From gender to race: how cancer inequality is being tackled across the UK

<span>A study found black people were less likely to receive their cancer diagnosis through screening than white people – which may mean cancer is diagnosed at a later stage</span><span>Photograph: CRUK</span>
A study found black people were less likely to receive their cancer diagnosis through screening than white people – which may mean cancer is diagnosed at a later stagePhotograph: CRUK

Since the 1970s, cancer survival has doubled in the UK, but who gets and survives cancer can be impacted by who you are and where you live. This is part of a bigger picture in which health inequalities are getting worse and the gap between the richest and poorest areas in the UK continues to widen. Life expectancy, for instance, sits consistently below average in the least wealthy areas.

It is estimated that there are more than 33,000 extra cases of cancer in the UK each year associated with deprivation. Investigations by Cancer Research UK have recently revealed useful insights about this disparity – as well as initiatives to remedy it, such as how to boost diversity among clinical trial participants so data exists on a more representative spectrum of the population, and how to encourage a broader uptake of cancer screening among diverse socioeconomic groups. Cancer Research UK is campaigning for all of this, which is possible thanks to their supporters. A third of the charity’s funds come from gifts in wills to work towards a greater understanding of the disease and help reduce inequalities across the different areas and services.

  • Light micrograph showing squamous cell carcinoma of the human bronchus, one type of lung cancer, which is more common in deprived areas, largely due to the effects of smoking. Photograph: Science Photo Library

Establishing the risks of deprivation

The prevalence of smoking across the UK – the biggest cause of cancer deaths – is in itself a stark illustration of our burgeoning health inequality. According to the Office for National Statistics, around a third of all adults who smoke in England in 2021 lived in the most deprived places; that’s 33.1%, up from 29.5% in 2017. People living in the most deprived areas are more than three times as likely to smoke compared with people living in the most affluent areas and, UK-wide, people in these deprived areas are twice as likely to develop smoking-related cancers, such as laryngeal and lung. This in large part accounts for why, the poorer you are, the more likely you are to die from cancer in the UK – but there are other factors.

  • Fluorescence light micrograph of metastatic melanoma cells. Photograph: NCI Center For Cancer Research/National Cancer Institute/Science Photo Library

Children in deprived areas are more likely to grow up overweight or obese, increasing their risk of developing a range of cancers, from colorectal and pancreatic to breast and uterine. And for some cancers, diagnosis comes later in the progression of the disease, deprivation being associated with a 50% greater chance of cancer being spotted through emergency routes, such as presenting at A&E, rather than through GP care. All this means that survival outcomes for certain cancers, such as bowel and breast, are lower in more deprived areas.

Closing the minorities screening gap

There are three cancer screening programmes in the UK, for bowel, breast and cervical cancers, but Cancer Research UK has learned that stigma surrounding these diseases is a significant barrier to participation in screening among some ethnic minority groups. Iyna, of south Asian heritage, found this after her breast cancer diagnosis. “It’s not seen as OK to speak about your breast or genitals or your bum,” she says of her family’s community. “You would say: ‘I’ve got a pain in my leg or my foot,’ but you wouldn’t say: ‘I’ve got a pain in my breast.’”

There is also a fearful association between cancer and certain death among some groups which, says Iyna, can lead to a fatalistic view of a diagnosis. “People would say: ‘Why would I want to know? You’re going to end up dying, so what’s the point?’” But the screening gap among some ethnic groups doesn’t end there. A 2022 study published in the journal Nature found that black people were less likely than white people to get their cancer diagnosis through screening – which aims to detect cancer at an early stage before the disease develops further.

But Cancer Research UK-funded work has found that regular gentle reminders can encourage screening uptake – for instance, by sending annual invites to non participants. And a pilot programme in Scotland to address low screening participation among Muslim women has recently been funded to expand into the north of England. In the pilot, it emerged that while some of the women simply hadn’t been aware of screening, others felt too shy to take part or were worried about physical examinations by male doctors. As part of the next phase, a series of workshops will tackle potential barriers to screening, empowering communities with specialised health education – because one size doesn’t fit all – and by hearing Muslim women’s experiences of screening. “Women can be uncertain as to how screening fits in with their faith,” says Cerysh Sadiq, research assistant at the University of Sunderland’s School of Medicine, who is giving talks as part of the programme. “It will be a great privilege to help guide women and assist with any religious concerns they may have about cervical, breast and bowel cancer screening.”

  • Top: Alfred, who took part in a clinical trial for prostate cancer. Below: a pilot scheme in Scotland helped more Muslim women take up cancer screening. Photograph: Shutterstock

Diversifying cancer research

In 2012, Alfred was diagnosed with advanced prostate cancer. It had spread to his bones, was inoperable and he was advised to think short-term. When his consultant asked if he wanted to take part in the Cancer Research UK-funded STAMPEDE trial, researching multiple combinations of treatments for prostate cancer, the former bodyguard to celebrities such as Beyoncé thought: “I have nothing to lose.” The trial involved a hormone injection every 12 weeks. It wasn’t without its side effects, but after six months, tests showed it was working and he has continued the treatment, with his cancer currently stable. Not only has he helped progress medical science, but he has contributed to the shamefully sparse trial data on people from minority ethnic groups.

Related: From chemo to surgery: how cancer treatments are becoming kinder

Only in recent years has it become a mainstream issue that much of the scientific research has traditionally focused on white men, to the exclusion of all others. Influential organisations, from the NHS to Cancer Research UK – the largest independent funder of cancer research – have been striving to redress this imbalance by ensuring that data exists not only across genders but also ethnic groups.

One way to tackle the problem is to ensure there’s a representative range of gender, race and physical ability across the research community. This is key in order to build trust with diverse groups, overcome cultural barriers, and raise awareness of clinical trials among traditionally underrepresented communities.

Progress is being made here through schemes such as Women of Influence, which pairs exceptional researchers and cancer scientists early in their careers with experienced female business mentors.

Then there’s the Black Leaders in Cancer PhD Scholarship programme, which funds black or black-mixed heritage cancer scientists for a four-year PhD course, offers places for doctorate training at a Cancer Research UK centre and continued mentorship. This is all in partnership with the organisation Black in Cancer, which champions black excellence in cancer research and medicine, and the Windsor Fellowship, a charity that aims to help unlock the talent of under-represented people.

Getting equitable treatment for LGBTQ+ people

In 2019, a study looking at how oncologists work with LGBTQ+ patients found that while most of them felt comfortable treating this community, gaps in their understanding often made these patients less at ease. Red flags for these patients included no effort being made to ascertain their chosen pronouns from the outset, and partners being assumed to be friends or siblings.

A cancer diagnosis in itself is a huge mental health challenge, and seemingly small slips like these can undermine the clinical relationship, potentially discouraging a patient from contacting a doctor when there’s a problem.

  • Top: cervical cancer cells. Photograph: Steve Gschmeissner/Science Photo Library. Below: some LGBTQ+ patients can feel less at ease discussing health concerns. Photograph: Getty Images

Older patients, who bear historic stigmas from the days when homosexuality was taboo, might instinctively be more secretive with doctors. Some patients have several differences they might face discrimination over – such as gender, sexuality, disability and race. So every patient’s needs and sensitivities must be treated as unique.

There’s a huge amount of catching up to do concerning cervical and breast cancer screening for trans people, and making the screening process less stressful and more accessible is essential for preventing and treating more cancers. Information of eligibility is lacking – for instance, trans men registered with a GP as male aren’t automatically invited for cervical cancer screening, although an update to the protocol is in the works.

Gender dysmorphia can be a barrier to screening in itself as some trans men with cervixes don’t identify with that part of their bodies. And because of their higher testosterone levels, the cervix is less naturally lubricated, which can make screening more physically uncomfortable, but offering muscle relaxants, a smaller speculum and applying more lubrication can help – if the medical staff are aware. This is why Cancer Research UK advocates better education for medical professionals, so they know to schedule a little additional appointment time, and use the right pronouns so they can fully support transmasculine patients. Meanwhile, research is underway for alternative ways to test for HPV – the virus that causes virtually all cases of cervical cancer – in transmasculine people (a development that would benefit cis women, too).

Actively generating greater diversity among researchers and oncologists is also essential, not least for better designed trials that appeal to and specifically help improve treatments for the LGBTQ+ community.

Funding the future
A pledge of a gift in your will could lead to investments in research that further change the outcomes for people affected by cancer, helping them live longer, better lives. These legacy gifts enable Cancer Research UK to commit to the large-scale, long-term research projects that yield the biggest breakthroughs.

Gifts in wills are vital to accelerating progress, and fund one-third of Cancer Research UK’s work, enabling lifesaving breakthroughs.
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