The need
Catching cancer earlier is one of the most effective ways to improve survival. It means patients can receive treatment sooner, making it more likely the cancer can be cured.
Cancer survival has been improving in the UK, but it still lags behind comparable countries. The NHS Long Term Plan aims to save thousands more lives each year by dramatically improving how and when cancer is detected and treated. It sets the ambition that, by 2028, 75% of people with cancer will be diagnosed at an early stage (up from just over 50%).
This Collection explores recent NIHR-supported research into the early detection of cancer. Some studies address the needs of specific groups, others look at new approaches to screening. The Collection brings together messages from research that has been highlighted in accessible summaries of evidence - NIHR Alerts - over the past year.
“Identifying cancer early is often critical to increasing the chances of improved management and better outcomes for patients. This is all the more important following the pandemic. But we know that there are considerable knowledge gaps in this field. Therefore, this research is timely and vital and will help ensure that patients have equitable access to evidence-informed cancer screening programmes underpinned by the highest technological advancements at the earliest point possible.”
Kamal Mahtani, GP & Associate Professor, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford
Addressing the needs of different groups to improve cancer screening
Screening is key to detecting cancer early. Screening looks for cancer in healthy people before they have any symptoms. To be most effective, however, the service needs to be taken up by all eligible people. Overall uptake of cancer screening has been a concern for some time. Another concern is the low uptake among disadvantaged groups, such as those with low income, mental illness, or from different ethnic groups.
People with a mental illness are more likely than others to die from cancer. Two recent studies showed that people with a mental illness are also much less likely (around 24% less likely) to receive cancer screening than the general population. First, a large international review included more than 4.5 million people. It suggested the screening gap was one explanation for why people with a mental illness tended to die 15-20 years earlier than others. The screening gap was particularly high for women with schizophrenia, but was also present for people with common mood disorders such as depression.
The second study focused on breast cancer screening. The research was carried out in Northern Ireland and included nearly 60,000 women. A woman who was not married, or who lived in a socially deprived or urban area was less likely to attend screening. After taking these factors into account, women with mental health problems were still less likely than others to attend screening.
Both studies provide evidence of the impact mental illness can have in reducing the uptake of cancer screening among people with mental illness. They highlight the need for action to close the screening gap and call for focused efforts to address these inequalities.
“Diagnosis and treatment of all physical conditions in people with mental health problems is difficult. I'm pleased to see it singled out for attention here.”
Jennifer Bostock, Public Contributor, Kent
People from some ethnic groups are also less likely than others to attend cancer screening appointments. South Asian women are less likely than any other ethnic group in the UK to attend breast cancer screening. When barriers to healthcare access are studied, these women tend to be considered as a single group. This means there is little research into barriers that specifically affect women of Pakistani, Bangladeshi or Indian backgrounds. Previous research has also failed to consider socioeconomic status, or has required participants to speak English. This means the experiences of the most under-served individuals have not been recorded and considered.
A recent study explored British-Pakistani women’s low attendance at breast screening. The women faced cultural and language barriers. For example, many were not aware that screening takes place in an all-female environment. The researchers strongly recommend that this information is included in all invitations to breast screening.
People living in deprived areas may be less able to take part in screening, yet may need it most. Making it easy for people to access screening can help improve uptake. Tests carried out on mobile units parked in supermarket car parks were a popular and effective way to check the lungs of current and former smokers. The study involved 2,541 people and was carried out in three deprived areas of Manchester. It helped demonstrate the benefit of a programme to check lung health. There are concerns that a UK screening programme would be too expensive and would not reach those who need it most. However, the Manchester project identified more cancers in this at-risk group, plus a range of other health conditions. This included the common breathing disorder, chronic obstructive pulmonary disease (COPD) which is a risk factor for lung cancer. The findings of the Manchester study were so encouraging that the programme has been extended to other areas in England.
“It is a missed opportunity that some people are less likely to take part in screening programmes. If the Government is serious about their levelling up agenda, they must fund and roll out targeted interventions to increase informed uptake in disadvantaged groups."
Genevieve Edwards, Chief Executive of Bowel Cancer UK
Innovative ways to improve early detection of cancer
New tests
GPs refer people to specialists if they suspect cancer. A recent study showed that patients of GPs who make the most urgent referrals are more likely to have their cancer diagnosed at an early stage. But GPs are in a difficult position. People with symptoms want to be referred, but hospital services are overloaded. New tests could ensure that GPs refer those most likely to have cancer.
Blood tests are a mainstay of medicine, with GPs ordering millions per year. Two recent research projects have suggested that standard blood tests can offer new ways to identify people who might have cancer. The first study included almost 300,000 patients who had blood tests at their GP surgery. It found that a routine blood test could help find several cancers early in men. This adds to previous knowledge that high levels of platelets – cells in the blood that help stop bleeding – can be a sign of cancer. The researchers found that even slightly raised levels of platelets may indicate cancer in men.
The second study showed a blood test could give women a personalised risk assessment for ovarian cancer. The test, for women with abdominal symptoms such as pain or bloating, was carried out at GPs’ surgeries. The study included data from 50,000 women. It found the test was most accurate in those aged over 50. As well as identifying women at risk of ovarian cancer, the test also picked up the risk of other cancers, including those of the pancreas and lung.
Both these studies provide information that could guide GPs' decisions on the need for further investigation or urgent referral to specialists.
Womb cancer is the fourth most common cancer among women in the UK. Current tests are expensive, invasive, or lack accuracy. Simple, effective new ways to detect womb cancer are needed. Researchers found that a new, low-cost blood test may be the answer. This test gave almost instant results and could accurately detect womb cancer, as well as changes that could lead to cancer (pre-cancerous growths) in the womb.
Detecting pre-cancerous changes is a well-known approach to catching cancer early. Identifying new methods to detect these changes could help GPs identify people in need of urgent referral. An innovative, swallowable sponge can detect a pre-cancerous throat condition called Barrett’s oesophagus in people with heartburn. This was the finding from a large trial including more than 13,000 people. At present, GPs have no easy way of checking for Barrett’s oesophagus, so they refer many people who complain of heartburn for an endoscopy. This simple new technique could serve as a screening tool for early oesophageal cancer. It could allow GPs to screen people with heartburn and identify those most in need of further tests and possible treatment.
These studies highlight promising new tests that could help identify cancer early. Another approach is to consider changes to existing national screening programmes.
“This research is important because these are new tests, and also because of where the tests are performed. Patients value being able to have diagnosed or detected via a test their GP can do. This approach presumably will save the NHS money especially when COVID is leading to such a backlog of hospital outpatient appointments.”
Jennifer Bostock, Public Contributor, Kent
"The average full time GP will see around 8 people with new cancer diagnoses per year. That same GP will have thousands of consultations with people who have potential cancer symptoms. Stretched primary care services need support, backed by research, particularly given the challenges of the COVID-19 pandemic on health services in the UK and around the world."
Thomas Round, GP and NIHR Doctoral Research Fellow, King’s College London
"Speaking as a patient and as a member of the public, the examples given of outcomes and impact of trials, will, I hope, encourage more people to seek medical help as soon as they notice anything untoward, and to share responsibility for their own wellbeing."
Ann Whitfield, Public Contributor, Nottingham
Alterations to existing screening programmes
The NHS Bowel Cancer Screening Programme aims to find warning signs in people aged 56 or over. They are invited to take a faecal immunochemical test (FIT) every two years. FIT measures blood in poo (faeces) and people with blood above a certain level are invited for further tests. Recent research found that the FIT threshold for further investigation is set at a point that may miss more than half of bowel cancer cases. This highlights a need to improve the NHS screening programme. The researchers suggest new screening pathways based on the amount of blood found in faeces.
“Due to a growing, ageing population and efforts to increase early diagnosis, more people will need to be sent for investigations for bowel cancer. It is vital the NHS has the capacity to undertake more tests and implement new evidence-based interventions swiftly so patients can benefit from them.”
Genevieve Edwards, Chief Executive of Bowel Cancer UK
Around 7,600 women in their 40s are diagnosed with breast cancer every year in the UK. But the NHS Breast Screening Programme only invites women aged 50 and over. There is long-standing debate about the possible benefits and harms of screening younger women. To help resolve the issue, a long-term study began in the 1990s to look at the impact of annual breast screening for women in their 40s. Women offered screening were 25% less likely to die of breast cancer in the first 10 years in the trial. Approximately one death was prevented for 1,000 women screened. The study found no greater risk of over-diagnosis among these younger women. This suggests that extending the screening programme to include women in their 40s may save lives and would not increase its harms.
“The extensive work by NIHR could have a considerable impact on healthcare and patient outcomes. Multiple recent studies evaluate an array of mechanisms to facilitate earlier diagnosis and reduced population cancer mortality. The approaches are innovative and achievable and could bring significant benefit to patients.
Co-production in research involving the NIHR, the National Institute for Health and Care Excellence (NICE), the NHS Breast Screening Programme and the NHS is valuable. It is a clear demonstration of the ambition to make the NHS Long Term Plan a reality.”
Suzanne Halliday, Advanced Nurse Practitioner in Breast Care, Cancer Pathway Manager, Surrey and Sussex Cancer Alliance, NICE Fellow (2020-2023)
Conclusion
More people are surviving cancer than ever before, but even more lives could be saved by catching cancers earlier. This Collection provides examples of recently published NIHR research that explores opportunities to improve the early detection of cancer. Addressing the needs of specific groups, new tests, or considering changes to current national screening programmes are all important. These studies highlight some of the promising new findings in the drive to find more cancers at an early stage.
“This NIHR Collection on earlier cancer diagnosis could have a significant real world impact. With 1 in 2 of us developing cancer in our lifetimes it is crucial to improve both screening uptake and symptomatic pathways. Exciting new technologies in screening and early diagnosis exist. Diagnostic decision support, and new ways of triaging have potential. Continued efforts are needed to raise awareness of potential cancer symptoms. We need to reduce inequalities, and invest in diagnostic capacity and access across primary and secondary care."
Thomas Round, GP and NIHR Doctoral Research Fellow, King’s College London
How to cite this Collection: NIHR Evidence: Catching cancer early: how research could help us improve; November 2021; doi: 10.3310/collection_48071
Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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