A new statisticalanalysis made possible by a research partnership between Cancer Research UK (CRUK) and NHS Digital has revealed that in England, Black women of Caribbean and African descent are up to twice as likely as British White women to receive a late-stage diagnosis for certain cancers.
The retrospective secondary data analysis, published today in BMJ Open, divulged that ethnicity was a significant factor in stage of diagnosis for women in England with breast, ovarian, uterine, non-small cell lung cancer (NSCLC), and colon cancer. In contrast to the late diagnoses for these cancers in women, Caribbean and African men were a fifth less likely to be diagnosed with late-stage prostate cancer than White British men.
Stage at Diagnosis Affects Treatment and Survival
"Cancer stage at diagnosis is a determinant of treatment options and survival," the study team commented. For example, they cited CRUK research showing that in England 93.1% of people diagnosed with colon cancer at stage 1 will survive 5 years or more, versus 9.8% of those diagnosed at stage 4.
Existing investigations had shown differences in barriers to presentation with cancer between ethnic groups, but previously, incomplete national cancer registration data had prevented this type of analysis, the authors said. However, "reporting of both stage at diagnosis and ethnicity has improved in the last decade", allowing for comparison of stage distributions at diagnosis between ethnic groups.
The new study used data from NHS Digital's National Cancer Registration and Analysis Service for nearly 697,000 cancers diagnosed in people aged 15 to –99 across six cancer sites in England between 2012 and 2016, noting ethnicity and stage after adjusting for patient case-mix.
The analysis showed that:
- Caribbean and African women were more than twice as likely to be diagnosed with late-stage uterine cancer as White British women (odds ratios [OR] 2.17 [95% CI 1.74 to 2.71] and 2.19 [95% CI 1.61 to 2.97] respectively)
- Caribbean women were more likely to receive a late-stage diagnosis for NSCLC (OR 1.62% [95% CI 1.20 to 2.19]), ovarian (OR 1.48 [95% CI 1.02 to 2.14]), colon (OR 1.37 [95% CI 1.11 to 1.68]), and breast (OR 1.27 [95% CI 1.12 to 1.43]) cancers than White British women
- African women had higher odds of being diagnosed with late-stage ovarian (OR 1.85 [95% CI 1.26 to 2.71]), breast (OR 1.71 [95% CI 1.51 to 1.95]), and colon (OR 1.42 [95% CI 1.07 to 1.88]) cancers
- Asian women - those from Indian, Bangladeshi and Pakistani backgrounds - were more likely to receive late-stage ovarian (OR 1.21 [95% CI 1.02 to 1.44]) and breast (OR 1.12 [95% CI 1.03 to 1.22]) cancer diagnoses
- There were no significant differences found between women of Chinese ethnicity and White British women
Poorer Symptom Awareness Among Ethnic Minority Groups
CRUK said there were many possible reasons behind the late diagnoses, including poorer symptom awareness, delays in seeking help, and barriers to presentation, including having to make multiple GP appointments before being referred for tests. A YouGov survey for CRUK in September 2022 found that 23% of women from ethnic minority backgrounds "didn't know any warning signs and symptoms of cancer", compared with 12% of White women.
In addition, ethnic minority women were more likely to delay or avoid speaking to a medical professional, due to embarrassment or lack of confidence talking about their symptoms than White women (10% vs 5% and 10% vs 4% respectively). They were also more likely to be worried about how their pay/earnings would be affected if they needed further tests or treatment (5% vs 1%) and to anticipate difficulties with remote consultations (10% vs 6%).
Lower Screening Uptake and 'Cancer Fatalism'
The charity also noted that previous research had shown that Black people were significantly less likely to be diagnosed with cancer via screening in England. It suggested that as well as lower screening uptake, fear of dying from cancer and beliefs that cancer is untreatable may also contribute to late-stage diagnoses among women from ethnic minority backgrounds. 'Cancer fatalism', a potential factor in diagnostic delay, has also been found to be higher in ethnic minority women compared with White British women, the study authors said.
Although cancer rates are generally lower for most cancer sites among minority ethnic groups in England – particularly for melanoma and smoking-related cancers of lung, bladder, and oesophagus – this gap is expected to close over time as contributory factors, such as obesity and smoking, rise to similar levels as those in White people.
Late Stage Prostate Cancer Less Common
The new data showed that among men, a link between ethnicity and stage at diagnosis was only found in one of the cancer types studied. Caribbean and African men were over 20% less likely to be diagnosed with late-stage prostate cancer than White British men, despite being at higher risk of developing the disease. This could be driven in part by targeted awareness campaigns for prostate cancer, the authors said. One study had suggested that Black men were more than twice as likely to be diagnosed with prostate cancer as White men, although more research was needed to understand whether overdiagnosis was a factor.
CRUK recommended that the Government should implement targeted intervention campaigns to help raise awareness of cancer signs and symptoms, as well as the benefits of early diagnosis, and screening uptake among ethnic minority groups. The study authors noted: "Certain cancer sites such as breast have a clear symptom signature, meaning ethnicity-related disparities in symptom awareness could greatly impact stage distributions."
They added: "Ensuring healthcare systems are not creating barriers that prevent people from particular ethnic groups being seen and referred appropriately without delays is an important area to focus on in the future."
Cancer Cases Likely to Increase in Future
Michelle Mitchell, CRUK chief executive, said: "Everyone deserves the best cancer care, from diagnosis to treatment. The fact that women from Black and South Asian backgrounds are more likely to be diagnosed with late-stage cancer, when treatment is less likely to be successful, is deeply troubling.
"More concerning still, is that we know the number of cancer cases diagnosed in ethnic minority groups is likely to grow over time. Meaning without any action, this gap will only continue to widen.
"Whilst the Health and Social Care Secretary's recent decision to drop its promised 10-year cancer plan is disappointing, it is now critical that the new 'catch-all' major conditions strategy sets out how the Government will reduce the inequalities that persist in cancer care."
Study author Jon Shelton, CRUK's head of cancer intelligence, said that it was important to tackle known barriers to help-seeking, whether that was fear or difficulty accessing a GP, so that more people came forward with symptoms.
"But we also need the Government to ensure primary care and diagnostic services are properly resourced. If people can't get appointments that work for them, aren't being referred for tests in a timely way or are stuck on waiting lists, they will not see the benefits of early diagnosis. And we risk making these inequalities worse."