There were nearly 330,000 new cancer diagnoses in England in 2021 – that’s more than 900 people a day finding out that they have a disease which is one of the most common causes of death in England.
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Current NHS policy is focused on diagnosing cancer at an earlier stage and improving the speed with which patients receive a definitive diagnosis.
By 2028
of people with cancer should be diagnosed at an early stage
Within
of referral patients should receive a definitive cancer diagnosis
Early cancer diagnosis is also considered to be a key component in the NHS’s plan to reduce inequalities in health care.
Most patients with cancer will have been to their GP before being diagnosed, but not all are immediately referred on to urgent suspected cancer pathways. While some patients present with clear-cut cancer symptoms (e.g. a craggy breast lump), others have symptoms with many potential causes, or symptoms not typical of cancer. The GP may organise investigations or treatment, or refer via non-cancer pathways, which can delay cancer diagnosis.
Worsening symptoms while waiting for planned hospital care may cause patients to go back to their GP or to A&E. Similarly, a patient may miss a cancer referral because of administrative problems, such as their contact details being incorrect, meaning they may return to the GP or go to A&E if symptoms persist or worsen.
In other situations, a patient with a recurring problem may be seen several times by different clinicians who only treat the immediate symptoms, so the pattern suggestive of a serious underlying cause is not immediately seen. The loss of continuity in general practice, such as not consistently seeing the same GP, makes this kind of delay more likely. Furthermore, GPs in more deprived areas are likely to be dealing with more patients and patients who are already in worse health, which makes it more likely that worsening problems will be missed.
Increasingly we are finding that patients tell us how hard it is to advocate for themselves, to follow up, to speak to anyone, to get things moving – I feel there's a real sense that the system is broken and that it's every person for themselves. The whole issue of self-advocacy within the NHS system has really only come up in the last year and I think it's a result of all the issues we see going on.
There are three national cancer screening programmes for certain populations in England that can detect early signs of bowel, breast and cervical cancer in people without symptoms. There will soon be a new national targeted one for lung cancer. We know that appropriate cancer screening reduces illnesses and deaths due to cancer, and where it detects precursors of cancer it reduces the heavy burden that comes with a cancer diagnosis.
But screening can also cause harm: side effects, missed cancers, picking up cancers that wouldn’t go on to cause harm, and incorrect diagnosis of cancers. The latter two can then lead to over-testing and treatment, adding pressure on staff and resources that are already overwhelmed, as well as risking more harm through further side effects. So screening is only suitable where the benefits strongly outweigh the risks and it is clinically useful. The balance of this is different for each type of cancer.
Success of cancer screening is dependent on eligible patients taking up the offer. Many might not because of fears, embarrassment and cancer stigma, or because they don’t understand the importance of screening and the risks of not doing it. But, there are other structural and systemic issues that cause barriers and can exclude certain groups of people. These include financial and time costs and practical challenges; trust in and relationships with health professionals; lack of reasonable adjustments for certain populations (such as people with learning disabilities); and exclusion from screening invitations due to a person’s gender being different from their sex at birth or because they are not registered at a GP practice (including people with no fixed address).
Not all cancers are the same, and patients’ needs vary, but some common themes have emerged from our analysis.
Despite the ambitions to improve cancer diagnosis in the NHS, the target the NHS has set itself to increase the percentage of people receiving early diagnosis is very unlikely to be met, and more widely, cancer service performance has been getting worse.There will need to be sustained investment in NHS staff, equipment and IT infrastructure to close the gap between demand for cancer diagnostics and what services can deliver.
There are stark inequalities in the proportion of people diagnosed with advanced cancer. Health systems in each area need to work together and with deprived groups; communities of Mixed, Asian and Black ethnicities; and other vulnerable groups to understand and tackle barriers to cancer diagnosis.
In particular, improving screening rates would help reduce inequalities for some cancers. More support and tailored responses for some groups, such as people with learning disabilities and trans people, is needed.
Younger people are more likely to be diagnosed at an early stage in their cancer, but also more likely to see a GP multiple times before being diagnosed. Enabling patients to see the same GP can help serious problems to be spotted earlier. The NHS must do better in communicating with patients, both prior to diagnosis and once they know whether they have cancer or not. Patients often feel unable to speak up for themselves – something that becomes more important when the whole system is under pressure.
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With thanks to National Voices and its member charities, Cancer Research UK and NHS England's cancer programme and analytical teams for supporting and advising us on this research.