3 Reducing geographical inequalities
11. There are clear and unacceptable inequalities
in outcome between different parts of the country. There is a
"North-South" contrast in mortality rates (Figure
3),[26] suggestive
of inequality between affluent and poorer areas, although the
degree varies between individual cancers. Figure
3: Cancer mortality rates 1998-2000: 10 highest and 10 lowest
health authorities
12. In the late 1990s, research established that
survival rates for 44 of the commonest 47 cancers were worse in
deprived areas. Further research in 2003 established that, as
survival rates improved generally during the 1990s, the five year
survival gap between better and worse off has widened for both
men and women, for the majority of cancers studied.[27]
13. England (together with Wales and Scotland) has
also traditionally suffered high cancer mortality rates compared
with other European countries. Male cancer mortality rates now
compare favourably with many countries in Europe and the United
States, due to long-term falls in smoking rates in the UK. On
the other hand, mortality rates for women remain among the highest
internationally. Historically more women in the UK have smoked
than in many other countries.
14. Variation in the stage at which the cancer is
diagnosed is an important contributory factor in explaining some
of these inequalities both within England and between England
and other countries. Unfortunately, it is not known how widespread
variations in 'staging' are, because of the difficulty cancer
registries have in collecting comprehensive data.[28]
In particular, people in less affluent areas seem more likely
to be diagnosed at a more advanced stage, for the reasons explored
in Part 1.
15. Figure 4 illustrates, however, that variable
outcomes are not limited to deprived areas. Mortality rates for
a number of cancers can also very widely between areas which have
a similar level of incidence.[29]
It is not clear how variations in access to skilled clinicians
and equipment might also contribute to variations. The Department
acknowledged that recruitment of skilled staff is still not meeting
demand nationally.[30]
But the distribution of pathologists and oncologists, for example,
does not indicate a bias towards more affluent areas.[31]
The provision of scanners has traditionally favoured London, although
new procurement is reducing the variations between regions. Figure
4: Differences in cancer mortality between areas with almost identical
levels of incidence
16. The C&AG's Report highlighted wide variations
in the availability of treatments such as Herceptin,[32]
which is suitable for the treatment of some women with advanced
breast cancer and can roughly double their survival time.[33]
The recent review of chemotherapy provision by the National Cancer
Director,[34] just before
our evidence session, revealed considerable variations around
the country in the availability of a significant number of chemotherapy
drugs approved by the National Institute for Clinical Excellence.
In the review, local NHS Cancer Networks reported that uneven
availability is not due to problems in getting funding for drug
purchases,[35] but rather
to:
- lack of specialist staff and
unsuitable pharmacy accommodation; and
- variations in clinical practice in the prescribing
of approved drugs, leading to local variations in the implementation
of NICE guidance.
17. The Secretary of State has accepted the recommendations
of the review. The main recommendations are that:
- NICE should include the resources
required for implementation in its appraisals of new treatments;
- capacity planning models should be developed
for chemotherapy at the local level; and
- implementing electronic prescribing of chemotherapy
in hospitals should be brought forward from its previous delivery
date of 2008-10.
26 Qq 28-30, 45-47 Back
27
Qq 32-42; C&AG's Report, para 1.5 Back
28
Q 131 Back
29
Qq 107-110 Back
30
Q 9 Back
31
C&AG's Report, paras 2.52-2.54, 2.59-2.61 and Figure 40 Back
32
Qq 132-135, 151-157 Back
33
Full guidance on Trastuzumab for advanced breast cancer,
National Institute for Clinical Excellence, 2002 Back
34
Qq 1, 11-13, 136 Back
35
Qq 92-104, 137-138, 147-150 Back
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