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With A&E and ambulance waiting times dominating the headlines and over 6.7 million people waiting for elective surgery, prevention can unfortunately fall down the priority list. But cancer screening helps pick up cancers at an earlier and more treatable stage, improving survival rates and lessening pressure on the NHS in the long run. It is therefore important that it is not forgotten in the face of seemingly more urgent demands.
What is cancer screening?
Cancer screening involves tests that look for early signs of cancer in people with no symptoms. These tests aim to spot cancers early on, or to prevent cancers from developing.
There are three main types of NHS cancer screening in the UK:
bowel cancer screening – offered to people aged 60–74 (50–74 in Scotland) every two years
breast cancer screening – offered to women aged 50–70 every three years
cervical cancer screening – offered to women aged 25–49 every three years, and women aged 50–64 every five years.
Over time, the take-up rates of these tests vary. Breast and cervical cancer screening rates decreased slightly between 2010/11 and 2019/20, and then breast cancer screening in particular fell sharply in 2020/21, most likely due to disruption caused by the Covid-19 pandemic. Bowel screening, however, has increased steadily from 2010/11 to 2019/20, albeit from a lower starting point, and this increase was not impacted by the pandemic, potentially as it is a test done at home rather than in a medical setting.
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As the below chart shows, the fall in breast and cervical screening in 2020/21 led to a significant drop in the number of cancers diagnosed through screening that year. This is especially evident in the spring and summer of 2020, when the number of breast cancers in particular diagnosed through screening decreased dramatically.
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This lack of diagnoses from screening fed into the fall in cancer diagnosed at an early stage – the percentage of all cancers diagnosed at stages 1 or 21 fell from 57 per cent in March 2020 to 48 per cent in May that year. The NHS Long Term Plan committed to ‘to dramatically improving cancer survival, partly by increasing the proportion of cancers diagnosed early, from a half to three quarters’ by 2028. The current early diagnosis rate is 57 per cent, so there is substantial progress to be made.
The impact of the pandemic on diagnosis rates shows how important it is to minimise any future disruptions to screening programmes. Reducing variation in screening take-up and reporting performance is also important to tackle long-standing inequalities and support improved outcomes.
Variation and inequalities
There are clear examples of variation in access to screening. Considering age, for cervical screening, older people are less likely to have had a test in the past five years; as of 2020/21, 28 per cent of 60–64-year-olds have not been screened, compared to 6 per cent of 30–34-year-olds. The reverse is the case for breast screening (albeit with less variation); 34 per cent of 70-year-olds have not been screened in the past three years, compared to 38 per cent of 50–52-year-olds.
And once people have presented for screening, there are large unexplained variations in how quickly results are processed. For cervical screening, 67 per cent of results are received within two weeks, but this varies significantly, from 91 per cent in the North West to 23 per cent in the East Midlands. In England, 11 per cent of results take more than three weeks, but again there is variation, from 1 per cent in the East of England to 35 per cent in the East Midlands.
Cancer diagnosis levels decrease with deprivation for bowel and breast cancer. While the data does not exist to see if this is due to lower screening rates in more deprived areas, it is important to ensure that all eligible populations are able to access screening and understand the benefits. It is also important to try and plug this data gap, to better understand any gaps in the system.
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Lessons could be learnt from how the Covid-19 vaccine rollout programme was able to reach underrepresented groups. Using data to map who had been vaccinated and outreach work to fill gaps in provision and overcome hesitancy would be just as useful in cancer screening as it was in the vaccination programme.
And at an international level, the UK continues to lag behind other developed countries in cancer survival rates; despite the screening programmes (that are not freely available in some other countries), it ranks 21st of 34 countries in the Organisation for Economic Co-operation and Development in breast cancer survival rates, and 24th for cervical cancer.
What now?
It’s not all bad news. As the charts above show, the uptake for bowel screening has increased consistently over the past decade, and the awareness raised by Dame Deborah James may improve this further. In addition, the disruption caused to screening by the pandemic has lessened, which again will hopefully improve uptake rates.
And on the performance side, the quality of testing is improving; the percentage of inadequate cervical screening samples hovered around 2.5 per cent between 2010 and 2019, but has fallen in the past two years and is now 0.4 per cent. Hospital trusts are also implementing innovative ways of diagnosing cancer earlier, such as the West Yorkshire and Harrogate Cancer Alliance, which works with local partners to create an NHS rapid response service to help streamline diagnosis.
However, the recent fall in breast and cervical screening uptake, the inconsistency in take-up among different groups, the current lag in survival rates compared to other countries and the lower than targeted percentage of cancers diagnosed early all show that the screening programmes could go further. It is therefore vital that screening does not get lost underneath the pile of other pressures facing the NHS.