Dr Anthony Cunliffe Explores the Role of Primary Care in Combating the Health Inequalities That People Can Experience at All Stages of the Cancer Pathway
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Find key points and implementation actions for clinical pharmacists in general practice at the end of this article
As primary care physicians, we are often looking after a varied patient demographic, so we should be acutely aware of how a person’s situation or status can affect their experience of health and health outcomes. These differences are referred to as health inequalities and they can impact individuals in many ways, affecting their opportunities and choices to support healthy living. Health inequalities cause significant variations in people’s access to healthcare, experiences of using the healthcare system, and exposure to discrimination.
Many will be familiar with Fair society, healthy lives: the Marmot review, an analysis of health inequalities in England published in 2010.1 The review highlighted that, in many ways, our experience of health is determined by where we are born, grow, live, work, and age. People with a lower socioeconomic status have poorer overall health, live with a greater burden of disability, and die younger.1
The Equality Act 2010 identifies specific protected characteristics, including age, disability, gender reassignment, race, religion or belief, and sex.2 These characteristics delineate some of the groups affected by inequalities in the workplace and wider society. However, when it comes to health inequalities, there are other demographics to consider, including social factors such as deprivation, education, and where people live.
To understand how these factors affect people’s experiences of health and the health service, we need the right data. Unfortunately, there is a recognised lack of good-quality data to provide the insight needed.3 In part, this dearth of data starts in primary care, in the inconsistent collection of important demographic information (for example, diversity data),4 and in the reported lack of trust the public has in sharing its health data with doctors.5
When considering cancer, evidence suggests that certain groups are more adversely affected than others, and that this effect spans the entire cancer pathway, from stage at diagnosis to mortality rate. Although we may never adequately address the myriad inequalities faced by people on the cancer pathway, we can try to gain a better understanding of them, as outlined in this article.
Risk Factors for Developing Cancer
In the UK, avoidable risk factors for developing cancer, such as smoking status and obesity, vary significantly by demographic and are much more common in certain groups, including those with a lower socioeconomic status.6,7 For example, smoking is the single most prolific avoidable risk factor for developing cancer.8 The proportion of current smokers is significantly higher among unemployed people compared with those in employment, among individuals who perform manual work compared with those in managerial occupations, and among people with no qualifications compared with those with a degree.6
Even though smoking prevalence has fallen in all four UK countries since 2011,6 some inequity gaps are widening. Obesity, which is one of the risk factors for developing cancer that has become more prevalent over the past 30 years, disproportionately affects certain groups, including people living in deprived areas, those with disabilities, people of Black ethnicity, and those with no qualifications.9
Other risk factors that show significant variation across different population groups include alcohol consumption10 and recreational and/or occupational sun exposure.11,12 Sadly, because many of these risk factors disproportionately affect underserved populations, it is unsurprising that individuals from these demographic groups experience significantly poorer cancer outcomes—as is the case with alcohol consumption.10
Inequalities in the Diagnosis of Cancer
Awareness of the Signs and Symptoms of Cancer
Compared with other, similar European countries, the UK has a lower rate of early stage cancer diagnosis; this contributes to poorer outcomes, with some specific population groups consistently diagnosed at a later stage.13 Figure 1 shows the proportion of patients diagnosed at each stage according to their deprivation status in England between 2014 and 2018.14
A lack of awareness of the signs and symptoms of cancer in the general population (see Figure 2), as well as a reluctance to present to primary care to seek help (see Figure 3), may be instrumental in this.14–16 Research has shown that awareness of the common signs and symptoms of cancer is lower in men, those who are younger, people with a low educational level, and individuals from lower socioeconomic groups or ethnic minorities.17,18
The International Cancer Benchmarking Partnership, a collaboration of policymakers, clinicians, and researchers from six high-income countries with similar healthcare systems across the world, found that the UK public had the highest perceived barriers to symptomatic presentation, in particular being worried about wasting the doctor’s time.19 Data from the 2020 GP survey found that certain groups reported being underserved by primary care services including, again, those living in more deprived areas and people with Black, Asian, and ethnic minority backgrounds.20 Therefore, it is not difficult to understand that those groups who are repeatedly highlighted as being marginalised show poorer cancer outcomes.
Access to Cancer Screening
In the UK, three national cancer screening programmes are in place to diagnose cancer early and, in some cases, to prevent its development. Uptake of screening varies significantly across the UK, with lower coverage in more deprived areas.21 Other populations underserved by screening programmes include people from Black, Asian, and ethnic minority groups, and those with physical or learning disabilities.21 Specific to breast and cervical screening, there is evidence to show discrimination against lesbian, bisexual, nonbinary, and transgender people, with transgender men reporting various issues, including incorrect coding of gender in their medical records and a lack of recognition and understanding of their specific health needs.21,22
Changes in Consulting Practice Following COVID-19
We have already highlighted that access to primary care varies by patient demographics, aspects of which have been affected by the COVID-19 pandemic. A significant change has occurred in the way that many healthcare consultations are conducted, with a move to greater use of virtual consultations. Certain sections of the media have tended to report dissatisfaction with this change, with articles claiming that the public and some members of the healthcare profession are unhappy.23,24 However, it is interesting to note that articles in the medical press do not seem to confirm this sense of discontent, although preferences may change as the pandemic recedes.25,26 This shift in consulting practice will affect some patient groups more than others, and concerns have been raised that the changes will worsen existing inequalities and create barriers to access for less digitally literate groups.27,28 As deliverers of healthcare, we will need to remain attuned to the differing consulting needs of our patients and continue to engage with emerging research, as current evidence in this area remains unclear.27,28
Inequalities in Cancer Treatment
Access to Radical Treatments
Of course, healthcare access is broader than primary care, and access to radical treatments is an area of significant variation in cancer. It may seem obvious but, because of issues such as frailty, more aggressive treatments may not be appropriate for older patients. Indeed, evidence suggests that older women with breast cancer are offered the opportunity to receive radical treatment less often than younger women with the disease.29 This is contrary to recommendations that chronological age alone should not be the main factor in the decision to offer certain treatments.29 However, physician recommendation is one of the main reasons that older people accept or decline treatment30 which leaves them vulnerable to discrimination. Other factors that may affect access to radical treatments are socioeconomic status and geography,31,32 but the evidence does not seem as strong in these areas, and more research is needed.
Representation in Research Trials
Access to research trials for new cancer treatments is also important, because patients treated in areas where access to clinical trials is robust have better outcomes.33 Some patients are under-represented in clinical trials, including older people,34 and Black, Asian, and minority ethnic groups.35 This not only risks their reduced access to new treatments, but also affects data collection on the efficacy of these treatments in certain groups.35,36 The reasons for poorer recruitment from these populations may be multifactorial, but it is an area in which greater research and more targeted recruitment support are needed.
Physical Barriers to Treatment
Challenges in accessing healthcare can be interpreted in many ways, but sometimes the barriers are simply physical and practical. A study published in 2019 found that adults with physical disabilities in England and Wales reported various barriers to accessing cancer services, relating not just to a lack of physical accessibility, but also to the fact that specific needs associated with an individual’s disabilities may be unacknowledged or even ignored.37
Experiences of Cancer Care
Everyone’s experience of cancer is unique, and access to good-quality, personalised care is fundamental to ensuring that all patients needs are identified and met. By delivering personalisation of care across the healthcare system we should, by definition, be able to identify and focus on those most at risk or with greatest need and, in doing so, start to tackle health inequalities.
The National Cancer Patient Experience Survey (NCPES) is run annually in England to monitor national and local progress in delivering high-quality cancer care.38 The results for 2019 show that people from minority ethnic groups reported a poorer experience of care than those from White British groups.39 A London-specific analysis of the NCPES 2016, commissioned by Macmillan Cancer Support, found that differences in the experience of care of patients from deprived areas and minority ethnic groups were particularly evident in the capital city.40 Various factors contribute to these differences, many of which are fundamental to personalised cancer care.
Provision of Information on Cancer
Making decisions about and understanding the possible outcomes of cancer treatment are difficult tasks for everyone, so the provision of high-quality information from healthcare practitioners is essential.41,42 The NCPES has found that fewer people from minority ethnic backgrounds report being given answers to questions about their diagnosis and treatment in a way that they can understand.43 In the London-specific analysis of the NCPES 2016, more patients from mixed ethnic backgrounds reported being talked about by their healthcare teams as if they were not there compared with White patients.40
Language and Cultural Barriers
A good-quality conversation is central to supporting people to identify their needs and make informed decisions about their cancer treatment, yet access to interpreters is variable and perhaps not prioritised. This often means that family members need to act as interpreters, which adds potential barriers to transparent conversations, and can lead to miscommunications between patients and healthcare professionals.44 However, language is not the only barrier. Self-empowerment can be important in improving patients’ quality of life after cancer treatment,45 but how can we truly empower patients without an accurate understanding of how cultural priorities may influence their needs?
Financial Effects of a Cancer Diagnosis
A diagnosis of cancer can leave an individual up to £891 a month worse off,46 and it is likely that those from the poorest areas are hit hardest. This issue affects both people diagnosed with the disease and closest to and/or reliant on them. The financial burden spreads beyond the individual diagnosed with cancer.
People With Serious Mental Illness
As this article highlights, some vulnerable groups are affected by inequalities in multiple ways and at multiple points along the cancer pathway, resulting in a cumulative negative effect on disease severity and treatment outcomes, experience of care, and information and support provision. People with serious mental illness are one such group. Despite the data not necessarily showing a higher incidence of cancer in this population,47 the prevalence of multiple modifiable risk factors47 and challenges in accessing cancer screening48 or presenting to the healthcare system can have a significant effect on prognosis. People with serious mental illness are less likely to be offered radical cancer treatments, and more likely to experience treatment complications and poorer outcomes.47
In this article, it has only been possible to scratch the surface of the health inequalities that influence cancer care, but they affect vulnerable populations across the entire cancer pathway, impacting everything from stage at diagnosis to mortality rate.
I hope that some of the issues discussed will trigger thought, in particular about how we as healthcare professionals can be mindful and raise awareness of these inequalities, and explore ways to address them in our own practice.
Dr Anthony Cunliffe
Joint National Lead Macmillan GP Adviser, Macmillan GP Adviser London; Joint Clinical Chair, South East London Cancer Alliance
|Implementation Actions for Clinical Pharmacists in General Practice|
Written by Daniella Fakhouri, Associate Director, Soar Beyond Ltd, and Primary Care Network Pharmacist for Northwest Surrey Integrated Care Services
Following their inclusion in the 2022–2023 IIF, two areas of focus for GP clinical pharmacists when completing SMRs will be tackling health inequalities and early cancer detection. The NHS long term plan commits to an investment of £4.5 billion for the expansion of MDTs aligned with PCNs, to both improve early cancer diagnosis and support people as they live with and beyond cancer.[A] The NHS long term plan also aims to transform cancer care so that 75% of cancers are diagnosed at an early stage by 2028.[A]
GP clinical pharmacists are already considered a vital part of the MDT within PCNs, for which they deliver holistic SMRs. They are well placed to support the NHS in tackling health inequalities and improving early cancer diagnosis by:
The i2i Network has a suite of training and implementation resources, both bespoke and free, for GP clinical pharmacists, including e-learning and on-demand training delivered by experts covering a range of long-term conditions, including cancer. Become a free member at: www.i2ipharmacists.co.uk
IIF=Investment and Impact Fund; SMR=structured medication review; MDT=multidisciplinary team; PCN=primary care network; VBA=very brief advice; BMI=body mass index; FIT=faecal immunochemical testing
[A] NHS England. Online version of the NHS long term plan. www.longtermplan.nhs.uk (accessed 1 June 2022).