Many people first encounter the Faecal Immunochemical Test (FIT) when they’re invited to take part in bowel screening. It’s a way to check poo samples for tiny traces of blood that could be a sign of bowel cancer.

That capability makes FITs useful in multiple contexts. GPs can also request them for patients presenting with bowel cancer symptoms. In these cases, the results can help determine the risk that a person with symptoms actually has bowel cancer, so doctors know when to order further tests like colonoscopies.

FITs have played a big part in improving how the NHS diagnoses bowel cancer, and they’re just one example of risk stratification in the cancer pathway. Risk stratification involves assigning individuals to groups based on their level of risk (of either having cancer or developing cancer in the future) and determining next steps based on this information. It has roles to play in preventing, diagnosing and treating all types of cancer, and has the potential to drive better outcomes for many patients.  

Now, with the National Cancer Plan for England on the horizon, it’s vital we make sure the NHS in England can get risk stratification right. To support this, we have been convening academics, policymakers, clinicians and health system leaders to understand exactly what we need to make this happen. In this article, we’ll be bringing together what we’ve learned and outlining the three shifts the Government needs to support to make risk stratification work best for everyone.

The right care at the right time

First, though, it’s important to explain exactly what makes risk stratification so powerful. The FIT testing example above shows how the approach can be used to triage individuals with cancer symptoms, but it can also be deployed across other parts of the cancer pathway.  

For example, proven risk assessment models that determine an individual’s risk based on data such as genetic information, lifestyle factors and test results can be used to develop more targeted screening programmes. Those identified as at a higher risk of developing cancer can be offered more frequent or intensive screening, while those at a lower risk can undergo less frequent screening and avoid unnecessary procedures.  

Although this means individuals will receive different care, it helps make sure each person can receive the care that’s right for them, tailored to their risk.  

This is already happening with lung cancer screening, which is currently in the process of being rolled out nationally. Eligible individuals must first complete a risk assessment with their health professional. Those identified at a higher risk of lung cancer are then offered a low-dose CT scan of the lungs.  

These moves away from a one-size-fits-all approach make it possible for healthcare professionals to identify individuals at a higher risk more proactively, which could help diagnose more cases of cancer earlier, when treatment outcomes are usually better. 

At the same time, risk stratification could also help the health system allocate resources more effectively by making sure people get the right care at the right time. This is important – our landmark Cancer in the UK report revealed that in the last 50 years, the proportion of people being diagnosed with cancer in Great Britain has increased by almost half, illustrating the increasing strain the NHS is under. While the aim of any risk stratification must be to provide better management and care of people with cancer, it’s certainly helpful if it can also reduce demand on the health system.  

And this might just be the beginning. Our understanding of cancer risk is continually evolving, as are our digital and data capabilities. In the coming years, we will likely see more risk-based approaches and tools being developed. So, as well as making the most of existing evidence-based risk stratification tools, the health system, policymakers and regulators must be prepared to evaluate and implement new tools equitably.  

With that in mind, these are the three shifts the UK Government should make to get risk stratification right for cancer. 

Shift 1: Take an agile approach to evidence–based implementation  

No risk stratification tool can be fully rolled out without a robust and comprehensive evidence base. But that’s not the only important consideration. Even when risk tools do have a strong evidence base, the process for deciding which ones to take forward to pilot, and how, is unclear, delaying their adoption into cancer pathways. With an increasing number of risk tools emerging, we urgently need a scalable system for prioritising and testing them. 

To address this, the Government should work with regulators, Integrated Care Boards, Health Innovation Networks and Cancer Alliances to develop a coordinated approach to prioritise which tools are evaluated and when, with frameworks outlining the amount and types of evidence needed to pilot a tool. It’s also important to ensure these pilots are properly funded.  

Equally, to make the process more efficient and effective, the Government should empower health systems to take an agile approach to testing new risk stratification tools.  

Agility is key to bridging the gap between rigorous evidence collection and timely implementation, particularly for tools that are promising but still need a stronger evidence base.  

For example, trialling a promising risk stratification approach at a local level before expanding its use nationally allows implementation and evidence generation to happen simultaneously. A learning health system is central to this agile approach, enabling insights from tools currently in use, like FIT, to continuously inform better use in the future.  

Overall, this more agile approach would make sure that patients and clinicians can benefit from effective, evidence-based risk tools sooner. 

Shift 2: Strengthen digital infrastructure

The development and delivery of many risk stratification approaches rely on adequate digital infrastructure and governance processes. This is especially the case when risk stratification involves the integration of multiple large datasets, such as GP records and screening data, to build an accurate picture of cancer risk.  

With a health system like the NHS, population-wide data should be a national asset. However, data access and linkage across the system is fragmented, resulting in a disconnect between researchers and the healthcare system.  

Screening research is one area where this poses a barrier, as screening data has been historically siloed and inaccessible. A digital system or database that works better for screening research could help to find new ways to do risk-stratified screening, enabling more efficient approaches to early detection. 

Investment into digital infrastructure that supports data access and linkage is essential to driving innovative approaches to cancer care and is key to realising the shift ‘from analogue to digital’ in the Government’s recent 10 Year Health Plan. The commitment to deliver a Health Data Research Service (HDRS) in the 10 Year Health Plan and Life Sciences Sector Plan is encouraging, as it brings us closer to leveraging the power of NHS data to drive new tools and technologies. Similarly, the Life Sciences Sector Plan’s commitment to enact policy and legislative change to speed up access to health data for research is welcome and necessary. Now, the Government must work with relevant stakeholders, including the public, to design the HDRS and ensure it delivers for cancer research while maintaining the support of patients and the public. 

Shift 3: Address barriers to equity   

Getting risk stratification tools rigorously evaluated and ready for adoption is only part of the challenge. It’s just as crucial to ensure these tools are implemented equitably. Some areas of England lag behind due to the lack of guidance on the use of new tools, which, coupled with immense resource constraints, fuels a postcode lottery in service provision.  

That’s why it’s vital that the National Cancer Plan prioritises the equitable and national rollout of proven risk stratification approaches. The Department of Health and Social Care should work with national and local delivery teams for screening and cancer care, Cancer Alliances and Health Innovation Networks to support all primary care professionals to implement and use existing proven risk stratification tools, while continuing to evaluate them where appropriate. 

It’s also important that risk stratification approaches are developed equitably and address the needs of different population groups. As part of that, tools should be designed in a way that does not complicate the diagnostic pathway for patients, which could affect uptake. Requiring patients to complete extra steps before accessing screening, for instance, could inadvertently reduce levels of participation and risk widening inequalities.  

Involving patients and healthcare professionals in the design of these approaches is critical to achieving equitable uptake, and ultimately, gives everyone the best chance of beating cancer. 

Looking to the future  

Risk stratification presents an exciting opportunity to optimise cancer pathways, ensuring patients receive the right care for them at the right time – and it’s only one of many types of innovations on the horizon that could improve cancer outcomes and help people live longer, better lives.  

For example, liquid biopsies are showing promise for personalising care for specific patients through a simple, non-invasive blood test. Meanwhile, the use of AI-based tools offers valuable opportunities in the short term to improve efficiency within services. Over the longer term, AI’s ability to find patterns in large complex datasets could also unleash opportunities to better predict, detect, diagnose and treat cancer.  

While these developments are exciting, translating their potential to impact depends on the health system and workforce being prepared to embrace and adopt proven innovations at scale.  

The upcoming National Cancer Plan for England is chance for the Government to lay these foundations for life-saving innovations, and in doing so, help to deliver a turning point for cancer.