Diagnosing cancer early – how far have we come?

To coincide with the publication of a series of new papers looking at early diagnosis of cancer, our director of early diagnosis and cancer intelligence, Sara Hiom, gives her thoughts on the progress being made in the field.

If cancer is diagnosed at an early stage it’s often much easier to treat successfully – simple. We wheel this phrase out a lot, but that’s because it’s important.

An early diagnosis can mean the difference between a tumour that’s had time to grow and spread, and one that has stayed put and can be more easily tackled with surgery or radical radiotherapy. And it could also save the NHS money in treatment costs.

So acknowledging the importance of early diagnosis is easy. But shifting more diagnoses into the category of ‘early’ is much more of a challenge.

That’s the goal of the National Awareness and Early Diagnosis Initiative (or ‘NAEDI’ if you like acronyms). Launched in 2008, the initiative is co-chaired by Cancer Research UK’s chief executive and the National Cancer Director.

And through research looking at the various ways people are diagnosed, we’re piecing together vital bits of information that have the potential to shift those cancers diagnosed at a later stage into the earlier stage categories and, we hope, improve survival.

Back in 2009, an important series of papers appeared in a special supplement of the British Journal of Cancer collating all the key bits of evidence that tie the initiative together, providing an impetus for action by calculating the number of ‘avoidable deaths’.

And today we provide an update – again freely available via the British Journal of Cancer – laying out where we stand right now in pursuit of our goal.

One of the recurring challenges for early diagnosis has been tackling differences in cancer survival that emerge between different groups: men and women, older and younger, north and south and among people from varying socioeconomic or cultural backgrounds.

But ongoing research looking to tackle these various inequalities is providing some interesting results. Let’s take a look at the recent findings.

Awareness of symptoms

England’s Be Clear on Cancer campaigns were established in 2010 to address differences in symptom awareness, as well as whether people act on these symptoms. And there have already been early signs of success for the 2012 lung cancer campaign.

And further evidence presented in two new papers reinforces this positive message, showing how the lung and bowel cancer campaigns that ran in 2012 successfully boosted symptom awareness and GP visits.

Both studies showed that overall symptom awareness increased across the target age group and among the most and least-deprived groups following both campaigns.

A poster that formed part of lung cancer campaign

The bowel cancer campaign boosted awareness of blood in stools as a potential sign of bowel cancer from 27 per cent before the campaign to 42 per cent afterwards. For lung cancer, awareness of a persistent cough or hoarseness jumped from 41 per cent to 50 per cent. This is a great sign that the key messages of the campaign were reaching the target audience.

Thanks to the bowel cancer campaign, significantly more people aged 75 and over recognised blood in their stools as a symptom compared to people aged 55-74. But there were no differences observed across age groups when acknowledging a persistent cough as a symptom of lung cancer.

Improvements in symptom awareness were seen in both men and women across multiple different occupations and social and ethnic groups. Evidence like this is crucial for finding the best ways to tackle inequality.

The data for this study came from surveys carried out several months after the campaigns had ended. So the findings also suggest that the campaigns triggered sustained symptom awareness, which is really important. But the responses to the surveys also showed no difference in how approachable people found their GP following the campaigns. A similar number of people still viewed reporting these symptoms as a potential waste of the doctor’s time, or they had concerns that the GP would be difficult to talk to.

Clearly, more work needs to be done to address this challenge.

But what about the number of people who actually visited their GP with these symptoms following the campaigns?

Should I see the GP?

Awareness is a vital first step, but the potential impact of greater awareness can only be felt if people act on these symptoms. Crucially, this study also showed that following the campaigns, substantially more people made a trip to their GP with these target symptoms – GP visits jumped 29 per cent for bowel cancer symptoms and 63 per cent for lung.

Interestingly, data for the bowel cancer campaign shows that the increase in GP visits was greater among men and for people from the most deprived group. And for the lung cancer campaign it seems that people from more affluent areas accounted for more of the GP visits. But GP practices in the poorest areas still saw the highest number of overall visits linked to the key symptom from the campaign, a persistent cough.

These studies suggest that the Be Clear on Cancer approach is playing a key role in getting important messages about symptoms to the people most likely to be affected, which is great news. Finding the best ways to tweak this approach and ensuring these campaigns continue to boost awareness and help close these inequality gaps will require further research.

Setting the stage

Inequalities also extend beyond first noticing symptoms and going to the GP. Previous research has found that far too many people are being diagnosed as an emergency case – especially older people.

This is important because cancers diagnosed via emergency routes are usually more advanced, difficult to treat and far from ideal from the patient’s perspective. And two further papers from the supplement address inequalities related to how advanced a tumour is when diagnosed (known as ‘stage at diagnosis’).

Why do some older women with breast cancer fare worse?

The first used data from the East of England from 2006-2010 to assess how addressing age inequalities could improve breast cancer survival.

They predict that in England, 280 women aged 75 and over would survive for at least five more years if their disease was diagnosed at the same stage as women aged 70-74 years.

The second paper used similar data to assess the potential impact that levelling socio-economic and gender differences could have on survival from melanoma across all stages of the disease.

Extending their predictions to England as a whole, the researchers believe that around 215 people would survive their melanoma for at least five more years if the differences in survival between men and women and richer and poorer backgrounds were removed.

Together these studies illustrate the potential improvements that could be made by addressing inequality. But narrowing these gaps isn’t an easy job. Further analysis will be needed to find out the best way of approaching these groups and making sure they can access the information they need.

Positive signs

The studies outlined here give just a snapshot of the new research presented in this special supplement, which itself is a fraction of the full field of early diagnosis research.

As with any research area, we must build on these studies to improve our understanding of cancer. And we should ensure that the evidence generated is used to improve practice, reduce inequalities and effectively guide policy to achieve better survival and fewer early deaths from cancer.

Much of this research has been made possible by the vastly improved and expanded cancer data collection that occurs nationally. Without these data, especially on cancer stage and how these data are linked to other data collections, we’d be much further behind in our understanding of survival and early diagnosis. So it’s crucial that researchers and analysts are given access to the data they need, and that the host organisations make safe data sharing a reality soon, in the way that cancer patients would want.

If the first supplement made the case for tackling late diagnosis, we hope that this update illustrates that our understanding of how to tackle it and measure our progress has grown considerably in this time thanks to new research, better data collection, initiatives and evaluation.

Just five years ago we were staring at a potential 10,000 lives that could be saved each year, but without a clear way of achieving this. Now, through continued research and evaluation, some promising approaches are emerging.

We hope the next five years will show the impact this research has made.

Sara Hiom is the director of early diagnosis and cancer intelligence at Cancer Research UK

• Read all the papers that feature in the special supplement

References

• Moffat, J., et al. (2015). The impact of national cancer awareness campaigns for bowel and lung cancer symptoms on sociodemographic inequalities in immediate key symptom awareness and GP attendances British Journal of Cancer DOI: 10.1038/bjc.2015.31
• Power, E., & Wardle, J. (2015). Change in public awareness of symptoms and perceived barriers to seeing a doctor following Be Clear on Cancer campaigns in England British Journal of Cancer DOI: 10.1038/bjc.2015.32
• Rutherford, M., et al. (2015). The impact of eliminating age inequalities in stage at diagnosis on breast cancer survival for older women British Journal of Cancer DOI: 10.1038/bjc.2015.51
• Rutherford, M., et al. (2015). Estimating the potential survival gains by eliminating socioeconomic and sex inequalities in stage at diagnosis of melanoma British Journal of Cancer DOI: 10.1038/bjc.2015.50

Image

• Road image from Flickr, under CC BY-NC-ND 2.0