Health inequalities: Improving early cancer diagnosis for everyone

You’re reading the fifth article in our Health Inequalities Series. It’s part of our ongoing investigation into how inequalities impact every aspect of cancer, from why people get it to how research contributes to helping them.

Today, we’re taking a closer look at early diagnosis. We spoke to Bernard Rachet, Professor of Cancer Epidemiology and leader of the Inequalities in Cancer Outcomes Network (ICON) at the London School of Hygiene & Tropical Medicine, about why some cancers, and some groups of people, tend to be diagnosed later. We’ve also scrutinised the evidence to see how we can make sure more people affected by cancer can be diagnosed early, whoever they may be.

The statistics referenced throughout this article are for England unless otherwise stated, due to limited data availability for routes to diagnosis across other UK nations. The stage at diagnosis isn’t available for every cancer case, so the statistics presented for stage at diagnosis are for those with a known stage.

What is early diagnosis? Who gets it?

The earlier a cancer is diagnosed, the more options we have for treating it, and the better people’s outcomes are likely to be. But some people are less likely to get an early diagnosis than others. 

Who is more likely to be diagnosed later, and why they face delays, are complex questions with many possible answers. We know certain cancer types are more likely to be diagnosed at particular stages, but personal characteristics, such as deprivation and ethnicity, also seem to play a part.  

Let’s start with cancer types. Testicular cancer has one of the highest proportions of people diagnosed early (at stage 1 or 2) at 91%. This has a big impact. Survival for testicular cancer is related to stage of the disease at diagnosis, coupled with the fact we have very effective treatments for it. Around 95% of people diagnosed with testicular cancer will survive their disease for at least 5 years after their diagnosis.   

Compare that to oesophageal cancer, which has the lowest percentage of early diagnoses, just 19%. Almost two-thirds (63%) of people diagnosed with oesophageal cancer in England at the earliest stage will survive their disease for 5 years or longer. But, because so few cases of oesophageal cancer are detected early, only 18% of all people diagnosed with it survive their disease for 5 years or more. 

That’s a striking comparison. It helps show the value of early diagnosis. But it doesn’t tell the whole story. 

We now know that, for some cancer types, people from an ethnic minority background are more likely to be diagnosed at a later stage than White people. 

And, overall, people from more deprived populations in England are more likely to be diagnosed with advanced cancers.  

That’s a key reason why people from some demographic groups have worse cancer survival. It’s a problem that needs to be fixed. 

In fact, reducing inequalities is one of the most important things we can do to make sure more cancers are diagnosed early. Making diagnosis fairer helps everyone. So, how do we do it?  

This article is a step towards answering that question. We’re going to delve into how people are diagnosed with cancer and look at why this varies across different groups. With a better understanding of why some people are more likely to be diagnosed at a late stage, we can start developing ways to catch their cancers sooner. 

How are people diagnosed with cancer, and why does this matter?

There are multiple ‘routes’ to a cancer diagnosis. People can be diagnosed after screening, following a GP referral, as an inpatient or outpatient in hospital, or after an emergency presentation, such as at A&E.  

The data from England and Northern Ireland tell us that a person is more likely to be diagnosed at a late stage if they present as an emergency compared to other routes.

As shown by the graphic below, in England in 2018, 90% of cancers found via screening were diagnosed at an early stage. The same was true of only 25% of cancers detected after an emergency presentation. 

Troublingly, the UK has higher rates of emergency presentations than other comparable countries. And people with cancer in the most deprived areas are 50% more likely to be diagnosed after an emergency presentation than those in the least deprived areas.  

That tells us a lot. Too often, the routes to diagnosis that catch cancers soonest aren’t reaching the UK’s most deprived populations. 

Why are some people more likely to be diagnosed after an emergency presentation?

So, we know there’s a connection between emergency presentation and late-stage diagnosis. Next, we need to work out why some people are more likely to be diagnosed in an emergency than others. 

Professor Bernard Rachet, an expert in inequalities in cancer care and cancer outcomes, spends a lot of time thinking about that question.  

“First, there may be barriers to accessing the GP, such as lack of convenient appointment times,” he says, “but it’s also communication. Time with the GP is often very short, and it’s hard to explain symptoms. Even if the patient understands there is something wrong, it can take more time to explain.” 

In fact, there’s evidence to suggest that patients who are diagnosed via emergency presentation might visit their GPs more often than those who get their diagnosis through other routes. Rachet thinks they may be facing barriers that make talking to their GPs about possible symptoms more difficult. 

Before COVID-19, the UK had some of the shortest doctor consultations in Europe. And the pandemic may have added extra difficulties, as there was a significant shift away from face-to-face appointments towards remote consultations, using the telephone or internet. We’ve started to investigate how this change may have impacted cancer diagnosis. 

So far, our Cancer Awareness Measure (CAM) survey from February 2023, has shown that people from ethnic minorities were significantly more likely to have had remote appointments than those from White backgrounds. 

The evidence base that will help us understand what this means for inequalities is still growing, but we know that some people don’t have access to all the technology needed for remote consultations. In line with current evidence, Rachet also thinks remote appointments might cause issues for people whose first language isn’t English, or who have lower health and digital literacy. Overall, though, we’re yet to see how the increase in remote consultations has impacted cancer care. 

We also still have some way to go to understand why some cancers develop differently in different people. Rachet highlights breast cancer as an example. Black women are more likely to be diagnosed with a faster growing type called triple negative breast cancer than other groups.  

Can education help?

One way of lessening some of these issues could be by improving health education for the groups that are most likely to be diagnosed after emergency presentations. 

In the February 2023 CAM survey, White respondents were significantly more likely than those from an ethnic minority to correctly identify signs and symptoms of cancer. Recall of cancer symptoms was also higher among those in higher socioeconomic groups.  

That suggests people in these groups might be more likely to talk to their doctors if they develop symptoms. They might also be more willing to start conversations about whether they might indicate cancer. 

But there are other aspects to consider as well. While concern about cancer can motivate some people to seek help, others might be so worried about it that they avoid speaking to doctors about potential symptoms. Educating people about the importance of early diagnosis could help them be more positive about discussing their health.  

On the other hand, people might not talk to their GP because the symptom they’re experiencing isn’t concerning to them. This is understandable, given many possible cancer symptoms are more commonly associated with less serious conditions (in other words, they are ‘non-specific’).  

Even in these cases, though, people experiencing non-specific symptoms often see their GP multiple times before they’re diagnosed. They’re concerned and aware enough to book appointments, but, ultimately, they’re more likely to be diagnosed with cancer at a later stage, and as an emergency presentation. Public awareness and help-seeking are very important factors, but they aren’t a total fix. More support for health professionals could help improve things too. 

What are we missing?

Right now, we don’t have all the pieces we need to solve this puzzle. An important part of working out what’s missing is tackling the ‘unknowns’ in our data.  

Around a quarter of cancers in England are diagnosed at an unknown stage. That rises to 35% of cancers diagnosed after an emergency presentation. And between 2006-2016, around a fifth (19%) of people with an ‘unknown’ ethnicity also had an ‘unknown’ route to diagnosis.  

That’s a big gap in our knowledge. 

It’s not the only one. Rachet also stresses that, unlike other countries in Europe, we don’t have good data about deprivation on an individual level. More detailed deprivation data could help us understand more about how people’s care is affected by inequalities and how we can address these variations. Ultimately, you can’t solve what you can’t see. 

How can we reduce emergency presentations and eliminate inequalities in routes to diagnosis?

Even though we might not have every piece of the puzzle yet, there’s a lot we can do with the ones we’ve already found. 

It’s clear that reducing the proportion of people diagnosed through emergency routes is one way of improving cancer patient outcomes.  

That will take a collective effort from the public, health professionals, policymakers and researchers. We want everyone to recognise possible signs and symptoms of cancer and feel empowered to seek help early. 

To start, we need the government to invest in the healthcare system’s ability to diagnose cancer sooner. Rachet is blunt on this point: “First, increase the resources. If you don’t have them, it will be a failure.”   

Awareness campaigns targeting those communities that we know are diagnosed at a later stage could help make our existing resources more effective, too.  

These could focus on the role of cancer screening in improving cancer outcomes. There are currently 3 cancer screening programmes in the UK, and it’s important people know which ones they are eligible for. There are barriers to break down there, too, as we discussed in our last article. Instead of missing out on screening because they don’t know enough, we want people to be able to make an informed decision about whether they want to participate. 

Healthcare providers also need to make sure they’re accessible to everyone. That means thinking of patients as unique people who may experience individual barriers to accessing healthcare.   

Providing other routes into the health system, via pharmacies for example, could help with that.  

Over the short term, Rachet thinks we could help some people by giving them the opportunity to start discussing their health concerns with nurses or medical assistants before they see their doctors. These conversations might feel more relaxed, making it easier for people to share their concerns. Doctors could then follow up on those concerns in appointments without putting pressure on patients to explain everything at high speed. 

Another approach could be to use more mobile healthcare units, which help bring doctors to people who might not otherwise see them. But Rachet stresses that they don’t come cheap. 

That goes back to resources and policymakers. If the UK’s government doesn’t commit money and attention to improving people’s health, things won’t get any better. But we also need robust evaluation to understand whether these alternatives will help to widen access for those that need it most. 

That’s where research comes in. It’s key to improving our understanding of cancers and cancer symptoms. It’s also how we can develop new tests that can better detect cancers at an early stage in anyone, no matter their personal characteristics. And by looking more closely at the barriers to help-seeking, researchers can guide us towards tailored interventions we need to break them down. 

Importantly, these interventions need to be built with the target population in mind. As Rachet puts it: “We need to see more of the people who find it hardest to access care. We need to hear their voices.”