Published on 7 December 2021
Why screening can bring better outcomes for patients, how the Cancer Alliance is supporting it, the impact of COVID-19 on services and what the future holds
By Tracey Wright, CMCA Associate Director
Screening for cancer is a key process in ensuring disease is found early in people across Cheshire and Merseyside – which gives them best chance of surviving and prospering after a diagnosis.
Screening involves checking for cancer – or abnormal cells that might become cancer in the future – in people who do not have symptoms but who have higher than usual risk factors.
The risk factors can include age, gender, race, lifestyle and a family history of cancer.
If you are invited to attend a screening check, it is really important that you do – it could save your life by finding cancer in its initial stages before symptoms appear and when it is much easier to treat successfully. Screening can also prevent cancer by alerting clinicians to the need to perform pre-cancerous procedures.
While screening is not all good, with some tests being invasive or having the chance of a wrong result, they are one of the main reasons why cancer has been discovered earlier and more people than a generation ago are being cured of the disease.
Cancer Alliances – including Cheshire & Merseyside Cancer Alliance – have ambitious targets set in NHS England's Long Term Plan with a commitment to improve this even further, by detecting 75% of cancers early – called stages I and II – by 2028. This means an extra 55,000 people each year in the UK would survive cancer for five years or more following their cancer diagnosis.
Screening programmes are only set up for a cancer type if they will save lives from the disease without too much risk. If there is not a good enough screening test, or screening would do more harm overall, then a screening programme is not introduced.
The three NHS screening services that are carried out routinely in England are for:
• Bowel – offered to people aged 60-74
• Breast – offered to women, some transgender men and some non-binary people aged 50-70
• Cervical – offered to women, some transgender men and some non-binary people aged 25-64
In Cheshire and Merseyside there are around 15,000 new cancer diagnoses each year. In 2018/19, new diagnoses rose to 15,895, equivalent to 598 new cases per 100,000 people in Cheshire and Merseyside. This is higher than the England average of 529 new cases per 100,000 people.
Of these 15,895 cases, around 2,800 (2018/19) were emergency presentations. An emergency presentation for cancer is where a patient’s first hospital admission due to cancer is identified as an emergency admission. Emergency admission routes can be via A&E, via an emergency admission request from a GP, or via any other emergency route.
Numbers of emergency presentations in Cheshire and Merseyside have reduced by over 8% in the past 10 years, as patients are identified earlier through other pathways, such as national screening programmes. The latest data for 2019/20 identified 2,684 emergency presentations in Cheshire and Merseyside, compared to 2,911 in 2009/10. This reducing trend in emergency presentations is also seen nationally.
Emergency presentation rates in Cheshire and Merseyside remain higher than the England average. In 2019/20 there were 100 emergency presentations per 100,000 people, compared to 85 per 100,000 nationally. The gap between Cheshire and Merseyside and England has remained consistent over the past 10 years.
Although the number of emergency presentations in Cheshire and Merseyside is reducing, it remains high compared to the national average. This is in line with the higher volume of cancer diagnoses seen in the area.
Patients diagnosed with cancer via emergency presentation tend to have a more advanced form of the disease. By identifying cancers at an earlier stage through screening programmes and GP referral pathways, we can improve outcomes for cancer patients and reduce emergency presentations.
National screening programmes can identify cancers at an earlier stage, making them more treatable, which is why it is so important that everyone eligible should take part in their check when invited. Currently, there are national screening programmes for cervical, breast and bowel cancers.
Uptake of cervical screening in younger women in Cheshire and Merseyside is significantly higher than the national average, however, in the older population, uptake is significantly lower than the national average.
In 2019/20, 72.9% of eligible women aged between 25 and 49 had undergone cervical screening in the past 3.5 years, compared to 70.4% nationally. Meanwhile, 74.5% of eligible women aged 50-64 in Cheshire and Merseyside had undergone cervical screening within the past 5.5 years, compared to 76.2% in England overall.
Uptake of bowel screening in Cheshire and Merseyside is significantly lower than in England as a whole. In 2019/20, 62.3% of eligible people aged 60 to 74 had been screened in the past 2.5 years, compared to 63.8% nationally. Uptake of breast screening in Cheshire and Merseyside in recent years has been higher than in England as a whole. In 2019/20, 70.5% of eligible women aged 50 to 75 had been screened in the past three years, compared to 70.1% nationally.
Prostate cancer is the most common cancer in men, but although there is a test – the PSA test – that can give an indication of the disease, it is not reliable enough to warrant it being used in a national screening programme.
There is also no national lung cancer screening programme, although the NHS has a service which targets people who have ever smoked between the ages of 55 and 75.
These Targeted Lung Health Checks have restarted in certain areas of Cheshire and Merseyside and those people with a high risk of lung cancer, and are implemented in areas where there is a high incidence of lung cancer.
These TLHCs restarted in Liverpool in July and by the end of November 2021, 10,000 people had been invited to have a check. During November and December 2021 eligible people in Knowsley and Halton have also been invited to them and the programme will also roll out to St Helens and South Sefton in mid-2022.
So, what is CMCA doing to improve the take-up of cancer screening?
CMCA has secured national cancer transformation funding to take forward an ambitious programme of work delivering improvements in the uptake of bowel, breast and cervical screening.
There is considerable organisational support across Cheshire and Merseyside to undertake a broad range of work including:
• Recruiting and training screening co-ordinators to support improvements in uptake of breast and bowel cancer screening
• Implementation of text messaging appointment reminders for cervical screening
• Engagement and mobilisation of community organisations for screening promotion
CMCA has been working on a Cancer Screening Toolkit with Champs public health collaborative – an organisation which brings together the nine Directors of Public Health and their teams across the sub-region – and communication experts to develop a cancer screening programme toolkit that provides education, engagement and resources to primary care professionals and wider partners on the cancer screening programme to empower them to promote uptake.
The Alliance is also:
• Partnering with the Health and Care Partnership to improve uptake in cancer screening programmes. This will include a particular focus on reducing health inequalities for people/communities who face barriers to participation in screening or are disengaged, including underrepresented ethnic communities; people living with a learning disability and the LGBTQ community
• Developing a range of materials to support engagement and uptake to cancer screening programmes
• Working to gain commitment from high-profile local people to support videos and blogs to promote uptake to cancer screening programmes
Cancer Screening Co-ordinators
One major initiative which CMCA is instigating to improve screening take-up is funding of Cancer Screening Co-ordinators, who promote and support the bowel and breast screening programme across Cheshire and Merseyside.
CMCA is funding this through NHS Transformation Funding and the co-ordinators are managed by Champs. The co-ordinators work with people to overcome barriers and help them to understand the medical system and explain the value of screening. Their support can help people get the screening and follow-up care they need.
One of the co-ordinators is Alysha Hughes, based in Aintree University Hospital, at Liverpool University Hospitals NHS Foundation Trust, who covers Southport and Ormskirk, Merseyside, St Helens, Knowsley, North Cheshire/Warrington and Halton.
Alysha has previously worked in the NHS as Endoscopy Team leader in Wales but was always interested in the cancer screening programme.
She said: “When this role became available I instantly knew it was something I would love to be involved in and progress. I was delighted to receive the news I had been offered the position and couldn’t wait to start this new chapter in my life in Liverpool and a new trust.
“I am extremely passionate when it comes to helping patients through their cancer pathway and early diagnoses.
“It is quite close to home as my auntie has had Triple Negative Breast Cancer in 2017, followed by TNBC Mets Brain tumour in 2020.
“The effect this has had on her long term has made me want to do more for those who are diagnosed – and cancer screening programmes are a great way to help prevent and reduce the chances of having a worrying diagnosis.
“I am dedicated to helping improve the uptake for bowel cancer screening and if I can make a difference to at least one person’s view on screening programmes then I will be exceptionally happy.”
Another bowel screening co-ordinator who joined the programme this year is Jake Cole.
Jake is employed by Mid Cheshire NHS Foundation Trust as Bowel Cancer Screening Coordinator, covering west, east and south Cheshire together with Vale Royal.
Jake’s role is to encourage those eligible for bowel cancer screening by sharing information and engaging directly with local people to answer their questions and support people throughout their screening journey.
Jake said: “I’ve worked in the NHS for three years and I’m committed to making a genuine difference to people’s lives.
“I applied for this role as almost all of us will have been affected by cancer, either directly or indirectly and I wanted to contribute to making cancer screening a well-informed, accessible process across society which will help tackle health inequalities and ultimately, save lives.”
You can find out more about the screening co-ordinators in Cheshire & Merseyside here.
Liverpool Bowel Screening Awareness Campaign
CMCA created a campaign to promote bowel cancer screening which targeted South Asian communities in Liverpool.
Bowel screening aims to find cancer early or to find changes in your bowel that could lead to cancer. The screening programme sends a bowel cancer testing kit every two years to people who can take part.
The test is called FIT, the Faecal Immunochemical Test. It looks for tiny traces of blood in poo, which can mean cancer could develop.
With support from Liverpool CCG and the city council’s public health team, the Alliance created videos in five South Asian languages to explain how to perform the test and also made videos which highlight the importance of doing the test if you receive one.
The videos were narrated by clinicians from the target communities, including GPs, in the five most common South Asian languages among people whose first language is not English.
People from South Asian communities are only 50% as likely to carry out the test compared with those from a white British background and the videos were promoted through community groups, PCNs and outreach workers, via a toolkit and quote cards, with links to the Alliance’s YouTube channel.
They will be used to promote the test with South Asian communities in other areas in the future, too.
The future of screening
At the moment, there is not enough evidence to say that screening for any type of cancer other than breast, bowel, and cervical cancer would be a good idea. However, this may change.
CMCA is helping with a large clinical trial being conducted by the NHS and healthcare company called GRAIL to see if a test for up to 50 different types of cancer could, eventually, become another screening programme.
A number of areas across Cheshire and Merseyside have already taken part in the NHS-Galleri study, including Runcorn, Warrington and St Helens.
It is a simple blood test that research has shown is particularly effective at finding cancers that are difficult to identify early – such as head and neck, bowel, lung, pancreatic, and throat cancers. It works by finding chemical changes in fragments of genetic code – cell-free DNA (cfDNA) – that leak from tumours into the bloodstream.
Initial results of the study are expected by 2023 and, if successful, NHS England plans to extend the rollout to a further one million people in 2024 and 2025.
CMCA Medical Director Dr Warburton said: “This quick and simple blood test could mark the beginning of a revolution in cancer detection and treatment here and around the world.
“By finding cancer before signs and symptoms even appear, we have the best chance of treating it and we can give people the best possible chance of survival.
“The NHS has a successful track record of leading the way on innovations in cancer diagnosis and treatment, from CAR-T therapy to COVID-friendly drugs.
“The Galleri blood test, if successful, could play a major part in achieving our NHS Long Term Plan ambition to catch three-quarters of cancers at an early stage, when they are easier to treat.”
The study of genomics may also play a major role in the development of screening for cancer in the future. There may be test for genes which increase the chances of someone developing cancer.
However, for the time being, the best way to find cancer earlier is for people to continue to attend their screening appointments – to reduce the chance of a poor outcome if cancer is found.
To find out more about Cheshire and Merseyside’s Cancer Screening Improvement Project, please visit: www.champspublichealth.com/cancer-screening or see https://www.champspublichealth.com/cancer-screening/
Statistics used in this blog are taken from PHE Cancer Services Fingertips tool – see: https://fingertips.phe.org.uk/profile/cancerservices