Cancer screening

There are three cancer screening programmes for adults in England delivered by the NHS:

  • Cervical screening – offered every 3 years to women aged 26-49 and every 5 years to women aged 50-64. Previously known as a “smear test” this involves taking samples of cells from the cervix.
  • Breast cancer screening – offered to women aged 50-70, though trials are in place to investigate extending this offer to women aged 47-73. This uses an x-ray test called a mammogram to identify early cancers that are too small to be picked up by examination.
  • Bowel cancer screening – a home testing kit is offered to both men and women aged 60-74, in some areas bowel scope screening is being offered to those aged 55. This involves a home-testing kit using a series of stool samples.

What do we know?

Screening programmes are designed to test for signs of a disease among people without symptoms. They can often detect diseases early, allowing treatment to be given at a stage when it is more likely to be effective at improving outcomes and lowering the risk of death.

In order for screening programmes to be effective they must meet a number of criteria relating to the disease itself (e.g. whether there is a detectable early stage), to the test proposed (e.g. whether the test is accurate or acceptable to the public) and to the treatment available (e.g. whether there is treatment available for early stage of disease which reduces death or disability). In addition, the benefits of the programme must outweigh the harms and costs of the procedures.

There are a number of cancers for which the current evidence shows that screening programmes would not be effective e.g. prostate cancer, bladder cancer and ovarian cancer.

Uptake of screening

While uptake of breast screening nationally is meeting the target of 70% and remains relatively high cervical screening coverage is decreasing year on year from >80% in 2004 to <75% in 2014. Bowel screening uptake, conversely, has historically been very poor but has increased in recent years on a national level.

There are many factors that affect people’s willingness to take part in screening; ranging from whether they aware or believe that they are at risk of cancer, to how much they know about the effects of cancer, to how acceptable the test is to them. Improving uptake needs to take into account all of these factors.

Two local studies have identified that a key problem is ensuring invitations for screening are understood by the population and the fact that the registered addresses of the population change when people move. There is a high rate of population churn in Slough meaning that people may have moved before receiving their invitation to screening.

A local community development research programme in Reading highlighted barriers to uptake of cervical screening among younger women, including community perceptions that you have to be married before you can attend screening.

Facts, figures, trends

Over 2014-15, 65.4% of women aged 50 to 70 in Slough had attended breast screening in the previous 3 years. This is an improvement on the figure for the previous year (62.6%) though is significantly worse than the national figure of 72.2% and is also below the government’s target of 70% coverage (Figure 1).

Figure 1. Females aged 50-70 screened for breast cancer in the last 3 years (Slough CCG)

Figure1

Over 2014-15, 68.3% of women aged 25 to 64 in Slough were screened for cervical cancer within the previous age-appropriate period (3.5 years for those aged 25-49; 5.5 years for those aged 50-64). This represents 26,762 women attending for cervical screening during this time period. This figure is slightly lower than that of the previous year and significantly worse than the national figure of 74.2%.

Figure 2. Females aged 25-64 screened for cervical cancer within 3.5-5.5 years (Slough CCG)

Figure 2

 In 2014/15, 6,656 eligible people in Slough CCG were sent an invitation to receive a Faecal Occult Blood Test (FOBt) home-testing kit. 41% took up this invitation and received an adequate screening outcome, which is lower than the Thames Valley average of 57.7%. This low uptake rate is particularly important as, of those screened in Slough, 4.6% had an abnormal test result, compared to only 1.9% overall in the Thames Valley region.

Figure . People aged 60-69 screened for bowel cancer in the last 2.5 years (Slough CCG)

Figure 3

National and local strategies (current best practices)

The UK National Screening committee (NSC) has responsibility to advise the government and the NHS about all aspects of screening and support the implementation of screening programmes. The NSC reviews the evidence for effectiveness of various screening programmes according to defined criteria.

The new National Cancer Strategy for England (2015-2020) published by the Independent Cancer Taskforce, led by Cancer Research UK’s Chief Executive, replaces the 2011 strategy and includes several recommendations relating to cancer screning including:

  • Recommendation 10: recommends that the FIT test should replace the gFOBt (see further explanation below) and that NHS England should incentivise GPs to take responsibility for increasing uptake of bowel screening with an ambition of achieving 75% uptake in all CCGs by 2020.
  • Recommendation 11: recommends roll-out of HPV testing into the cervical screening programme, with an aim of full national coverage by 2020. The NSC should also regularly review whether the upper age limit for cervical screening remains appropriate.
  • Recommendation 12: discusses the need for new screening teams within both Public Health England and NHS England to drive quality improvements and implementation of new services.
  • Recommendation 13: recommends that the NSC should examine the evidence for lung and ovarian cancer screening, and that PHE should be ready to pilot lung or ovarian screening within 12 months of receiving positive results from studies currently under way.

Local

The Slough Macmillan Bowel Screening Improvement Programme was established in recognition of the poor uptake of bowel screening in Slough, and particularly to improve uptake in “hard to reach” groups specifically males, those from deprived communities and those from black and minority ethnic group (BME) communities.

The project aims to first explore attitudes and barriers to screening in these communities and then to focus interventions according to these needs.

In addition to the screening improvement programme, there are anticipated changes to the bowel screening programme locally, due to national redesign. These changes include:

  • Replacement of the current bowel screening test kit (gFOBt) to a new Faecal Immunochemical Test (FIT) which is easier to undertake as only requires a single faecal sample (as opposed to three with the old test). The new test also provides better accuracy. The FIT test has been approved by the NSC and is expected to be rolled out in Slough by 2017.
  • One-off screening using a bowel scope for all at age 55 is currently being piloted across England and is due to be rolled out first in the Royal Berkshire Hospital in December 2016 and then at Wexham Park Hospital in 2017.

What is this telling us?

Uptake of all three cancer screening programmes is poor in Slough compared to the national uptake, though bowel screening uptake is the worst. This is particularly important given that those screened in Slough are more likely to have a positive result of cancer.

Recognition of this poor uptake in bowel screening has seen action taken in terms of the establishment of the joint Macmillan/CCG project. Additional promotional work on a national level through Cancer Research UK is also underway. The results of these efforts will not be apparent until data for uptake over 2016 is gathered.

What are the service gaps/unmet needs?

Though work is underway to improve uptake of bowel screening, as the poorest performing programme currently, there continues to be a reduction in uptake of cervical screening in young women which should be considered next.

What are the key inequalities?

As with the pattern of use of other preventative health services, uptake of cancer screening is lower within those from lower socioeconomic groups than those who are less deprived. There are also differences in screening uptake according to age, with younger groups tending to be less likely to take up and offer of screening. People with learning disability have also been identified as a group for whom screening coverage is poor (Source: Cancer Research UK).

Uptake of cancer screening is generally lower in people from BME groups than the white population (Source: Macmillan Rich Picture). Sexuality is also a source of health inequality in screening uptake with those who identify as lesbian or transgender men being much less likely to take up cervical screening ¬¬(Source: NCIN Evidence on Cancer Inequalities)

Recommendations for consideration by other key organisations:

  • To engage in the partnership working between Macmillan and the NHS to improve bowel screening uptake.
  • To continue and expand the good work on improving bowel screening uptake to next work on the other cancer screening programmes.

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