Journal of the National Cancer Institute Advance Access originally published online on March 25, 2008
JNCI Journal of the National Cancer Institute 2008 100(7):454-455; doi:10.1093/jnci/djn093
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© Oxford University Press 2008.
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Prevention, Survivorship Highlighted in England's Cancer Plan Update
Cancer prevention and survivorship feature prominently in England's latest update to its national cancer plan. The update—called the cancer reform strategy—comes with £370 million (US$740 million) in new funding, though critics say that's not nearly enough to make effective changes.
"Cancer's a fast-moving area, and we’ve made a lot of strides in a lot of different areas. [The cancer reform strategy] is moving the agenda on with a focus on areas that weren’t focused on as strongly in the cancer plan," said Teresa Moss, director of the National Cancer Action Team, part of England's National Health Service (NHS).
Although the original cancer plan in 2000 did cover some aspects of prevention, the update strengthens the focus. "It's a slightly different emphasis," said Catherine Foot, head of policy for Cancer Research UK. "For instance, in 2000, the evidence wasn’t as clear as it is now on the link between obesity and cancer. In 2000, the policy initiatives on diet and cancer were things like the 5-a-day fruit and vegetable initiative, whereas now, we’re looking at obesity and weight management. It's a shift in priorities."
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The reform strategy's prevention measures include a commitment from the government to reassess tobacco control policies, a specific initiative to target obesity in children, and the expansion of the government's campaign on skin cancer awareness.
Also coming up in the next few years is a national human papillomavirus (HPV) vaccination campaign. Beginning in September of this year, all 12- and 13-year-old girls will receive the HPV vaccine. The following year, the health service will provide a catch-up program for girls up to the age of 18 who haven’t received the vaccine for HPV.
Unlike prevention, cancer survivorship was largely absent from the original cancer plan. To that end, the reform strategy announced the creation of a national cancer survivorship initiative that will connect government, cancer charities, doctors, and patients to improve services for people living with cancer. "It's going to bring all major stakeholders together to try to understand these models of follow-up better and try to work out how we can develop more personalized care for cancer survivors," Foot said.
Part of improving survivorship is understanding the factors that contribute to it. Cancer survival rates in England are fairly low compared with those in the rest of Europe—on par with Eastern European countries that spend far less on cancer care, according to last September's EUROCARE-4 study, a pan-European comparison of cancer rates. A major reason for the low survival rates, Foot said, is late diagnosis. At issue is "what can we do to encourage people to go to their doctor earlier, to understand what the signs and symptoms of cancer are, and, in primary care, [to] have speedy access to the right diagnostic tests and onward referral to get treatment quicker," she said.
A fair portion of the reform strategy focuses on what happens after cancers are diagnosed. About £200 million (US$400 million) of the budget allocated to the reform plan will go to radiotherapy, both for new equipment and new staff. "With [the 2000] cancer plan, we gave out radiotherapy machines. That was very effective in developing radiotherapy services," said Michael Williams, M.D., vice president of the Royal College of Radiologists. "Radiotherapy services are better than they were in 2000."
But there's still a lot of room for improvement. Williams and his colleagues published a study last year showing that England would need to increase its services by more than a third if all cancer patients are to receive the recommended course of radiotherapy for their cancer. And indeed, the new strategy acknowledges that services will have to be improved to meet its ambitious mandate regarding wait times. Previously, cancer patients could expect to receive their first treatment, whether it was surgery or chemotherapy, within 31 days of diagnosis, according to national wait time targets. The updated plan extends this 31-day target to all subsequent treatments as well. "The largest impact of this change will be in radiotherapy delivery, where increased capacity will particularly be needed and some areas will not be able to meet this deadline," the report notes.
Although the reform strategy comes with some of its own funding, it's not enough, said Karol Sikora, M.D., who chaired the independent-sector advisory group. "It was made clear at the beginning that there was going to be very little money to add, and indeed there is very little money added—it's trivial," he said. The overall budget for cancer services in England—which doesn’t include cancer prevention programs—is about £4.35 billion (US$8.74 billion) per year, and the reform strategy comes with just £370 million (US$740 million) for the next 3 years. And not all of that is new money; some is money that the NHS expects to save over the next few years by eliminating unnecessary hospital admissions.
Sikora said he thinks that to truly improve cancer services, the national health system needs a major overhaul. "You can get the best care in the world out of the NHS," he said. "But you can also get some pretty shoddy care, and that's the paradox. It can be in the same town, or even the same street, depending on what referral you get."
Officials hope this cancer plan update will ultimately improve cancer services in all aspects, from diagnosis to treatment and beyond. "[The reform strategy] is making sure that we work at both ends of the cancer pathway—getting people into the system earlier so they’ve got a better chance of cure through screening and through new initiatives, but also recognizing that people will live longer with their cancer and helping them to take an active part in making sure that they have fulfilling lives," Moss said.
Highlights of the Cancer Reform Strategy
Prevention
- Tobacco control: This spring, the UK government will consider proposals on new tobacco control measures, such as banning cigarette machines and cigarette advertising in shops.
- Obesity: Given new evidence on obesity and cancer since the 2000 plan, the update lends its support to a cross-government strategy on reducing obesity in children.
Early Diagnosis
- Breast screening: The reform strategy extends the breast screening program to provide women nine screenings between the ages of 47 and 73, instead of seven between the ages of 50 and 70.
- Colon screening: Currently, fecal occult blood testing is offered only to men and women aged 60–69 years. The new plan will include those aged 70–75 years.
- National Awareness and Early Diagnosis Initiative: The initiative will work to develop tools to increase symptom awareness among the general public.
Treatment
- Wait times: The 2000 cancer plan set a 31-day standard for the maximum time from cancer diagnosis to first treatment. The reform plan now applies this standard to all subsequent treatments.
- Laparoscopic surgery: The government will establish a training program for laparoscopic surgery for colorectal cancer.
- Radiotherapy: The plan allocates £200 million (US$400 million) to invest in staff and equipment.
Living With Cancer
- The health service will develop cancer-specific information for cancer survivors.
- Psychological support services will be made available for cancer survivors.
- Financial support will be provided for cancer survivors.
These tasks will be carried out through the National Cancer Survivorship Initiative.
Reducing Inequalities National Cancer Equality Initiative: This initiative will focus on collecting data to understand inequalities among groups on the basis of socioeconomic status, ethnicity, age, religion, disability, or sexual orientation. It was established to ensure "that we drive out inequalities in all areas, such as differential access to services and making sure that different groups all have good access and good information to support them," Moss said.
Data Collection Various sections of the reform plan address issues of data collection to better understand the cancer problem. For example, the report calls for the following:
- a national audit of primary care for newly diagnosed cancers;
- chemotherapy providers to collect specific data on patients to better understand why there are variations in chemotherapy administration;
- national surveys to assess awareness of cancer risk factors and symptoms; and
- a National Cancer Intelligence Network to collect, analyze, and annually report data on clinical outcomes and patient experiences.
The full text of the cancer reform strategy is available on the UK's Department of Health Web site at http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Cancer/index.htm.
—Kate Travis
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