5 Saving lives: cancer

Target: to reduce the death rate from cancer in people under 75 years by at least a fifth by 2010 - saving up to 100,000 livesin total

5.1 Cancer is a word that produces a feeling of dread - a disease which can attack most parts of the body and then spread to others, and a disease which can, by returning, sometimes after long intervals, cast its shadow over the future.

'cancer is one of the biggest challenges
facing us'

5.2 In reality cancer is many different diseases affecting different organs and tissues of the body. Some types of cancer are almost completely preventable but they are not all being prevented. Some types of cancer if caught early can be cured, yet not all are being cured. Some people can be helped to survive for much longer with serious forms of cancer but many are not surviving as long as they could. Ensuring that cancer is tackled as never before is one of the biggest challenges facing us.

5.3 Cancer in our country is amongst the three leading causes of death at all ages except for pre-school age children. The most common killers are lung, breast, colorectal and prostate cancer which together account for about 62,000 deaths each year.

5.4 Overall the risk of developing cancer appears to be increasing and there are now approximately 200,000 new cases each year. On the other hand the rate of death in the population from cancer has been falling for the last decade, though there have been strikingly different trends in death rates for individual cancers in different groups.

Fig 5.1 Change in annual cancer death rates: some improving, some worsening

'Cancer attacks the population unevenly'

5.5 Explanations for these death rate trends differ. In the case of lung cancer, for example, death rates differ by gender, reflecting the fact that men took up smoking sooner than women and have also reduced their smoking rates at an earlier stage. Other cancer death rates in the population have fallen because treatment has become more effective: for example, in testicular cancer where death rates have reduced by nearly 75 per cent in the last twenty years even though the rate of new cases has grown substantially.

5.6 Cancer also attacks the population unevenly. For example, among working age men unskilled workers are twice as likely to die from cancer as professionals. There is inequality between one part of the country and another. For example women in the North West of England have a 33 per cent greater chance of suffering from cervical cancer than the national average. There is inequality between people of different ethnic origins, where for example women born in the Caribbean are about 25 per cent less likely to die from breast cancer than other women living in this country. And there is inequality between the sexes, with women more likely than men to contract melanoma skin cancer but men more likely to die from it.

How do we compare?

5.7 Overall death rates from cancer in England for people under the age of 65 years are slightly better than the average for all European Union countries. But that conceals an important difference between genders: while death rates among men are better than average, women have substantially worse than average rates especially for breast and cervical cancers.

Fig 5.2 Death rates from all cancers: England better than the Western Europe average

Fig 5.3 Death rates from breast cancer: UK amongst the worst in Western Europe

Fig 5.4 Death rates from cervical cancer: English women amongst the worst in Western Europe

5.8 Mortality rates in our country may be high for some cancers even though these cancers may not occur more commonly in this country. This suggests that the chances of surviving after diagnosis may be poorer here than in some other countries. For many of the main causes of cancer death - for example, lung, colorectal and breast - survival in England and Wales is lower than in the United States and lower than the average for the European Union.

Fig 5.5 Cancer survival: England and Wales generally lag behind Europe and USA

'people in more deprived areas tend to have
lower survival rates'

5.9 There is no single explanation for these figures but part of the difference may reflect the fact that there are cancer services in other countries which are better than we are in this country at treating cancer. Even in England and Wales people in more deprived areas tend to have lower survival rates, in part reflecting the fact that they may find it harder to gain access to the services available. If all patients shared the survival rates of the best off, there would have been more than 12,700 fewer cancer deaths in England and Wales among those diagnosed between 1986 and 1990.

Fig 5.6 Survival is better in affluent than in deprived areas

'a third of all cancer deaths are caused by smoking'

Causes

5.10 Cancer occurs when the normal process of cell growth in the body goes wrong. Why this happens is not fully understood, but the causes are known to be complex. The trigger to start the process off is different for different cancers and different people. Sometimes factors which we cannot control, such as our genes, have a big part to play. Research has shown that there are several major risk factors:

• Tobacco smoking causes most lung cancer. It is also implicated in many other types of cancer. Overall about a third of all cancer deaths are caused by smoking.

• Diet accounts for about a quarter of cancer deaths in this country (as compared to about a third in developed countries as a whole). Low levels of consumption of fruit and vegetables are linked with an increased risk of colorectal and stomach cancer, and possibly some other cancers. In some cases heavy alcohol consumption is associated with a 3- to 15-fold extra risk. Those who also smoke are at even higher risk of several of these cancers.

• Exposure to infections appears to cause some cancers, and understanding of this cause is growing all the time. For instance, the hepatitis B and C viruses are associated with an increased risk of liver cancer; and the human papilloma virus, linked to most cervical cancer, which is associated with about 3,000 cases and more than 1,000 deaths from cancer each year. Hepatitis B may be transferred from mother to child at birth, and both hepatitis B and the human papilloma virus may be sexually transmitted and then infect, respectively, the liver or the cells which line the cervix. In addition stomach cancer which accounts for about 10,000 cases and 6,000 deaths each year may in many cases be associated with certain bacterial infections, particularly amongst those who grow up in disadvantaged areas.

• Exposure to chemicals can induce cancer. For instance asbestos fibres may lodge in the chest and may silently promote the development of several forms of cancer as well as other diseases. Approximately 3,000 deaths each year are thought to be caused in this way by asbestos exposure in Great Britain. Similarly dyes used in certain industries may increase the risk of bladder cancer

• Pollutants in the environment may cause cancer if inhaled or swallowed. So may radiation, whether through exposure to radon gas in certain homes or excessive sunlight. Getting sunburnt in childhood may result in an increased risk of skin cancer which accounts for nearly 2,000 deaths each year.

'Pollutants in the environment may cause cancer'

Action: reducing risk and staying healthy

5.11 By taking effective action to promote healthier behaviour and reduce exposure to risk we can make a huge impact on cancer. Two changes above all would have the greatest impact: a reduction of tobacco smoking and adoption of a diet rich in cereals and fruit and vegetables. These two steps alone could account for about a ten per cent reduction in cancer death rates in those under 75 years by 2010. Other measures too will promote health and protect people from cancer. For example, by avoiding excessive exposure to sunlight people can reduce their risk of skin cancer. In particular we must ensure that young children are not exposed to too much sun.

5.12 Our programme of health measures will contribute towards combating cancer:

• the White Paper Smoking Kills, published in December 1998, commits us to a new public education campaign, a network
  of smoking cessation clinics and the promotion of nicotine replacement therapy as well as a range of other detailed measures

• the regulations we introduced on 17 June set out our intention to ban tobacco advertising from 10 December 1999

• through our Healthy Schools programme, healthy living centres and elsewhere, the promotion of information on healthy diets, including cooking skills; and more effective advice for people on maintaining appropriate body weight.

5.13 Vaccines to prevent cancer already exist and are in use. For example we are running a programme to provide hepatitis B vaccine for those at increased risk of acquiring the infection. Looking to the future, more cancer vaccines are in prospect, for instance against cervical cancer in women. As we better understand the role of infections in malignant disease so, looking ten years or so into the future, we may be able to develop vaccines for their prevention. Also, in the longer term, we should be able to tailor treatments to the genetic characteristics of tumours.

Action: early recognition

5.14 Pre-symptomatic tests through screening can detect cancer either in its very first stages or, as with cervical screening, even before the disease develops. The NHS has been providing screening programmes for breast and cervical cancer since the late 1980s and in general they have been a considerable success. The cervical screening programme alone prevents up to 3,900 cases of cancer each year in the UK.

5.15 Regular screening of women aged between 50-64 years for breast cancer will eventually save up to an estimated 1,250 lives each year in the UK. And we are currently undertaking pilot studies to assess the feasibility of routinely inviting women aged 65-69 years for breast screening. These pilots are due to be completed in 2000.

5.16 However, screening does not provide a guarantee that cancerous or pre-cancerous cells will be found if they are present. And, although they have proved to be effective, screening programmes have not been as reliable as they should have been. We have taken far-reaching action to improve the quality of the service. We are reviewing the possibility of using automated techniques in the cervical screening programme. In addition we are working to ensure that women at risk of cancer take up screening invitations as we know that some groups, such as Bangladeshi women, have been reluctant to come forward. We will publish our strategy on breast and cervical screening later this year.

5.17 So we are taking action to:

• Stop cervical screening in those laboratories which screen fewer than the recommended 15,000 smears a year and do not achieve expected results

• Require all laboratories undertaking cervical screening to apply for external accreditation

• Ensure that all health authorities should achieve 80 per cent coverage rates for cervical screening by March 2002

• Make clear that all health authorities must achieve three-yearly intervals for breast screening by March 2000.

5.18 However just because a simple and reliable test exists it does not follow that it should be offered to all healthy people to see whether they have the early stages of cancer. Early detection in itself does not prolong survival: but if a safe and effective treatment is available which can be started before symptoms would otherwise have appeared then screening can lead to a better chance of cure or improved life expectancy.

5.19 To give expert, evidence-based advice on which screening programmes should be introduced, a National Screening Committee was established. In addition to the breast and cervical cancer screening programmes which are now population-wide, pilot studies are currently being undertaken to assess the feasibility of screening for colorectal cancer. The results will be available in the year 2002. The National Screening Committee has advised that on present evidence population screening for prostate cancer would not be justified. This is being kept under review.

5.20 Besides this, our Healthy Citizens initiative will help. NHS Direct will provide an immediate advice line for people worried that they might have cancer, while our Expert Patients programme will help to ensure that people with the disease are best able to manage it, giving the best hope of a good outcome.

Action: more effective treatment

5.21 In the middle of this century the chances of surviving cancer were low and showed little improvement from one year to the next. Over the last few decades, however, there have been some striking changes. In one form of childhood cancer - acute lymphoblastic leukaemia - the chances of surviving for at least five years were less than ten per cent over 30 years ago. By the late 1980s/early 1990s they had improved to over 70 per cent.

Fig 5.7 Some spectacular breakthroughs: five year survival rates for acute lymphoblastic leukaemia in children

5.22 Between the 1960s and the 1970s survival from Hodgkin's disease nearly doubled from 30 per cent to about 55 per cent. Similarly between the 1970s and the late 1980s/early 1990s survival improved from nearly 50 per cent to more than 70 per cent for melanoma skin cancer in men and from nearly 30 per cent to nearly 40 per cent for cancer of the large bowel
in women.

5.23 For other forms of cancer there has been less progress. Cancer of the prostate and of the lung, for example, have shown almost no improvement in recent years.

'tackling cancer means high quality, specialist services
for everyone'

5.24 Effectively tackling the problem of cancer means achieving consistently high quality, specialist services for patients, with their carers and families, available to everyone. It also means providing special support, for example, to black and ethnic minorities to encourage their participation in managing
their condition.

5.25 On 20 May 1999 the Prime Minister hosted a summit meeting on cancer which brought together the country's top cancer experts - patient representatives, policy-makers and health professionals - to take stock of prevention and treatment services in this country, and to define the new challenges which must be met in those services in the future.

5.26 It was recognised that there were many excellent aspects of cancer services in Britain but that overall there was much that needed
to be improved if patients in all parts of the country were to benefit from the high quality of care which could be achieved in the best centres.

5.27 As a result of that meeting a five-point action plan was published to focus attention on the essential changes that were required:

'develop and implement consistent national standards'

Integrated action

5.28 In our fight against cancer we can be successful only if everyone recognises that:

• a fundamental attack is needed on the risk factors which cause cancer, concentrating mainly on sustained reductions in smoking and improvements in diet, in which action at all levels - individual, local, Government - is co-ordinated to secure the maximum benefit

• efforts to combat the fragmentation and the variable quality of cancer treatment services, which have accounted for our past record of unequal survival patterns, must be stepped up through the five-point action plan outlined above, in order to give everyone the best chance of beating the disease

• a new strategic approach must be taken to research which recognises the links between cancer prevention and treatment, and which ensures that the practice of cancer care does not lag behind the science of cancer as it so often has in the past

• partnerships with cancer charities and other non-Governmental organisations involved in cancer treatment and research are a cornerstone of a high-quality approach to combating cancer.

5.29 We will develop and implement consistent national standards and develop the workforce strategy necessary to deliver high quality care. We will work with a range of organisations to look at how better to plan and share research; to provide the support and information necessary to enable individuals to participate fully in prevention and treatment decisions, and to set us on course to reduce the death rate from cancer and reduce by about 100,000 the premature deaths from this disease by 2010.

5.30 We recognise that these improvements will mean extra effort. Some of the changes we want to see will not cost money. Better communication, better organisation and changes in the way people tackle problems can be achieved without significant extra resource. But there are some areas where we need to invest for success. As well as the extra money which we are putting into cancer through the Modernisation Fund, the New Opportunities Fund is also contributing £150 million over three years across the United Kingdom to help with cancer prevention, early detection, diagnosis and treatment, and palliative care. This will build on local fundraising to meet local need. It will help in the move to fair access to high quality services across the country, and will bring together the NHS, the voluntary sector, local authorities and other local partners.

5.31 A Cancer Action Team will drive progress to achieve this target, supported by investment from the Public Health Development Fund (see paragraphs 11.39 and 11.40).

Fig 5.8 Ways of beating cancer: examples of how everyone can play their part

We welcome your comments on this site. Prepared 5 July 1999