Building cancer services equitably in primary care

Cancer survival in the UK has improved in recent years and is higher than ever before. Unfortunately, these improvements have not led to a reduction in inequalities. According to estimates, approximately 33,800 more cases of cancer in the UK each year can be attributed to socioeconomic deprivation alone. More socioeconomically deprived groups have been shown to have lower rates of screening, lower recognition of symptoms and signs, and more barriers to seeking help – all of which could contribute to worse outcomes. Although non-white ethnic minorities in England are estimated to have lower rates of cancer for the most cancer types, they are more likely to be diagnosed at later stages, when the cancer has spread and is harder to treat. Women, younger and older patients, and ethnic minorities also report worse experiences in cancer care. 

Another related area of concern is the variation in access to cancer services based on sociodemographic factors and geographic location, meaning certain groups may face obstacles in accessing appropriate care. Professor Eva Morris, who recently gave a talk at the Cancer Group Seminars in our department, discussed this issue within colorectal cancer care in the UK, specifically highlighting the large variation in colonoscopy quality between providers. 

The NHS Long Term Plan ambition is to diagnose 75% of cancers at stages 1 and 2 by 2028, and primary care services will play a vital role in the system-wide efforts that will be required to achieve this aim. As part of this effort, there are currently a host of new early cancer detection initiatives being planned for implementation within primary care. Running alongside this is the CORE20PLUS5 framework, which is a national initiative in England aiming to reduce health inequalities across five levels of clinical focus, including early cancer diagnosis. This approach targets both national and system levels to identify a target population made up of the most deprived 20% of the national population. Additionally, it encompasses PLUS population groups including ethnic minority communities, people with a learning disability, people with multiple long-term health conditions, and other groups that share some protected characteristics. 

Taken together these two approaches hold the possibility of better cancer outcomes for everyone, delivered efficiently and equitably to the whole population. However, it requires appropriate attention and resource invested into understanding and addressing existing inequalities in cancer pathways and outcomes, otherwise there is a risk that new interventions may further exacerbate these disparities. 

There are many reasons why some population groups face worse cancer outcomes than others. This may be due to higher levels of exposure to cancer risks – for example, smoking, pollution or unhealthy diets – which are more prevalent among socially-disadvantaged groups. The growing cost of living crisis in the UK has shifted ever increasing numbers of people into poverty, making it a challenge to live healthy lives. There are also powerful structural forces that target vulnerable groups for commercial gain, such as the tobacco and food advertising industry. Even when people experience symptoms, they may delay accessing healthcare, either because of feeling unable to prioritise their health (due to competing pressures on their time), or because they perceive, often based on past negative experiences, that healthcare services are difficult to access, or discriminatory towards their social group. For example, 78% of Black women in the UK do not believe that their health was equally protected by the NHS compared to white women. 

Implementation of all cancer initiatives should actively incorporate health equity approaches through explicit consideration of the systemic social and structural disadvantages that exist in society. Co-designing implementation processes with patients and community partners to establish locally relevant adaptations for different populations holds promise for impacting equity in cancer detection outcomes. For example, historically-neglected groups could be identified and supported to access cancer services, such as by using patient navigators, who may be individuals who share cultural background with the specified population; in one US study, this model demonstrated success in improving detection rates.  

In our Cancer Theme Group, we are working with patients and families, clinicians, service providers, researchers and other stakeholders to co-develop a number of projects to improve cancer control at the level of primary care. This means working to improve pathways to cancer diagnosis, so it is caught at an early stage, with the best possible prognoses. Delivering this work equitably is one of the key ambitions for this work and we are developing a range of novel processes to ensure that all our efforts are conceived through a health equity lens, right from the early stages and all the way through. For example, our data team are currently investigating variations in care according to membership of different socio-demographic groupings in the MAINROUTE project, using consultation data from GP surgeries. In further planned work, funded by Cancer Research UK and the NIHR Cancer Policy Research Unit, areas of inequality identified in the MAINROUTE project will be explored in more detail, by working directly with the communities where inequalities have been identified. By carefully understanding where and how these inequities manifest for different people, and working in partnership with the groups most affected, we will we will develop new context-sensitive interventions that are resourced appropriately, in order to reduce existing inequities in cancer care.