Inequalities in cancer can manifest as differences in the cancer care experience or outcomes in relation to an individual’s socio-economic status, cancer type, race, age, gender, disability, belief, sexual orientation and geographical location (All Party Parliamentary Group on Cancer 2009).
Tackling inequalities has been at the forefront of all the cancer strategies reviewed. The Cancer Plan recognised the presence of acute inequalities in cancer care and outcomes stating that; ‘People from deprived backgrounds are more likely to get some types of cancer, and overall are more likely to die from it once they have been diagnosed’ (Department of Health 2000) (pg. 19). This strategy sought to reduce inequalities by targeted efforts in the most deprived such as efforts to reduce smoking rates in manual groups (Department of Health 2000). The Cancer Reform Strategy also highlighted inequalities as a priority, declaring that a lack of evidence on their nature was a hindrance to addressing the issue. In response, the Government set up the National Cancer Equality Initiative (NCEI) which was mandated to optimise data collection in order to enable a better understanding of inequalities, to promote research and evidence on cancer inequalities, and to spread good practice (Department of Health 2007). More recently, the Improving Outcomes Strategy on cancer has attributed England’s poorer outcomes to the worse outcomes observed in vulnerable groups and deprived areas; ‘Higher morbidity and mortality in disadvantaged groups and areas are a key driver for our poor average outcomes’ (Department of Health 2011a) (pg. 3). The most recent strategy, Achieving World-Class Outcomes Cancer Strategy, also reiterates the impact of socio-economic variations and attributes 15,300 cases and 19,200 deaths per year to the gap between the most and least deprived (Independent Cancer Taskforce 2015).
58 Cancer inequalities in England manifest as; higher cancer incidence and mortality in deprived groups, in older people, in some ethnic minorities and in men. The exception here is breast cancer where women who are more affluent have higher incidence, although they also have lower mortality than the less affluent women. Cancer incidence is generally lower amongst ethnic minority groups, with the exception of prostate cancer where incidence is greater amongst Black African and African-Caribbean men. Liver cancer incidence is higher among South Asians, and mouth cancer is highest among Bangladeshis (Department of Health 2010). Inequalities have also been reported in levels of patient experience, with black and minority ethnic groups reporting poorer experience of care (Department of Health 2012a). Some older people also experience clinically inappropriate under treatment, which may be attributed to the slower rate of improvements in mortality in older people in comparison to younger age groups (Department of Health 2010).
There are also known geographical inequalities in cancer diagnosis, treatment and outcomes in England that are intrinsically related to how services are organised and how patients access them. These geographical inequalities have been reported as the regional differences in survival whereby survival rates are generally lower in Northern England than in the South of the country (Walters et al. 2010). Trend data shows that the north-south divide has become less pronounced over time (Office of National Statistics 2013b); Figure 2.9 demonstrates the narrowing of cancer survival rates between Clinical Commissioning Groups located in the north and south of England. This reduction in geographical inequality is particularly significant in breast cancer survival, which has been attributed to the successful implementation of the NHS Cancer Plan recommendations (Walters et al. 2010).
59 Figure 2.9 - Smoothed maps of the one-year survival index (%) for all cancers combined in 211 Clinical Commissioning Groups: England, 1996, 2001, 2006 and 2011, patients’ ages 15-99 years
Source - ONS, 2013 ©. Re-used with permission. Licence for re-use is available at
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/
Analysis of individual level data reveals geographical inequalities that are associated with access to cancer services. For instance, poor geographical access has been associated with decreased likelihood of histological diagnosis (Crawford et al. 2009) and poorer uptake of optimal treatment (Sauerzapf et al. 2008; Jones et al. 2008). Proximity to specialist services has been associated with uptake of care, in lung cancer; large variations in resection rates has been linked to local provision of specialist thoracic surgeons, whereby, presence of a surgeon at a lung MDT, has been associated with higher resection rates (Lau et al. 2013). Another study found that specialist thoracic surgical services have higher resection rates for patients referred directly to them compared to those patients referred from the wider and much larger catchment areas that they serve (Khakwani et al. 2013).
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2.6.1 Closing the gap
Despite the consistent policy attention on tackling unjustified inequalities, there has been little progress in closing the inequality gap. For example, inequalities by socio-economic groups have persisted despite the universal access to health in the UK. The exact origins of these inequalities remain unclear, but it is likely that they arise from complex interactions of factors that operate at different levels; biological, behavioural or psychosocial and health system levels (Munro 2005). Thus, inequalities may be as a result to differences in tumour aggression (Woods et al. 2006), disease stage (Møller et al. 2009), or comorbidity (Møller et al. 2012). At a behavioural level, inequalities may be as a result to different attitudes towards seeking health care (Niksic et al. 2015; Moffat et al. 2017). They may also arise due to factors operating at the health system level such as differences in clinical practice (King’s Fund 2011), or as a result of environmental factors such as variations geographical and locational access to services (Munro 2005).
It is estimated that closing the gap in survival between the most and least affluent would prevent anywhere between 7,000 (Ellis et al. 2012) to 19,200 deaths (Independent Cancer Taskforce 2015) in England only. Whilst understanding healthcare inequalities requires the rigour of scientific investigation, addressing them fully requires political will power that involves addressing inequalities of the wider determinants of health that operate outside the health system (Navarro 2009; Whitehead & Popay 2010; Marmot et al. 2017). It is therefore welcoming that most of the cancer strategies reviewed had a political commitment to addressing inequalities, by targeted action on determinants of poor survival such as diet, smoking, alcohol consumption and physical activity, and focussing initiatives on the most disadvantaged groups and areas (Department of Health 2011a; Independent Cancer Taskforce 2015; Department of Health 2000).
The extent to which cancer strategies have successfully achieved the objective to reduce inequalities is not fully known. An assessment on the impact of the Cancer Plan on the equity goal found that the strategy was successful in improving cancer survival rates, but was unsuccessful in reducing the socio-economic gap in survival (Rachet et al. 2010). Figure 2.10 shows the consistency of the survival gap in 1 year relative survival rates between the most and least deprived groups. Secondly, the assessment found that the socio-economic gap in relative survival differed between cancers of good vs. poor prognosis; socio-economic inequalities
61 were wider for cancers of good prognosis‡ (Figure 2.10). Lastly, the assessment reported ‘persistent and wide socioeconomic inequalities in the excess hazard of death in the period immediately after a cancer diagnosis’ (Rachet et al. 2010) (pg. 452), suggesting that more attention should be given to earlier diagnosis and prompt access to optimal treatment across all socioeconomic groups (Rachet et al. 2010).
Figure 2.10 - Trends in 1-year relative survival for the most deprived (solid line) and most affluent (dashed line) groups, by cancer prognosis, England 1996–2006. Lines are
the regression plots fitted in a single model, which comprises every survival estimate by deprivation and calendar year.
Source – Rachet et al, 2010, Re-used with permission. Licence for re-use is available at
https://creativecommons.org/licenses/by-nc-sa/3.0/
Most of the socioeconomic deficits in survival occur shortly after diagnosis, and they tend to attenuate or disappear with time since diagnosis (Rachet et al. 2008; Møller et al. 2012). In colorectal cancer for instance, excess mortality (survival deficit) in the most deprived groups is a short term phenomenon, that is largely confined to the first year (colon cancer) and two years (rectal cancer) after diagnosis (Møller et al. 2012). As described earlier in this section, these variations in survival may explained by differences in patient and disease characteristics
‡ Cancers of good prognosis are bladder, breast, cervix, colon, Hodgkin’s disease, kidney, larynx, leukaemia, melanoma, myeloma, Non-Hodgkin lymphoma, ovary, prostate, rectum, testis and uterus. Cancer of poor prognosis are brain, lung, oesophagus, pancreas and stomach, (Rachet et al, 2010).
62 and a number of studies have demonstrated this. Another suggested explanations is in relation to the organisation and quality of cancer care services (Møller et al. 2009), inequalities from this may arise as a result to variations in optimal access to early diagnosis and treatment services (Richards 2009; Rachet et al. 2010). As described elsewhere in this section, there is evidence showing how the structure of treatment services may exacerbate inequalities in cancer outcomes (Khakwani et al. 2013; Lau et al. 2013). The extent by which access to early diagnosis services may generate or perpetuate any inequalities in cancer outcomes is largely unknown, this research will contribute to towards generating evidence for this.