Londoners have the lowest participation in all three national cancer screening programmes, recent data from NHS Digital and NHS England shows.
The coverage of breast, cervical and bowel cancer screening across London is only 60-65%, significantly below NHS targets and up to 10% less than the rest of England.
Bowel cancer screening, in particular, saw an uptake rate of only 58% in London last year – which is below the achievable threshold of 60% set by the NHS.
Genevieve Edwards, Chief Executive of Bowel Cancer UK, said: “It’s concerning that over a third of people eligible for bowel cancer screening in London don’t complete their test, well below the national average in England as a whole.
“There have been huge efforts to encourage people to take part in bowel cancer screening, but these figures show that we must go further.
“Bowel cancer is the UK’s fourth most common cancer, and screening is one of the best ways to spot the disease early when it’s likely to be easier to treat.”
There are 11 national screening programmes in the UK. Of these, three screen for cancers – specifically breast, cervical and bowel cancer.
The latest figures from the NHS show that uptake rates vary hugely across different London boroughs.
For example, breast cancer screening coverage is 78% in Havering, the borough with the highest uptake, but only 48% in Kensington, the borough with the lowest uptake.
However, despite this huge variation across London, there are some consistencies: the boroughs with the highest uptake are the same for all cancer screening programmes, and the same applies for the boroughs with the lowest uptake.
Each cancer screening programme involves a different type of test and is accessed differently, so why does London consistently struggle to engage with all three, and why do the same boroughs struggle with all three?
What do they have in common?
Invitations for all the cervical cancer screening programmes are sent out based on people’s registration details with a GP.
Although invitations are now transitioning to a digital-first approach – meaning that people are first sent invitations through the NHS app – this is followed by a letter through the post.
In areas where there is high population mobility, this can lead to invitations being sent to incorrect addresses and people not receiving their invitations as a result.
This is a well-known issue and was highlighted at the London Assembly in February when last year’s figures for breast cancer screening were discussed, and is also identified in Breast Cancer Now’s report titled No One Left Behind: opportunities to improve breast screening uptake in London.
According to the latest ONS data on internal migration, the London boroughs which saw the least “population churn” were Havering, Bexley and Bromley.
These are also the London boroughs which consistently have the best cancer screening uptake in London, with levels generally above the national average even if below NHS targets.
However, it does not fully account for the London boroughs with the poorest uptake – which for all three screening programmes are Westminster, Kensington and Chelsea, and Tower Hamlets.
These boroughs are not in the top five experiencing high population mobility.
Helen Hyndman MBE, Lead Nurse at the Eve Appeal, which supports women with gynaecological cancers such as cervical cancer, said: “The main reasons that I come across are general challenges and obstacles to accessing healthcare, fear, embarrassment and other psychological deterrents, and finally some demographic factors.
“A lot of people are really afraid of cervical screening. They’re afraid of it being painful.
“Alongside that is the embarrassment of getting undressed and having other people see their genital area, particularly in certain cultures.
“We have people who have experienced trauma – this can be sexual trauma, it can be medical trauma, or they may have had bad previous experiences.
“Some people are afraid that another member of their family may open their mail and may find out they’re HPV positive – they’re afraid of the impact that this is going to have within their family and their community.”
The latter is a risk that is being mitigated by switching to sending results via the NHS app.
Hyndman also talked about the challenges experienced around fitting appointments around work schedules, childcare and other commitments, which disproportionately affect people experiencing higher levels of socioeconomic deprivation.
The latter is well-recognised, especially in the bowel cancer screening programme, where the annual report provides data by deprivation quintile, but it has also been highlighted as a significant factor by many stakeholders involved in breast cancer screening, including Breast Cancer Now.
Another issue which is referenced by Hyndman as “demographic factors” is the lower uptake rate among some communities, particular those who are from ethnic minority groups, those who are disabled or those who are LGBTQ+.
This is again a well-established issue across all cancer screening programmes and was discussed at the London Assembly and highlighted in reports from many cancer charities, as well as acknowledged on the NHS information pages.
These factors are especially pertinent to London as they often do not exist as separate problems but instead often have intersectionality.
Especially in an area as diverse as London, this becomes a widespread issue.
How racism affects health is a joint report by the Runnymede Trust and the Health Foundation released last year which found that people of colour are more likely to be affected by socioeconomic deprivation and more likely to move homes or face homelessness.
A stark example is the finding that over half of Bangladeshi households are in the lowest income quintile compared to 18% of White British households.
How can we improve screening uptake?
Breast Cancer Now urges that greater collaboration and partnership between all London services is vital to increase uptake and tackle health inequalities in breast cancer screening services.
Their No One Left Behind report makes recommendations to address each barrier to screening identified, including a Transport for London (TfL) public health awareness campaign which is under consideration, and more accessible screening facilities, which at present are mostly located in hospital a significant commute away.
Many charities are also organising awareness campaigns and funding research projects to improve access to cancer screening in London.
Breast Cancer Now recently awarded funding to Dr Judith Offman at Queen Mary University of London to investigate the experiences of women from different ethnic backgrounds and identify ways to make screening more comfortable.
Bowel Cancer UK is running an awareness campaign called the Early Diagnosis Programme which begins this month and will focus on five regions in the UK, of which Croydon is one.
Hyndman said: “The Eve Appeal and the NHS are now providing lots of information in different formats and languages to try to overcome some of the cultural barriers we encounter.
All of the information has been co-designed with members of these communities – they are people who will be receiving this information and they give us really good insight.”
Hyndman also talked about the implementation of reasonable adjustments for people who are disabled or have experienced trauma.
Many communities are also leading with local initiatives of their own which centre around shared identities, cultures or faith, to better improve uptake within their communities.
One significant change which is awaited for cervical cancer screening is the introduction of self-testing kits later this year.
Many charities also provide resources to help reduce pain during screening, with UK Cervical Cancer providing a comfort checklist as well as a menopause checklist.
Jenny Greenfield, Trustee of UK Cervical Cancer, said: “I feel we are all doing bits and pieces but I worry that it may not be enough – we need more coordination and funding. But it’s difficult.”
With significant attention called to other screening programmes, Greenfield feels cervical cancer has been somewhat forgotten lately.
“It’s a bit as if it’s the poor man’s disease,” she said.
There are strong associations between poverty and worse cervical cancer outcomes – with Cancer Research UK linking about 500 cases per year in England with socioeconomic deprivation.
Cervical cancer is not one of the commonest cancers in England but unlike breast and bowel cancer, it is considered largely preventable as almost all cancers are a direct consequence of infection with the human papilloma virus (HPV).
Despite the NHS pledging to eliminate cervical cancer by 2040 through a combination of the HPV vaccination programme and the cervical screening programme, Cancer Research UK projections suggest there could be 1,200 cervical cancer deaths annually in the UK by 2040, an increase from the current 700 deaths per year.
Concerningly, unlike breast and bowel cancer screening, cervical cancer screening uptake has been steadily falling for the past decade.
In Kensington and Chelsea and in Westminster, less than half of women take part in cervical cancer screening – which is far below the NHS target of 80%.
Cervical cancer screening results in London also tend to be worse than the national average – only 93% of tests are normal compared to 95% across the rest of England, and there are nearly twice as many cases of abnormal cell changes.
Greenfield said: “I feel that it’s just so, so hard to break down the barriers that have been built into women for so many years.”
Featured image by Martin Dunst under CC BY-SA 4.0
Join the discussion