tackle the barriers to accessing screening/vaccines collectively – we could really target our conversations to those who need to hear the message most clearly.’
There is ‘a real opportunity in the 10-year plan to scale up access to innovations that enable detection and treatment, particularly for communities who do not traditionally come forward for help until it’s too late’, she says.
For example, the work the ICB did in Luton highlighted that certain disadvantaged groups such as the homeless or travelling communities ‘don’t access healthcare easily’, she says.
‘Efforts to raise awareness and increase uptake of the HPV vaccine are currently embedded within ICBs/EMCA plans,’ says Ms Brennan.
‘EMCA is leading the development of educational toolkits for general practice, aimed at supporting GP education and public engagement around HPV vaccination. These resources will target both clinical staff and the wider community to drive improved vaccine uptake and reduce future incidence of HPV-related cancers.’
EMCA’s 10-year strategy recommendations include to embed HPV awareness into school and community health programmes, and strengthen general practice capacity for proactive vaccination outreach. EMCA also recommends expanding research and participation in cancer vaccine trials, particularly for high-burden cancers, and monitoring and addressing inequalities in HPV vaccine uptake.
An uncertain picture
The picture of early diagnosis of cancer at system level is continually evolving, contains much that is innovative, and will be shaped by the input and influence of those responding to the 10 Year Health Plan and the National Cancer Plan.
But with the restructuring of the NHS and ICB cuts, it is also a picture surrounded by uncertainty.
On the restructuring of the NHS and ICB cuts, Ms Arnold says: ‘It is hard to tell exactly what’s going to happen. We know there is going to be 50% running costs cuts to ICBs. NHS England and DHSC are being merged and also being reduced by roughly 50%.’
‘Clearly a lot of time and effort is having to go into figuring out what the new ICBs will look like and what NHS England and DHSC are going to look like going forwards.’
‘There are changes across the entire system, and a lot of uncertainty right now, which is drawing energy.’
She says that theoretically prevention and cancer are still ‘important focuses’, but ‘a real risk is that this could get a bit lost, and all this reorganisation will be somewhat disruptive, even if in the long term it might end up being better’.
The restructuring of the NHS and ICB cuts are something CRUK is ‘watching closely’, says Ms Norman. ‘Our main concern is making sure that we continue to have good strategies at the national level and the more local level for driving forward better cancer outcomes.
‘We want to avoid disruption in what already works, and we want to see progress in things where we know that there’s room for improvement.’
‘Ongoing NHS restructuring and associated budget constraints are a source of uncertainty, with potential implications for the delivery and scale-up of transformation projects,’ says Ms Brennan.
‘Workforce shortages pose a significant risk to sustaining progress in early diagnosis and cancer care. The long-term impact of these pressures remains to be fully realised but must be closely monitored.’
Of the restructuring of the NHS and ICB cuts, Ms Nelson says: ‘There will always be concerns on how changes impact the work – cancer remains a national priority and presents an opportunity to focus on improving outcomes, reducing variation and inequalities across a wider geographical footprint.’
Alongside early cancer diagnosis, The King’s Fund would like to see ‘more preventive activity’, making sure staff have the training and time to talk to people and understand the barriers to them quitting unhealthy behaviours, says Ms Arnold.
With the 10 Year Health Plan, ‘we’d like to see prevention front and centre – to see the health system focusing more on supporting people stay well as much as they can’.
Ms Norman emphasises the importance of ‘focusing on early diagnosis of cancer’.
‘I would urge ICBs to take an interest in screening uptake rates in their area, and think about how they can work with their local services and with their communities to get the most value from screening,’ she says.
‘I would encourage them to work closely with Cancer Alliances and make use of their expertise. And I would urge them to be thinking about how they can make sure they have good access to primary care and to diagnostics.’
‘ICBs should utilise national data, local analytics, and clinical insight to identify tumour sites and geographic areas with persistently high rates of late-stage diagnosis,’ says Ms Brennan.
‘Resources should be concentrated in areas of high deprivation and low screening uptake. This includes tailored outreach to underserved and seldom-heard populations.
‘And regular review of referral patterns, screening uptake, and diagnosis timelines will allow ICBs to adjust strategies and reduce unwarranted variation,’ she adds.
It is also important to sustain innovation. ‘EMCA funding is supporting pilot projects across the East Midlands focused on community engagement, innovative diagnostic tools, and digital outreach to non-responders. Scaling successful models will be essential,’ says Ms Brennan.
With early cancer diagnosis, it is important to have ‘a clear strategy at system level, and to be consistent’, says Ms Nelson.
ICBs also need a strategy that is ‘bespoke to the area and population’, she says.
‘It’s also time to embrace the use of innovations, so that we can take the learning from other countries.’
