Detect cancer early

Early diagnosis of cancer is often hampered by deprivation. But how is the DoH tackling the inequalities gap? Ingrid Torjesen finds out

People from deprived backgrounds are more likely to develop certain types of cancer and die from it once they are diagnosed. There are a variety of reasons for this inequalities gap. Although genetics play some part in why some ethnic groups are more likely to develop certain types of cancer, most importantly people in deprived areas are more at risk because they are more likely to be exposed to factors such as smoking and poor diet.

The Department of Health is trying to reduce the effect of these risk factors in deprived communities through initiatives to help people quit smoking and efforts to increase their intake of fruit and vegetables, which have been shown to be protective against cancer, through initiatives such as 'Five-a-Day' and the National School Fruit Scheme. In addition, the Cancer Plan outlined a series of measures in 2000 to improve cancer services as a whole and to reduce the inequalities gap.

These included increasing the provision of diagnostic services, such as MRI and CT scans, increasing access to radiotherapy through the provision of new linear accelerators and increasing the number of cancer specialists. All these services will be targeted at areas where they are needed most in order to reduce inequalities in the diagnosis and treatment of cancer.

Putting in initiatives to reduce the impact of risk factors on deprived communities and increasing the level of cancer services available will only have an impact on the incidence of cancer if the population in these areas make use of the services. Unfortunately the Cancer Plan highlighted that health inequalities also exist in cancer because people in some social groups have less awareness of the symptoms of cancer, present later to GPs and are less likely to make use of screening services. As a result, uptake rates for programmes such as cervical screening are much lower in deprived areas.

The Cancer Plan instructed PCTs to draw up plans where necessary to increase the accessibility of screening among deprived and minority ethnic groups as part of their Health Improvement Programmes. In 2004 the Treasury set the DoH a firm target under its spending review - to reduce deaths from cancer by at least 20 per cent in people under 75 by 2010 with a reduction in the inequalities gap of at least 6 per cent between the fifth of areas with the worst health and deprivation indicators and the population as a whole.

People from minority ethnic groups have particular needs. There is evidence to suggest that women from these groups do not come forward for breast and cervical screening. Different approaches to giving information and ensuring that it is culturally sensitive information can often improve the uptake of screening among these groups.

Although the NHS currently only has screening programmes for breast and cervical cancer, inevitably screening for other cancers will be introduced. There are already plans for a colorectal screening programme, and screening for prostate cancer, ovarian cancer and lung cancer is under discussion. However, more screening programmes will only increase inequalities unless uptake can be increased within deprived areas.

The Improvement Foundation is working with the Department of Health on a programme that will encourage earlier presentation of symptoms for three types of cancer: bowel, breast and lung. It will build on the work of the Healthy Communities Collaborative, which has been working in small geographical areas (8,000 to 10,000 people) of disadvantage to improve health outcomes. It achieves this by involving local people and voluntary agencies, supported by representatives of statutory organisations. The model has so far been applied successfully to reducing falls in older people and widening access to a healthier diet in low-income groups.

The DoH now wants to use this model to raise awareness of the symptoms of cancer in deprived communities, using local people with local knowledge and relevant cultural understanding to get people with symptoms of cancer to present at an earlier stage. Local primary care services and the cancer networks will also be involved.

Jenny Knowles, acting programme director for Healthy Communities at the Improvement Foundation, emphasises that this will be about raising awareness of the symptoms of cancer and the benefits of screening, rather than about attempting to reduce the risks of cancer within that particular community.

'We are very clear the message is about presenting early not about preventing,' she says. 'One of the big problems we will need to overcome, particularly where lung cancer is concerned, is often a certain amount of self-blame that can affect people's willingness to present with a cough because they think they are going to be read the riot act and lectured at. We want to get away from that to make it easier for people to understand what the symptoms of various cancers are, and make it easier for them to present at a stage where their symptoms are more easily and successfully treated.'

The work is still at an early stage, and no pilot sites have been identified. The strategies which will be used to educate the communities about cancer are also still being developed but will involve mechanisms for targeting hard-to-reach groups such as men. The approaches are likely to be based upon initiatives that are already tackling cancer inequalities or inequalities in other diseases successfully.

Lai-Fong Chui, a health researcher specialising in health communication at the University of Leeds, has researched inequalities of access to cancer screening programmes for the NHS Cancer Screening Programme 1, and is working with the programme on increasing uptake in deprived communities.

She says there is a dearth of research from the UK on tackling cancer inequalities and one of the few models that has been evaluated is the community health educator model, developed by the NHS Cancer Screening Programme. This has been adopted by several PCTs. Under this model lay people are recruited and trained to go back into the community and disseminate cancer screening messages and wider information about cancer.

'A more passive approach like sending out leaflets won't work,' Ms Chui says, because some sections of minority ethnic groups do not speak English and/or have minimal education, so a more interpersonal community approach is required.

She says it is important to ensure that people in deprived areas have a sufficient understanding of cancer risk to enable them to make the right choices on screening. Certain communities believe numerical risk statements such as 'one in nine women will develop cancer in their lifetime' are not relevant to them, she says. 'They think &Quot;I am a Chinese woman, does it really apply to me?&Quot; But it just says &Quot;woman&Quot;. There is a community myth that because Chinese women have smaller breasts, we are not susceptible to breast cancer. Also some people don't understand what is meant by &Quot;lifetime&Quot;.'

Vague statements like 'the older you are the more at risk you are' can also have different meanings to different communities, because for some communities 50 is very old, whereas in others 80 is old.

Community programmes are important for ensuring that people in deprived communities are aware of information that has been relayed through the mainstream media because they find it hard to challenge professionals to get the information. For example, many women are unaware that the breast-screening programme has been extended to the age of 70.

One 70-year-old white woman with a family history of cancer, but not breast cancer, told Ms Chui she asked her GP if she could carry on having mammograms when she was 65, but her GP dismissed her request saying: 'I think you have other problems to worry about than your breasts.'

'Her confidence was undermined and she could not talk to the doctor about her perception of risk,' Ms Chui says. 'She has paid£350 every year for her own mammography ever since.'