London School of Hygiene & Tropical Medicine

Within the new NHS Long Term Plan, a response to the £20.5 billion funding allocation to NHS England over the next five years, sits the new cancer strategy announced by Prime Minister Theresa May in October.

Although still falling short of projected need, this investment has been welcomed following a decade of austerity in the NHS. Austerity has been felt keenly in cancer services—waiting times are at their worst ever level since records began in 2009; mortality from some cancers has contributed to the overall slowed rate of improvement in life expectancy; and cancer survival remains lower in England than in comparable high-income countries.

The aim of the new cancer strategy is to close this cancer survival gap with other countries by improving early diagnosis in England—increasing the proportion of cancers being diagnosed early (stage I-II) from 50% to 75% by 2028.

Achieving world-class cancer outcomes through improving early diagnosis has been core to government cancer policy for over a decade. The early diagnosis focus has led to important initiatives, such as: public awareness campaigns; investment in screening, especially for bowel cancer; multidisciplinary diagnostic centres; monitoring of patient routes to diagnosis and waiting times targets; and increased availability of tumour stage data. However, to-date there is little evidence that the gap between England and other comparable countries has closed, and successive strategies have not accelerated improvement in survival within this country.

One reason for the lack of impact of national cancer plans on survival, is that the survival deficit is not only driven by the timing of diagnosis, but also by inequalities in treatment.

The potential contribution of treatment differences to the international survival deficit was indicated by evidence of lower stage-specific survival for patients in England than in a number of other high-income countries for several cancers.

New research led by the London School of Hygiene & Tropical Medicine and published in the Lancet Oncology confirms this treatment inequality, showing that colorectal cancer patients in England are less likely to receive surgery than in Denmark, Norway and Sweden—where survival is higher—and these differences are especially stark for older patients.

Within England, there are also large gaps in survival between the young and old, rich and poor, and those living in the north and south. Again, evidence is mounting that this survival variation partly arises from inequalities in the receipt of optimal treatment. Older and poorer lung cancer patients in England are less likely to receive surgery than richer and younger patients. Geographic variation in lung cancer treatment is associated with regional inequalities in survival in England. There may also be inequalities in the quality of care received. Current research shows older colorectal cancer patients are less likely than younger patients to receive a complete diagnostic investigation—an important step towards treatment.

Until recently, we could not know whether differences in treatment between population sub-groups were justified, because of incomplete data on patient and tumour characteristics, such as stage at diagnosis and the existence of other chronic conditions. For example, under-treatment of some older patients could arise because of other health conditions which make cancer treatment too risky. Crucially, using current improved data streams, we now know that inequalities in treatment hold true even after accounting for these potential individual artefacts.

That some patients who are eligible for treatment are not receiving it, or are being treated sub-optimally, is a missed opportunity, and one which is unacceptable in a system of universal healthcare.

Experience with lung cancer in England has shown that in the context of good data, evidenced-based action can be taken to identify and reduce treatment inequalities. In one area, the lung cancer surgery rate tripled in one year after inequalities were identified using lung cancer audit data, and efforts were made to improve access to care.

The additional funding planned for more deprived areas in the NHS Long Term Plan is therefore welcome. It is however disappointing that it does not specifically address the inequalities in NHS infrastructure observed between areas by deprivation, or rural and urban areas. Instead, the emphasis is on prevention, reducing risk factors and diagnosing earlier, as well as introducing new technologies for more targeted diagnosis and care.

Influencing individuals to take responsibility for their health and to prevent disease is important, and achieving prevention is undeniably preferable to resorting to cure. Yet, the NHS Long Term Plan may go too far in stating that “we cannot treat our way out of inequalities”. The evidence is clear that certain—older, more deprived—sub-groups of our cancer patient population are not receiving optimal treatment, and that this is an important determinant of the gap in cancer survival between this country and others. Similarly, introducing new technologies is commendable and welcome, but may also serve to exacerbate inequalities in the short term in the absence of specific support towards vulnerable groups.

It seems we could do far more than the NHS plan allows to ensure that our cancer patients are treated equally despite their age, social status, or address. Focusing on equitable treatment as well as primary prevention and early diagnosis is important to reduce inequalities in cancer survival, and the international survival gap.

*This piece was edited on 9 January 2019 to reflect launch of the NHS Long Term Plan*

Publication

Sara Benitez Majano, Chiara Di Girolamo, Bernard Rachet, Camille Maringe, Marianne Grønlie Guren, Bengt Glimelius, Lene Hjerrild Iversen, Edrun Andrea Schnell, Kristina Lundqvist, Jane Christensen, Melanie Morris, Michel P Coleman, Sarah Walters. Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study. The Lancet Oncology. DOI: 10.1016/s1470-2045(18)30646-6