- Diagnostics
A faster diagnosis standard from 2020 to ensure most patients receive a definitive diagnosis or ruling out of cancer within 28 days of referral from GP or from screening
By 2028 the proportion of cancers diagnosed at stages 1 and 2 will rise from around 50% now to 75% of cancer patients
Was the commitment met overall? or (in the case of a commitment whose deadline has not yet been reached) Is the commitment on track to be met? |
1. Does the commitment have a clear and fixed deadline for implementation?
The NHS Long Term plan, launched in January 2019, stipulated a standard that will ensure “patients will be diagnosed or have cancer ruled out within 28 days of being referred urgently by their GP for suspected cancer.”1
The Long Term Plan also set an ambition that, by 2028, the proportion of cancers diagnosed at stages 1 and 2 will rise from 50% to 75% of cancer patients.
To achieve the goal set for 2028 would mean in real terms, 55,000 more people each year surviving their cancer for at least five years after diagnosis.
Prostate Cancer UK are concerned that for prostate cancer patients, if the focus shifts to increasing stage 1 and 2 diagnosis, it may result in more men being diagnosed with clinically insignificant cancers, which will not cause them any harm and instead would cause worry and anxiety. Prostate Cancer UK state that for improving outcomes for men with prostate cancer, the aim should be to reduce the number of late-stage diagnoses that are identified when they are not curable.
2. Are there any mitigating factors or conflicting policy decisions that may have led to the commitment not being met or not being on track to be met? How significant are these? Was appropriate action taken to account for any mitigating factors?
The PSA test is the first test that measures the prostate specific antigen (PSA) levels of a person with a prostate and, depending on the result, informs what action is taken. The National Screening Committee has consistently recommended against screening for prostate cancer due to the inadequate specificity and sensitivity of PSA testing. The test results in a high number of false positives, a large number of clinically insignificant cancers being diagnosed and many clinically significant cancers being missed. Although the pathway has improved in recent years with the introduction of pre-biopsy MRI and more consistent use of active surveillance, recent evidence reviews suggest that the 20% cause-specific mortality reduction seen in trials that use PSA to screen for prostate cancer comes at too high a cost in terms of overall harm and detriment to quality of life. This is a mitigating factor when considering a national screening programme.
To address this, we need to improve the diagnostic pathway and this will require large scale trials of promising new approaches to prostate cancer screening. Prostate Cancer UK is committed to funding those trials but will need support from funders including MRC and NIHR to fully fund and support those trials. We will be engaging potential funding partners over the next 12 months and hope that this review will highlight the importance of research in this area to relevant government departments and agencies.
We have not seen the roll out of a risk stratified screening approach, based on risk factors like the lung screening pilots that are running in different parts of the country. Albeit, some Cancer Alliances are piloting a number of different approaches to adopting a risk stratified approach to screening by targeting men who are Black African, Caribbean, of a certain age and in South East London Alliance, have a family history of prostate cancer. However, more evidence is needed to understand how the risk of prostate cancer varies by specific characteristics.
Although the PCRMP2 identifies family history as being a risk factor for prostate cancer, the NICE3 prostate cancer referral guidance does not allow men to be referred into secondary care for further tests based upon having a family history of prostate cancer. Prostate Cancer UK are not aware of there being any targeted individual testing of family members of prostate cancer patients.
3. To what extent has the NHS’s Covid-19 response affected progress on targets?
During the pandemic, there was a drop in urgent referrals4, with around 55,000 fewer referrals for urological cancers in England for April 2020 – April 2021 compared to the same period the previous year.
This has resulted in fewer men starting their first treatment for prostate cancer.
The below table provided by the National Prostate Cancer Audit5 demonstrates the drop in the number of men diagnosed in 2020 to those in 2019 and how this trend continued throughout the year, albeit reduced.
Prostate Cancer UK know that COVID-19 has also caused a drop in stage 1, 2, and 3 diagnoses but that stage 4 diagnoses remain as high as during the pre-pandemic period.6
Prostate Cancer UK are highly concerned that this drop in staging diagnosis will result in mortality and that 'too late' diagnoses in the advanced stages will be on the rise, as is being seen in Europe. The pandemic has affected access to GPs, diagnosis, treatment and care. This is expected to further contribute to delayed diagnoses, being diagnosed at a later stage and a marked increase in the numbers of avoidable cancer deaths. It should also be noted that this also results in more complex and costly care.
Indeed, this concern has recently been picked up by NHSE and we are working in conjunction with them to raise awareness of prostate cancer by promoting risk messaging and getting men to understand their risk factors of potentially being diagnosed with prostate cancer.
A national awareness raising campaign will launch on 17th February 2022.
There should be a sense of urgency for the Government to ensure that prostate cancer is prioritised at a national level and for urgent investment to be made to save men’s lives. Unless we find these missing men quickly, this would translate into thousands being diagnosed late and less cancers being caught whilst they can be cured.
Regional variation
The ONS in their Cancer Registration Statistics of 20167, found that the rate of prostate cancer incidence was generally highest in the south of England and lowest in the north of England; varying from 147.9 per 100,000 in the North East to 192.5 in the South East.
However Prostate Cancer UK expect the missing diagnoses to be spread out broadly throughout the country.
4. How has this commitment been interpreted in practice at trust/patient level?
Rapid Diagnostic Centres
The rollout of Rapid Diagnostic Centres (RDCs) across England started in 2019 and is designed to speed up diagnosis of cancer and other serious conditions.
Vague, non-specific pathway
RDCs also introduced a new non-specific symptom pathway for patients who display symptoms that could indicate cancer that don’t align to specific cancers. The new non-specific pathway complements current cancer diagnostic pathways, as well as providing elements that can be applied to existing pathways.
Improvements in pathway
NHS England published four national best practice timed pathway handbooks in 2018/2019. The pathways aim to support improvements in operational performance and patient experience, as well as providing models to support sustainable improvement.
The four pathways are suspected lung, prostate, colorectal, and oesophago-gastric (OG) cancers. The features of faster timed pathways will be delivered as part of the rapid diagnostic centre programme.
As Integrated Care Systems (ICSs) become embedded post July 2022, we will be able to feed into how the new structure is working and its’ effectiveness.
The Office of Health Improvements and Disparity was launched late 2021, with the aim of addressing health inequalities. We are yet to receive clarity and policy on how this will be achieved, how they will work cross departments and with ICSs.
Collaborative work
We are seeing pockets of work nationally, where Cancer Alliances are working in collaboration with local 3rd sector partners to help address health inequalities, develop innovations and models of good practice and will be able to provide examples of this at a future date and time if necessary.
5. Does data show achievement against the target (if applicable)?
Prostate cancer usually develops slowly, so there may be no signs for many years.
The statistics for 20188 demonstrate that approximately:
If we remove the cancers diagnosed at an unknown stage from the total, the proportion of men diagnosed with metastatic prostate cancer increases from: 13% to approximately 15%.
One of the reasons why the proportion of stage IV diagnoses is so high for prostate cancer is because it is rarely symptomatic until already metastasised. This limits the effectiveness of any awareness raising campaign based on “symptoms”.
Prostate Cancer UK are concerned that approximately 40% of men are diagnosed at later stages, where the prognosis is poorer and the chances of cures diminish significantly or disappear entirely. Since we are currently lacking a national screening programme we are unlikely to be able to dramatically drive down that number.
We can also see from the below chart9 that men who are diagnosed at stage 4, see their survival rates drop significantly after 1 and 5 years. We need to get more men diagnosed at an earlier stage to help improve outcomes for them, increase their treatment options and chances of survival.
The below graph demonstrates that the percentage of Trusts in England not meeting the target of 85% of patients being treated within 62 days between Feb-April 2021. It is apparent that the figure does not fluctuate and is the same as the monthly average prior to the pandemic (76%). We can infer from this that performance remains poor despite fewer referrals.
Urgent support needs to be provided to the Trusts identified by Prostate Cancer UK, to help improve performance and for them to reach their 62 day targets.
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Was the commitment effectively funded (or resourced)? |
4. Do healthcare stakeholders view the funding as sufficient?
We are aware that in the recent Spending Review (October 2021) the concept of Community Diagnostic Hubs was initiated. They are currently being developed and when they are rolled out, will take on board some scanning responsibility. We have spoken with a number of Cancer Alliances and the sentiment is that urologists want to keep their patients within their departments vs sending them to CDHCs.
A question was recently tabled for the Department of Health and Social Care10 about the number of MRI machines and how much money has been invested in the scanners.
The Department of Health and Social care noted that a total of 97 MRI machines were purchased through the £200 million equipment replacement programme to this specification from October 2019 to March 2021. Since the data is not held centrally, Prostate Cancer UK have in the past, submitted FOI requests to gather which Trusts have what machinery.
We note that the information requested on the number of multi-parametric magnetic resonance imaging (mpMRI) capable scanners and the investment in such scanners in the last three years is not held centrally. Thus making it a more onerous task to effectively audit scanners, the age of the scanner, and understand whether it is still fit for purpose etc.
We would recommend that this information is collected centrally, so that there is an increased accountability for machinery and Trusts. It would also become more apparent if the money that has been allocated for diagnostic equipment is adequate, below what is necessary or in fact too much.
Instead, accountability is given to the Trusts, with the Government stating that NHS trusts are encouraged to adopt the national specification as a minimum requirement when purchasing new MRI equipment. Since it is not a requirement, only an audit via a FOI request to all the Trusts, will give us this information as to whether scanners are out of date, appropriate, and whether they provide the quality and improved experience a patient requires.
Health Inequality
There needs to be additional monies provided to address the widening health inequalities that have become more prevalent since the pandemic. Currently, there are no health inequality leads within Cancer Alliances to specifically address the inequity in the balance of access to care and treatment, including diagnoses. We urgently request that the inquiry looks into this matter and provides guidance and an allocated budget so that Cancer Alliances can begin to redress the balance.
Further investment would help improve diagnosis and get it to the current gold standard. However, this will not be enough to reduce the number of men being diagnosed late (Stage IV). Therefore, it's critical that prostate cancer diagnosis research is recognised as a priority and funded appropriately.
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Did the commitment achieve a positive impact for patients? |
1. What was the impact on equity of outcome for different groups?
It is difficult to answer this question as there is a lack of national and regional data measuring equity of outcome for different groups. Indeed, when looking at ethnicity capture for prostate cancer, 146,905 cases were identified; 37% had no known ethnicity. 11 There is good data regarding deprivation, which is summarised below. - Prostate cancer incidence rates (European age-standardised (AS) rates) in England in males are 17% lower in the most deprived quintile compared with the least (2013-2017). 11 - It is estimated that there are around 3,100 fewer cases of prostate cancer each year in England than there would be if every deprivation quintile had the same age-specific crude incidence rates as the least deprived quintile.11 - Prostate cancer is most common in Black males, then White males and least common in Asian males.11
We need to improve data capture regionally as well as nationally. For us to be able to understand the impact of the prostate pathway for patients we need data for those within different age groups, ethnicity, learning disability and other protected characteristics.
We would recommend that this data capture should be standardised nationally, so that it is possible to cross compare regions and to measure the impact for different patient groups. Eg, ensuring that ethnicity capture is standardised and the use of READ CODES are universal.
We welcome the recent announcement by the Director of Cancer Services at the recent Department of Health and Social Care inquiry (20/1/22) into cancer services, stating that Cancer Alliances are now beginning to collect data according to ethnicity and provide a breakdown of cancers according to ethnicity. It is unclear whether this data capture is standardised, allowing for cross comparison of regions and would recommend this as good practice.
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Was it an appropriate commitment? |
1. Was (or is) the commitment likely to achieve meaningful improvement for service users, healthcare staff and/or the healthcare system as a whole?
Patient awareness of prostate cancer
A large-scale study commissioned by Prostate Cancer UK in 2013, demonstrated that:
This data suggests that a considerable amount of national investment and work has to be done to raise awareness in men about their risk to prostate cancer, so that they are informed and can make better informed decisions about their health.
To go further and faster, we would advocate a focus at the beginning of the diagnostic pathway and where responsibility lies with the patient to speak to their GP. Increasing awareness of men’s risk to prostate cancer needs to be made not only for the general public, but also for GPs in primary care.
When we polled GPs about what were the risk factors for prostate cancer, over 50% did not know that ethnicity was a risk factor. This is concerning and an improvement in GPs knowledge would help to address this.
Views of Patients
The Cancer Patient Experience Survey of 2020 was offered to Trusts on a voluntary basis. Reports for each of the 55 participating Trusts are available here. These are designed to inform commissioners and providers about their patients’ experiences and to identify areas for local improvement.
As there were no Cancer Alliances with full Trust participation, it was not possible to produce Cancer Alliance level reports. Therefore, the results from the Cancer Patient Experience Survey in 2020 cannot be used to make comparisons at a national or Cancer Alliance level with previous years”12 As a consequence there is no up to date data to be able to provide on whether the commitments made have made a meaningful improvement for patients.
We would strongly advocate national data capture as it plays a vital part of being able to inform, develop strategy and provide targeted support to areas that need it.
2. Is the commitment specific enough?
“We will build on work to raise greater awareness of symptoms of cancer” is a commitment specified in the NHS Long Term Plan.13
Prostate Cancer UK would advocate that for prostate cancer, it is crucial that the awareness focuses on the risks of prostate cancer, not symptoms, as early prostate cancer often does not show symptoms and if patients wait for these before going to the GP it might result in a higher number of late-stage diagnoses.
To meet the ambitions of the plan, investment needs to be made into embedding changes in public behaviour regarding what they do when they are sick or ill. Barriers that have been evidenced via Cancer Awareness Measures (2018)14 demonstrated that for many, the availability and accessibility of certain GPs was a major barrier.
Many patients also state that they did not want to be seen to be a “fuss”, reinforcing that many will sit on their symptoms longer, thus delaying diagnosis and treatment. So, although the commitment to raise greater awareness of cancer symptoms is good, it should be noted that a one size fits all approach is not appropriate for all cancers and that risk awareness should be the focus for prostate cancer. Further systemic changes also need to be made to help change men’s attitudes towards healthcare nationally.
Use of personalised and risk stratified screening: See answer 2.
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