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Unpacking cancer disparities in England

Despite major gains in diagnosis and treatment, England continues to experience high disparities in cancer outcomes, with social and financial deprivation major drivers.

By Rachel Millar

In December 2023, The Lancet Oncology published a landmark paper highlighting the “astounding inequality” in the risk of dying from cancer in England. Researchers from Imperial College London looked at the 10 most deadly cancer types in England and analysed the risk of dying from these across England’s 314 districts from 2002 to 2019.

Although the overall risk of dying from cancer before the age of 80 had declined over that time period, their analysis shows huge inequalities in risk depending on where in the country someone lives. For women, the risk of dying from cancer was one in 10 in Westminster, while for women in Manchester the risk was one in six. Meanwhile, the picture for men ranged from one in eight in London’s Harrow to one in five in Manchester. The study found that lung cancer had one of the highest inequalities in risk across areas with those at greatest risk areas having triple the risk of dying from lung cancer compared with those in lowest risk regions.

The concept of health inequalities is now well established in the UK and beyond. The publication of the DHSC Black Report in 1980 demonstrated that, although there had been a general improvement in public health since the introduction of the welfare state, there were widespread health inequalities across the country. It found that the primary cause for these inequalities was deprivation. Over four decades later, there is now a vast body of evidence examining health inequalities and the evidence suggests that despite new treatments and technologies, overall health is deteriorating, and the inequalities are widening.

Social determinants still a major influence

Research has shown that for cancer, the social determinants of health impact both prevalence and prognosis. The Health Foundation describes the social determinants of health as the “social, cultural, political, economic, commercial and environmental factors that shape the conditions in which people are born, grow, live, work and age”.

A 2020 report demonstrated that more than 30,000 extra cases of cancer in the UK each year can be attributed to social and financial deprivation, while survival was found to be worse among the most deprived groups. Many of the risk factors for cancer are influenced by the social determinants of health. For example, individuals residing in areas with higher levels of deprivation are 2.5 times as likely to smoke compared to those in the least deprived areas, and they find it harder to quit.

Diet inequality is also an issue that affects the most deprived in society. Research has shown that people in deprivation have poorer diets, and consumer higher levels of poor quality, ultra processed, high calorie food than those in the least deprived areas. This population also suffers from much higher rates of obesity. As a result of such social determinants of health, those that grow up and live in deprivation are more likely to get cancer, but the story doesn’t stop there.

Variations in diagnosis

There is huge variation across the UK in cancer diagnosis. There are currently three UK screening programmes: for bowel, breast and cervical cancers. In theory these screenings are open to everyone eligible, however, in reality there are various barriers to screening that disproportionately affect certain populations, and this leads to inequalities in diagnosis.

Barriers to screening are an active area of research but there are several factors that have been identified to contribute. Stigma is one factor, with research showing that cancer stigma is linked to lower screening uptake, and this tends to be more prevalent among people from ethnic minority backgrounds.

Another barrier recognised is the practicality of attending a screening. For example, other responsibilities such as work or caring may make it difficult to get to an appointment. There are ways to overcome these barriers and increasingly NHS services are implementing changes to make screening more accessible to everyone. For instance, research suggests language barriers hamper screening uptake and therefore translation services can help overcome this. Also, offering greater flexibility on appointment times and re-invitations for those that haven’t responded have been found to positively impact uptake in underserved populations.

Overall, there are clearly gross inequalities across both the risk of developing cancer and the prognosis once it has developed. However, as researchers gain deeper insights into these inequalities and the mechanisms that contribute to them, NHS and public health services can implement best practices in order to try and level the playing field for cancer care. In April, Public Policy Projects will be hosting a round table event looking at regional inequalities in prostate cancer, so look out for the report later this year.

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