The cancer legacy could do more damage than Covid
Britain is in the middle of a ‘cancer catastrophe’, say experts. Laura Donnelly asks them what can be done
ASainsbury’s car park in south London seems an unlikely place to find the “holy grail” for the NHS. But it’s where Edward Wood, 60, is one of 140,000 people taking part in the world’s largest trial of a revolutionary blood test which could detect more than 50 types of cancer before symptoms appear.
A lot depends on it.
This week a damning report by the National Audit Office found that up to 740,000 potential cancer cases which should have been urgently referred by GPS have been “missed” since the first lockdown.
Which takes us to this car park in Sydenham, where a steady stream of men and women in their 50s, 60s and 70s are arriving to take part in the most radical of research.
The site is one of dozens taking part in the “Grail” study – a three-year trial which uses annual blood tests to seek chemical changes in fragments of genetic code, cell-free DNA, that can leak from tumours into the bloodstream long before a person experiences symptoms.
The Galleri test – which has been found to correctly detect cancer in more than half of cases – is already available to over-50s in the United States but the NHS pilot is the world’s largest trial of the single blood test.
Most crucially, this is about identifying changes early, dramatically boosting the effectiveness of treatment. But it is a long-term strategy. The study will take three years to even report its findings, at a time when the need for action to tackle Britain’s backlog has never been more urgent.
Britain was already languishing at the bottom of international cancer league tables published just before the pandemic, with the lowest survival rates for five in seven common cancers, according to research on almost four million people by the World Health Organisation.
The data published in 2019, which compared seven major nations, showed that some of Britain’s survival rates were worse than those of other countries 20 years earlier.
While all countries have improved since the 1990s, the UK has failed to catch up – ranked bottom of the table for bowel, lung, stomach, pancreatic and rectal cancer, second worst for oesophageal disease and in third worst position for ovarian cancer.
Five-year survival rates for stomach cancer were 20.8 per cent – worse than those of Norway, Canada, Australia and New Zealand two decades before. For ovarian cancer, UK five-year survival was 37.1 per cent – on a par with Norway’s rates in the 1990s. For bowel cancer, UK survival was 58.9 per cent, compared with 70.1 per cent in Australia.
The international league tables covered the period from 2010 to 2014, since when many countries, including Britain, have made strenuous efforts to achieve earlier diagnosis and treatment of cancer. Three years ago, then-prime minister Theresa May launched a new cancer strategy at the Conservative party conference, promising that three in four cancers would be diagnosed at early stages within a decade, up from around half.
But that was before the pandemic reaped its devastation, making it harder for many people to see their GP, with a huge fall in face-to-face appointments. Some patients did not come forward, trying to play their part in efforts to “protect the NHS”; others held back for fear of catching Covid. But many who wanted to see their GP struggled to obtain face-to-face appointments, following national orders which said anyone seeking an appointment must first undergo telephone or online assessment.
The result? Britain stands in the middle of a “cancer catastrophe”, say experts. The NAO’S estimate of between 240,000 and 740,000 “missing” urgent referrals since the first lockdown came less than a week after research by Macmillan Cancer Support calculated almost 50,000 people who should have been diagnosed 18 months ago remain without one. The later these cases are found, the worse the prognosis will be.
“The NHS and Government did not prioritise cancer – it was not given the urgency it needs,” says Professor Pat Price, an oncologist from Imperial College London, and chairman of the charity Action Radiotherapy. “If you fall off a motorbike you get patched up, babies are still born, emergencies are still seen in Accident & Emergency.
“When it comes to cancer, a fourweek delay in treatment means a 10 per cent fall in survival, but we can’t see the damage from that yet – the people who are not being treated when they are curable, who will die in four or five years, when they otherwise would have lived.”
Prof Price, who co-founded the #Catchupwithcancer campaign, because of her concerns, fears government and NHS leaders “have their heads in the sand” about the scale of the crisis facing Britain.
“There is a risk that the cancer legacy of the pandemic could be worse than the damage caused by Covid, in health terms,” she says. “The cancer deaths will keep rising for far longer than those from Covid: this crisis will continue to keep costing thousands of lives.”
The oncologist is among several experts who say cancer needs to be made a national priority, with the same urgent focus that was given to the vaccine rollout – otherwise, “the NHS may never clear the backlog”. Some of the missing cases are among the most difficult to diagnose. For years, health campaigners have been trying to persuade people – and in particular men – to come forward to GPS with niggling symptoms, regardless of embarrassment, or fear they are wasting doctors’ time.
Latest official statistics show just how badly the pandemic has set back this cause. The biggest impact has been seen in diagnosis of prostate cancer, with confirmed cases in England down by almost a quarter since the pandemic.
The UK already offers some of the shortest GP appointments in the Western world and the average 10-minute slot has been criticised by patient groups and doctors alike as “inadequate”. Difficulties getting to see the same doctor twice have also been partly blamed for the UK’S cancer survival rates lagging behind those of other Western nations.
This week the NHS was due to publish an Elective Recovery Plan, setting out how services would deal with the existing backlog of almost 6million people on waiting lists for planned treatment. Ministers have warned that the numbers will get “worse before they get better” with fears the list could hit 13million, as more people come forward.
But its launch was delayed when news emerged of the omicron variant. That threat, and a pledge to offer boosters to everyone over the age of 18 by the end of January, means GPS have been told to once again set aside many of their regular duties.
On Wednesday, Health Secretary Sajid Javid said “there was nothing more important” than the booster rollout as he confirmed that he was “revisiting” the workload of family doctors, and pledges to increase the number of patients being seen face-to-face. Difficulties getting to see a GP in person have been one of the major flashpoints of the pandemic.
Amid growing public concern, ministers vowed to take action to improve patient access – only to find that their plans triggered a threat of industrial action by the British Medical Association. For years ministers had promised that access to the NHS should be as easy as online banking, but despite pledges in 2018 to give patients the opportunity for smartphone consultations, progress was slow. That changed – almost overnight – as Britain entered the first lockdown, in March 2020.
GPS were instructed to ensure that anyone trying to see a doctor should have an online or phone consultation, at least in the first instance. Many assumed the measure was a short-term arrangement, to mitigate the worst of the crisis. But there was an outcry when the instructions became embedded in long-term planning guidance this year, despite growing concern that the most vulnerable patients were struggling to access care.
Before the pandemic around 80 per cent of appointments with GPS were face-to-face, but this dropped to 47 per cent during the first wave of the pandemic. Despite mounting public concern, it was not until repeated interventions by ministers – including the Prime Minister in September – that this climbed back to 64.4 per cent in October.
But as health officials scramble to arrange the rollout of booster jabs to all adults, they spent much of the week locked in talks with the doctors union about which work GPS should put on hold. Last night health officials finally agreed a deal which will see GPS receive payments of up to £30 for every jab administered, and continue to receive “protected incomes” for many health checks on patients during the rollout – regardless of whether they take place.
Screening programmes – such as mammograms – key to early diagnosis, were largely suspended for the first lockdown, with estimates that 1.5million fewer women have undergone breast cancer screening as a result.
Last week, former Vogue editor Alexandra Shulman, 64, revealed her diagnosis and treatment for breast cancer, found after she saw a private GP, who referred her to a hospital specialist.
Ms Shulman said she sought private care because she thought it would take longer to get an appointment with her NHS GP, and to be referred for hospital checks. The journalist had been suffering from an intermittent sharp pain under her breast, one of the less common signs of disease, which is not classed by the NHS as grounds for an urgent cancer referral.
While a private mammogram did not detect the deeply hidden tumour, she was also referred for an ultrasound, which did, enabling a swift diagnosis and short course of radiotherapy treatment.
Ms Shulman is not alone.
The Independent Doctors Federation, which represents 1,500 private GPS and specialists, says its members have seen a significant rise in the numbers prepared to pay for a visit. Its president, Dr Neil Haughton, a private GP in Notting Hill, said: “We just can’t keep up with the demand.”
Meanwhile, private hospital groups such as Spire have reported an 80 per cent rise in “self-funded” treatments since before the pandemic.
GPS have long been known as the “gatekeepers” of the NHS; the arbiters of whether or not patients get tests or a specialist assessment. But research has repeatedly found that this system may contribute to Britain’s poor cancer survival rates, by creating delays and bottlenecks accessing care.
A 2019 paper by Imperial College London analysed 21 studies comparing different healthcare systems in both the US and 19 European countries. It found “significantly lower” cancer survival rates under systems which insist that a patient must be referred by a GP for hospital care, with one study finding a difference of 11 per cent in one-year survival.
In countries like France and Germany – which have higher survival rates than the UK for major cancers such as bowel and breast cancer – patients can see a specialist directly, rather than wait to be referred by a GP.
Finland has one of the highest survival rates for major cancers. Its healthcare system prides itself on good GP access and pioneering work using genetic data for more accurate diagnoses and personalised treatments. Research from 2018 found 85 per cent of patients in Finland felt it was “easy” to make a GP appointment. A similar poll in England the same year found just 70 per cent of patients found it easy to get through to their practice on the phone.
Australia – which outperforms most countries for survival from most cancers – takes yet another approach. There, GPS are expected to refer patients directly for a barrage of diagnostic tests, instead of waiting for a specialist to make recommendations.
Here the UK again fares poorly; while British scientists were instrumental to the invention of both MRI and CT scanners, our provision is far worse than that of comparable nations. The latest data shows the UK carrying out just 171 per 1,000 population, above only Serbia and North Macedonia, compared with an EU average of 204.
Health officials have drawn up plans for a national network of 150 “one stop shops” – including 40 to open in the next six months – as part of efforts to detect cancer sooner, under one roof. The scheme will see blood tests, MRI and CT scans carried out in shopping centres and football stadiums, seven days a week, speeding up diagnosis and treatment.
It has been a long time coming, having been recommended by former cancer tsar Sir Mike Richards, who warned of “woefully poor” diagnostic services back in 2019.
However, patients would still need to be referred to such centres by GPS, or other health professionals. Some wonder whether Britain needs to learn from other countries, and make it easier for patients to cut out the GP, and refer themselves directly for tests.
Dr Jodie Moffat, Cancer Research UK’S head of early diagnosis, is keen to see more research about self referral: “It doesn’t always seem that GPS are so keen on it, but we think it is something that needs to be looked at more closely.”
She believes that Britain could learn from Australia, where “it seems that GPS are not so constrained by pressure to limit referrals, the costs of tests. There seems to be much more willingness to refer, outside of the UK.”
Meanwhile, experts warn that the biggest obstacle to overcome is perhaps the most basic: shortages of key staff, including consultants, radiologists and specialist nurses.
Ministers announced a record extra £5.4billion for the NHS this year, and an extra £36billion for health and social care, funded by National Insurance, with the Health Secretary promising to be “watchful of any waste or wokery” in use of the funding boost. But there are growing reports of Treasury concern about how the NHS funding boost is being spent. While £2.8billion has been allocated for Covid-19 costs including infection control, £600million for “day to day” costs of hospitals, £478million to speed up discharges and £1.5 billion set aside to deal with record waiting lists, the lack of any published plan is causing concern.
So far, government announcements have focused far more on extra facilities, and buildings, creating the danger that staff are simply more thinly spread. Dr Moffat quotes a colleague: “You can’t fly a plane without pilots.”
Baroness Morgan, chief executive of Breast Cancer Now, agrees that the greatest problem facing cancer services is staff shortages, and the numbers leaving the service; a crisis which was looming long before the pandemic but has never been worse.
“We need a plan for the workforce, because otherwise it is going to disintegrate in three to four years,” she says.
Ministers have promised a 15-year plan, to tackle the long-term challenge of training and recruiting this workforce, but even this will not be published until next spring.
In the long-term, advances like the Grail trial, genetically personalised treatment, and an expanded role for artificial intelligence in diagnosis may well reshape the way cancer services are offered. But without far more immediate action, cancer experts fear that the UK is simply “replacing the Covid crisis with a cancer crisis”, which could cut short tens of thousands of lives.
David Hare, chief executive of the Independent Healthcare Provider Network, which represents private hospitals, unsurprisingly wants the NHS to make far more use of spare capacity in the sector, giving patients the option to travel for earlier treatment. “It’s the best option for keeping the foot on the floor on elective [planned] work instead of having to cancel operations.” Such policies have existed in the NHS for more than a decade, yet are barely used.
Prof Pat Price says some of the most urgent actions would cost very little: “Sometimes it is about a kit that costs £200. We need new machinery, there are scanners that can treat three times as many patients that we should be using.”
She calls for cancer services to be “ringfenced” so operations are no longer cancelled, for increases in beds and intensive care services, so surgeons are able to operate.
Today a survey of 275 medics by Action Radiotherapy warns of another “alarming” rise in incurable cases among patients who saw diagnosis and treatment delayed by lockdowns. In total, 83 per cent of clinicians polled said they were seeing increasing numbers of patients starting treatment at the point that their disease was too late to cure.
“We need the Government to recognise that this is a national crisis, that we are in the midst of a catastrophe which will mean thousands of patients dying,” says Prof Price. “We need a minister in charge – to give this the same priority we gave vaccines – and we need to move heaven and earth to get cancer on track.”
‘With cancer, a four-week delay in treatment means a 10 per cent fall in survival’ Professor Pat Price