Cancer inequalities: The problem of unwarranted variation in access to treatment

The UK is a world leader in cancer research, but in other areas we’re lagging behind.  

We’ve known for a while that cancer survival in the UK is worse than in other comparable countries. And new data from the Organisation for Economic Cooperation and Development (OECD) shows that cancer mortality in the UK in 2021 was still worse than in similar countries. 

So why is this happening?  

The reason isn’t clear cut, and there are a wide range of factors that are likely influencing this.  

For example, cancer patients in the UK are too often faced with late diagnosis. Cancer that is diagnosed at a later stage often has fewer treatment options which can lead to poorer outcomes.  

When it comes to actually getting treatment, wider system barriers like limited bed capacity in intensive care services could also be contributing to the problem.  

On top of this, workforce pressures are leading to consistently missed targets for cancer waiting times, meaning that some people are waiting too long for tests and treatment. 

But outside of these problems, some people with cancer in the UK are still struggling more than others to get access to treatment. 

What is unwarranted variation and why does it matter? 

No two people’s cancer diagnoses are the same, and there are lots of reasons why people with cancer may be offered, and receive, different treatment options. These factors range from the type of cancer someone has and at what stage it is diagnosed, to patient choice and fitness, and whether someone has other health conditions that need to be considered.  

But even when we take these factors into account, we still see variation in the treatment people receive. This is called unwarranted variation, and it presents a big problem as it suggests potential inequalities in access to treatment.  

This is not acceptable. Beating cancer means beating it for everyone so it is key that everyone with cancer receives equitable, timely access to effective treatments.  

This is becoming more important than ever. Although we can see progress, as with the ongoing efforts to optimise cancer screening programmes, we still have a long way to go to achieve the targets set for earlier stage diagnosis in the UK. Then, for the benefits of earlier diagnosis to be fully realised, it’s vital that we ensure people have access to the right treatment options.  

For this reason, it’s crucial that we have a clear understanding of where there is variation so that we can tackle inequalities where we know they exist. But that’s not easy. At the moment there are big issues when it comes to availability and access to patient data that make it difficult for us to fully understand why access to treatments might vary, and to pick out when differences are unwarranted or not.  

What do we know about how access to treatments can vary? 

Although we don’t have access to lots of data, we do have clear evidence that cancer treatment in the UK can vary based on geographic and sociodemographic factors (e.g. age, gender, ethnicity, socioeconomic background).  

Let’s start with location. Research from 2018 found differences in the treatment given to lung cancer patients in different geographical areas of England. It showed that the proportion of patients receiving radical radiotherapy – high-dose radiotherapy used with intent to cure a cancer, rather than to control or treat symptoms of cancer – was up to 8.9 percentage points higher in some locations compared to others. There was also a difference in the proportion of patients receiving chemotherapy as part of their treatment, which was up to 12.9 percentage points higher in some locations than in others. These numbers are important, because for each of these treatment types, higher treatment rates were linked to better survival outcomes.  

Socioeconomic background is also linked to a reduced likelihood of receiving some treatments. For example, in 2022, analysis from the National Oesophago-Gastric Cancer Audit showed that some cancer patients from the most deprived communities were less likely to receive a curative treatment plan, even when important factors such as tumour site, sex and presence of comorbidities were taken into account.  

And cancer inequalities linked to socioeconomic background are not a small problem. In fact, it is estimated that over 33,000 cases of cancer in the UK are linked to deprivation each year. 

Why is there variation across the UK? 

There are lots of potential reasons for unwarranted variation in treatment access.  

When it comes to regional differences, it can be partly due to how cancer services are set up and the resources are available in different parts of the country. For instance, different clinicians could recommend different treatment plans depending on local waiting times and the hospital equipment available.  

For example, in 2018, only 6 out of every 10 radiotherapy centres delivered an advanced type of radiotherapy called stereotactic ablative radiotherapy (SABR) for lung cancer. The centres not delivering SABR reported that they referred suitable patients to SABR centres for treatment, with some also offering conventional radiotherapy locally as an alternative option. So, until recently, some people may have missed out on the offer of this innovative therapy or had large distances to travel to receive it. Now, all eligible centres can deliver SABR. 

It can also be harder for some people with cancer to access new treatments being offered, such as through clinical trials, if traveling a long distance to a specialist centre is not possible.  

Wider system barriers, such as limited bed capacity, could also be a contributing factor. For example, a 2020 study into international differences in ovarian cancer treatment suggested that patients in the UK may be less likely to receive extensive or ultra-radical surgery, with less willingness from UK surgeons to perform ultra-radical procedures, who reported lack of intensive care beds as a barrier.  

Variation can also be linked to a stretched cancer workforce. Without time to familiarise themselves with the new treatments available and opportunities to refer patients to clinical trials, some clinicians cannot pass this information on to patients. Implementing new innovations in treatment is time consuming, which can create challenges when staff capacity is already stretched by increasing demand and workforce shortages. 

Quality improvement programmes, such as Getting It Right First Time (GIRFT), are a helpful way to spot problems and implement best practice to ensure an optimum and efficient health service. However, because of problems with data access and ongoing NHS resource and investment constraints, these programmes currently aren’t having as much impact as they could be. This means that a problem in a particular hospital (e.g., insufficient equipment) may not be picked up as quickly as possible, and patients’ treatment experience may be affected as a consequence. These issues then also make it harder for hospitals to implement the ‘best practice’ recommendations set out by the quality improvement programmes. 

But what can we do to address the unjustified disparities in the treatment people can access? 

What needs to happen next? 

With many decades of research and innovation behind us, we know that we can turn the tide on cancer. We can build on progress that’s already been made and go further to reduce unwarranted variation in access to cancer treatments. It is now time for the UK Government to act. 

Firstly, to understand the drivers of treatment variation, we need more reliable and detailed data collection. Once we can see why there is variation, we can develop and implement the most effective interventions to address the problems.  

With improvements to data, we can make better use of initiatives to improve quality of care, such as the national cancer audits, to spot areas of concern and examples of best practice. With a clear picture of ‘what good looks like’, steps can be taken to reduce unwarranted variation and address inequalities in cancer care provision. This will become even more important as new innovative treatments continue to be adopted into the NHS, to make sure uptake is swift and equitable, benefitting all patients with cancer across the UK, and not widening inequalities in treatment.  

Fortunately, there are already some initiatives helping to gather the next piece of the data puzzle – for example, the International Cancer Benchmarking Partnership (ICBP). The ICBP is a unique and innovative collaboration that brings together clinicians, policymakers, researchers and data experts across the world. The ICBP produces high quality research to help identify best international practice, and generate insights needed for policy and practice change. We hope that upcoming ICBP research on international treatment differences will help us to enable optimisation of cancer services and improvement of outcomes for cancer patients in the UK. 

We believe that all cancer patients deserve timely access to high quality, effective care. And that’s why we have written Longer, better lives: A manifesto for cancer research and care. Ahead of the next general election, we are calling for the UK Government and NHS England to implement a new 10-year cancer strategy for England that includes a strategic approach to addressing unwarranted variation in access to treatment.  

If we work together, we can beat cancer.