Cancer Screening Nottingham City Joint Strategic Needs Assessment April 2009 Introduction Cancer screening aims to detect disease at an early stage in people with no symptoms, when treatment is more likely to be effective. The UK National Screening Committee (NSC) assesses the appropriateness of screening programmes. Cancer screening is a statutory responsibility of the Director of Public Health. Cancer screening programmes invite defined populations of well people to undergo a screening test. If the screening test is positive, further tests are carried out to detect a cancer early. Not all with a positive screening test will have cancer, and some people with cancer may have a negative screening test. Screening programmes should do more benefit than harm and should be cost effective. There are three national cancer screening programmes that are all run locally. These are for breast, cervical and bowel cancer. This chapter considers cancer screening only, see elsewhere for prevention and treatment of cancer. Key issues and gaps Breast screening programme is to be extended to nine screening episodes between the ages of 47 and 73 Identification of whether additional staffing capacity will be required to achieve this extension and maintain current screening performance There is inequity in uptake of screening between City Practices, with lower uptake in smaller and more deprived practices Challenging target that by 2010 all women should be informed of their results within two weeks of screening There are a number of different providers and steps in the process from screen to results being delivered. This is currently being reviewed by the SHA. Potential development of inequities in uptake of the programme due to deprivation and cultural/religious issues from some ethnic minority communities. Higher percentage of positive screens than expected Recommendations for Commissioning Appropriate investment to ensure delivery of extension Local publicity campaigns targeting women in this age range Local work with practices where screening uptake is low Focused work is needed to ensure that the two week target for women being informed of results is met 1
Targeted response to any inequities in uptake that come to light as the programme is monitored Ensure provision of appropriate follow up investigations for all those who have a positive screening test Expansion of the programme to include all people aged 70 75 years by 2010 2
1. Who s at risk and why The criteria for who receives screening are laid down by the NSC. This is based on evidence from high quality randomised controlled trials (RCTs) that the screening programme is effective in reducing mortality and morbidity. The NHS Breast Screening Programme provides free breast screening every three years for all women in the UK aged 50 and over. Women aged between 50 and 70 are currently routinely invited for screening seven times. By 2012 this is to be increased to nine screening episodes between 47 and 73 years, with a guarantee that women will have their first screening before the age of 50. Women aged over 70 years may also opt into the programme. All women between the ages of 25 and 64 are eligible for a free cervical screening test every three to five years. In the light of evidence published in 2003, the NHS Cervical Screening Programme now offers screening at different intervals depending on age. This means that women are provided with a more targeted and effective screening programme. Screening commences at age 25, is three yearly for women aged 25-49, five yearly for those aged 50-64 and as required (those not screened since 50 or abnormal tests) for those aged over 65. The NHS Bowel Cancer Screening Programme commenced in April 2008 and offers screening every two years to all men and women aged 60 to 69. People over 70 can request a screening kit by calling a freephone helpline to the programme. 2. The level of need in the population Breast Cancer Screening One in nine women will develop breast cancer at some point in their lives. There are approximately 22,800 women in Nottingham aged between 50 and 70 and therefore eligible for breast cancer screening. Cervical Cancer caused 949 deaths in the UK in 2006 i. There are approximately 67,500 women aged between 25 and 64 living in Nottingham, based on the intervals at which women in different age groups are screened this translates into approximately 20,500 screening tests per year should all women be tested (excluding those tested when over the age of 65). Bowel Screening, About one in 20 people in the UK will develop bowel cancer during their lifetime. Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16 per cent. There are approximately 19,700 people aged 60-69 in Nottingham, given that people are offered screening every two years, this equates to a total of approximately 10,000 people being eligible for screening each year (excluding those tested when over the age of 70). Issues of Inequality See next section Notable changes in need since JSNA April 08 None Nottingham City Joint Strategic Needs Assessment April 2009 3
3. Current services in relation to need Nottinghamshire County PCT lead on the cancer screening programmes for Nottingham City PCT on behalf of the Director of Public Health. There is Patient and Public Involvement representation in the Nottinghamshire Breast Screening Liaison and the Nottingham District Cervical Screening Programme Working Group Meeting. The Nottingham City PCT Bowel Cancer Screening Implementation Group has voluntary sector and public involvement representation. As at March 2007, 76.2% of eligible women within the PCT had been screened in the last 3 years ii. This exceeds the national standard of 70% of women to be screened within 3 years. However, there is considerable variation between practices and groups within the population. A recent Health Equity Audit for Nottinghamshire County (including City) indicates that attendance at breast screening is lower in smaller, more deprived practices iii. It also found lower attendance in women of black and minority ethnic groups. The national standard for cervical screening is for 80% of eligible women to be screened within the last 5 years. In 2007-08 within Nottingham City PCT, 81.5% of eligible women had been screened in the last 5 years iv. For East Midlands, it was 82.4% and England was 78.6%. Nationally, and locally, there has been concern about the decreasing uptake in younger women in recent years. As of September 2005, using deprivation quintiles by GP practice, GP practices in more deprived areas achieved marginally lower uptake rates, reflecting a range of effects of deprivation on the use of preventive health services. This programme commenced in April 2008 so there is not yet published data regarding the performance. Nottingham City PCT is actively monitoring uptake and has developed an implementation group. One of the aims of this group is to identify and address the potential development of inequalities in uptake of the programme due to deprivation and cultural/religious issues from some ethnic minority communities. The percentage of screening tests that are positive has exceeded projections and this has put pressure on the capacity to deliver appropriate diagnostic tests. Work is underway to address this. This high positive rate is not local to Nottingham but appears to reflect a national trend of increasing positive screens with increasing Northern geography. Issues raised by Equality Impact Assessment Lower attendance at screening by those living with higher levels of deprivation and by BME groups Notable changes since JSNA April 08 Statistics updated 4. Projected service use in 3-5 years and 5-10 years Nottingham City Joint Strategic Needs Assessment April 2009 4
There should be a continued achievement of and improvement on the national standard of 70% of women to be screened within 3 years. The extension of breast screening to nine screening rounds between 47 and 73 years will increase the need for breast screening, and will require appropriate investment. The impact of the baby boomers becoming eligible for screening and further increasing demand needs to be assessed locally. The breast screening units should also be adopting digital mammography and by 2010 all women under 50 routinely screened should have this available for assessment visits. There should be a continued achievement of and improvement on the national standard of 80% of eligible women to be screened within the last 5 years. Despite the introduction of the HPV vaccination in 2008 which protects against some of the viruses which are important in the development of cervical cancer, the cervical screening programme will continue. It is possible that attendance at screening will be lower in those women who have been vaccinated and appropriate education programmes may be needed in the future to address this. The Cancer Reform Strategy proposes plans to extend the NHS Bowel Cancer Screening Programme in 2010 to invite men and women aged 70 to 75 to take part v. National guidance regarding this expansion is awaited as is a decision regarding a possible extension to people in their 50 s. These extensions will both impact on the level of service required in the future. 5. Expert Opinion and Evidence Base The UK National Screening Committee (NSC) provides advice about all aspects of screening policy and supports the implementation of recommended screening programmes. The NSC s criteria for screening programmes includes that the opportunity cost of the screening programme (including testing, diagnosis, treatment, administration, training and quality assurance) should be economically balanced in relation to expenditure on medical care as a whole i.e. value for money. http://www.nsc.nhs.uk/ Evidence relating to the effectiveness of the three specific cancer screening programmes is provided on the NHS Cancer Screening Programme website. http://www.cancerscreening.nhs.uk/ The Cancer Reform Strategy sets out the Department of Health policy for the development of cancer services, including screening, over the five years 2007-2012 Department of Health (2007) Cancer Reform Strategy 6. Unmet needs and service gaps Nottingham City Joint Strategic Needs Assessment April 2009 5
Whilst achieving the national standard for breast screening, there still is almost a quarter of the eligible female population not receiving screening. Deprivation and BME have decreased likelihood of attending screening. Late presentation in these groups who are not attending screening may in part explain the high mortality from breast cancer in Nottingham (see cancer chapter). By 2010 all women should be informed of their results within two weeks. The current performance is 6% and work is underway to identify what needs to be done to meet the target. Continued monitoring of the uptake of this newly introduced programme is required. This monitoring will look at levels of uptake within the population as well as results of screening. 7. Recommendations for Commissioning Appropriate investment to ensure delivery of extension Local publicity campaigns targeting women in this age range Local work with practices where screening uptake is low Focused work is needed to ensure that the two week target for women being informed of results is met Targeted response to any inequities in uptake that come to light as the programme is monitored Ensure provision of appropriate follow up investigations for all those who have a positive screening test Expansion of the programme to include all people aged 70 75 years by 2010 8. Recommendations for further Needs Assessment Continuous monitoring of the uptake of the breast, cervical and bowel screening programmes. 9. Key Contacts Caroline Jordan, Health Equality, Nottingham City PCT, caroline.jordan@nottinghamcitypct.nhs.uk i Cancer Research UK (http://info.cancerresearchuk.org/cancerstats/types/cervix/) ii Breast Screening Programme England 2006-07. The Information Centre for Health and Social Care. National Statistics. 2008 iii Breast screening Health Equity Audit for the County of Nottinghamshire. Jullian Mallinson et al. November 2008 iv Cervical Screening Programme, England 2007-2008. The Information Centre for Health and Social Care. 28 October 2008. v Cancer Reform Strategy. Department of Health. December 2007. Nottingham City Joint Strategic Needs Assessment April 2009 6