Britain: cancer death rates reflect social divide

A report from the all-party Public Accounts Committee, Tackling cancer in England: saving more lives, shows that survival rates from cancer in England are well below the best in Europe, especially for people living in the most deprived areas. The report does not cover Wales and Scotland, which if factored in would show an even greater discrepancy.

At some point in their lives, more than a third of England’s population develops cancer. There are more than 220,000 new cases a year and 128,000 deaths. Cancer is the country’s biggest killer, accounting for a quarter of all deaths.

The report states that people in northern England are now twice as likely to die of cancer than those in parts of the south. “There are clear and unacceptable inequalities in outcome between different parts of the country. There is a ‘North-South’ contrast in mortality rates suggestive of inequality between affluent and poorer areas, although the degree varies between individual cancers,” it notes.

Research carried out in the late 1990s established that survival rates for 44 of the commonest 47 cancers were worse in deprived areas. Further research in 2003 showed that whilst rates improved generally during the 1990s, the five-year survival gap between better- and worse-off has widened for both men and women, for the majority of cancers studied.

The figures provided in the report are based on an analysis of mortality rates between 1998 and 2000. These show almost 200 deaths amongst 100,000 people in Manchester, compared with 100 in the wealthy Kensington, Chelsea and Westminster London boroughs.

The 10 worst areas for cancer death rates are all those in the former industrial heartlands of northern England and the Midlands. Employment factors alone cannot explain the regional disparity, however, especially as the report explains that “England (together with Wales and Scotland) has traditionally suffered high cancer mortality rates compared with other European countries.”

The discrepancy has more to do with the lottery that now exists within the National Health Service (NHS). The report states that “Variation in the stage at which the cancer is diagnosed is an important contributory factor in explaining some of these inequalities both within England and between England and other countries. In particular, people in less affluent areas seem more likely to be diagnosed at a more advanced stage.”

It continues that “a key factor is the tendency of some patients, especially the old and those from deprived areas, to be diagnosed at a later stage of the disease.”

Factors contributing to this are lack of patient awareness of possible symptoms and delays in onward referrals from general practitioners (GPs) for treatment and in diagnostic tests being carried through.

Research has yet to be published about why patients with symptoms delay consulting their GPs. A contributory factor must be the emphasis made by health ministers discouraging visits to the GP unless deemed essential. Furthermore, in densely populated areas with a high elderly population, it is not uncommon for someone to have to wait over one week to see a GP.

Half of the GPs that responded to a recent survey said they did not find existing guidance on the early identification of cancer symptoms helpful. Others found such advice unnecessary—an attitude described as complacent in the report. Crucially, the report notes, patients referred as “urgent” by GPs are usually seen by specialists within two weeks, but the one third or more not deemed as priority cases can take several months to be seen.

This is further complicated by delays in diagnostic tests, which are common throughout England, partly due to lack of training and staff shortages of radiographers and pathologists.

In the last 30 years, cancer rates have increased across the developed world. Between 1971 and 2000, total cancer incidence increased by 21 percent for men and 39 percent for women. At the same time, mortality fell by 18 percent for men and 7 percent for women. The larger fall amongst men is attributable to a sharp decline in cases of lung cancer, whilst for women, a decrease in breast and bowel cancer rates has been partially offset by an increase in lung cancer mortality.

The increase of incidences are mainly due to a growing aging population, but despite the fall in lung cancer, smoking remains the largest single factor influencing the overall level of cancer incidence and mortality.

In spite of government claims that its Stop Smoking programme is successful, the report points out that the Department of Health considers that a person has successfully quit smoking if he or she abstains for four weeks. The effectiveness of this seems even less credible as the report also shows that it “is estimated that only about 30 percent of people quitting will still not be smoking 12 months later.”

Women receive routine screening only for cervical and breast cancer. Screening for bowel cancer is due to be introduced in 2006, but only in those older than 60. The report makes clear that more skilled staff will have to be recruited to make this possible.

Similarly, whilst surgery remains the main curative treatment for a large majority of cancer patients, research shows that the best results come when surgery is carried out by specialist surgeons.

“For the most prevalent cancers, such as breast cancer, specialisation in surgery is becoming the norm,” it states. But in relation to prostate cancer, “out of 133 Trusts where prostatectomies were carried out in 2002-03, only 12 Trusts carried out more than 50 operations. There are also insufficient specialist surgical resources to increase surgery for lung cancer to desirable levels.”

It is also noted that many lives are being put at risk because radiotherapy waiting times in many parts of the country are too long to conform with clinical guidelines on the maximum acceptable delay before the start of treatment.

Nationally, there is also considerable regional variations for the provision of scanners and the availability of chemotherapy treatments. The local NHS Cancer Networks say this is due to the lack of specialist staff, unsuitable pharmacy accommodation and variations in clinical practice in the prescribing of approved drugs. Joanne Rule, chief executive of CancerBACUP, the patient charity, said, “We need clarity about who is responsible for ensuring that money and treatments reach cancer patients.”