Doctors in a hospital corridor

Cancer survival is a key measure of the effectiveness of healthcare systems. In the UK, the fact that people are less likely to survive their cancer when compared to people in other, similar countries, has been an important driver of reform and investment in healthcare.

International differences in how likely people are to survive cancer can be the result of a variety of factors, from late-stage diagnosis to patients not having the most effective treatment.

When it comes to how cancers are diagnosed, there are a range of different ways, or routes, through which this can happen.

Previous research has shown that a large proportion of patients with cancer are diagnosed via an emergency route, and these patients are more likely to have poor survival, even when you take account of the fact that they’re also more likely to be diagnosed at a late stage. People diagnosed through this route tend to be older, more deprived, or those with cancers with non-specific symptoms.

Patients with cancer diagnosed through the other, more ‘managed’ routes, like cancer screening, are more likely to have early-stage disease and higher survival.

“Cancers diagnosed through emergency routes are often more advanced than those caught after GP referral or through screening. This can affect someone’s chances of surviving cancer, and affects the type of treatment they’re offered,” says Dr John Butler, clinical lead for the International Cancer Benchmarking Partnership (ICBP).

The ICBP, which is hosted by Cancer Research UK, has been reporting international variation in cancer survival for over 10 years, giving us insight into how the UK compares internationally. The partnership also, uniquely, explores what factors are driving differences in cancer survival, so that it can identify changes to policy and practice that could make an impact for patients.

For the first time, a new study from the ICBP, published in The Lancet Oncology, has reported international differences in proportions of cancer emergency presentations, and links this to differences in cancer survival.

A state of emergency

The study looked at over 800,000 cancer cases diagnosed between 2012 and 2017. Cancer types included were oesophageal, stomach, colon, rectal, liver, pancreatic, lung and ovarian cancers.

It found that more cancers are being diagnosed through emergency routes in the UK than in comparable, high-income countries like Australia and Canada. The proportion of emergency presentations for all sites ranged from 24% in the Australian state of Victoria to 42.5% in New Zealand, indicating that this is a global issue.

Scotland and Wales had some of the highest rates of diagnosis after emergency presentation at 38.5% and 37.4% respectively, but England wasn’t far behind at 37%. Rates in Northern Ireland around 27.9%, but these were measured using a different definition. And that’s where it gets complicated.

Emergency presentations were defined in two different ways, and the definition used varied between UK nations. Scotland and Wales used a ‘broad’ definition – emergency hospital admission in the 30 days before the date of cancer diagnosis.

On the other hand, Northern Ireland used a ‘narrow’ definition – additionally requiring that emergency hospitalisations occurred without there being an intervening non-emergency admission. England was measured using both definitions.

The researchers report that using a broad definition increases the level of emergency presentations for all sites by up to 6%, so comparisons between countries using different definitions isn’t comparing apples with apples.

But getting back to the study in full, when the researchers looked at the data on emergency presentations alongside the data on cancer survival, they saw that countries with higher levels of emergency presentation were also found to have poorer survival. For every 10% increase in emergency presentations in the countries analysed, there was a decrease in one-year survival for 6 of the 8 cancer types.

How did we get here?

Receiving a cancer diagnosis through emergency routes doesn’t have one simple cause. It can be due to tumour biology, healthcare systems, or individual patient factors. Often, it’s down to a combination of these things.

Sometimes, it may be that someone shows no early symptoms. In these situations, a disease emergency, like a haemorrhage or obstruction, is the first sign that something’s wrong. In these cases, emergency presentation may not be avoidable.

But some emergency presentations come as a result of patients not seeking help as soon as they might have, or cancer not being suspected by a healthcare professional. These situations are considered avoidable and could be prevented through public health or healthcare system interventions.

And experts are worried that COVID-19 might have worsened the situation. Fewer people coming forward with symptoms and challenges in access, including the ongoing impacts of the pauses in cancer screening early in the pandemic, mean the number of emergency presentations are expected to have increased since the pandemic began.

“Across the globe, the pandemic has challenged healthcare systems. In the UK, access to primary care and diagnostic tests were challenged and cancer screening paused. This means some cancers, especially those with vague, non-specific symptoms, may have gone unnoticed,” says Butler.

“Cancer plans across the UK must prioritise early diagnosis, bringing people in through managed routes and reducing the diagnoses that come about via emergency presentation. To have a better chance of beating their cancer, people must be treated as soon as possible.”

Matthew Black, who was diagnosed through an emergency routeMatthew’s story

For some patients, COVID-19 has had an even greater impact in delaying their diagnosis.

Matthew Black, a 57-year-old chartered surveyor and father of two, started having stomach problems and losing weight in April 2020, so he got in touch with his GP. Initially it was thought that his symptoms could be the after effects of an asymptomatic COVID-19 infection, but after dropping 14kg in just one month, Matthew’s family encouraged him to go to A&E.

Scans revealed a blockage in his colon and he was admitted to hospital for a colonoscopy. The next day he underwent a five-hour surgery to remove the grapefruit-sized tumour that was obstructing his bowels.

Matthew, who was given the all-clear three weeks after his operation, said: “Being admitted to hospital and diagnosed with cancer in one fell swoop was overwhelming. And COVID-19 restrictions meant my wife, Stef, couldn’t be by my side while I was being tested or when I was woken up at 1:30am and told I likely had cancer.

“It’s too bad my cancer wasn’t caught earlier, but I consider myself extremely lucky. It’s important people do not ignore sudden or unusual changes to their bodies. And don’t leave it too long to get back in touch with the GP practice if symptoms don’t go away or get worse. It could save your life.”

What can we do about it?

Just as the causes of emergency presentation are complex, reducing the proportion of patients presenting as emergencies will require a multi-pronged approach. This will include greater awareness of, and timely response to, potential cancer symptoms among the public, improving screening programmes, and optimising referral routes for patients with suspected cancer.

“Getting better at preventing cancer, detecting it through screening, or diagnosing it soon after symptoms appear can help decrease emergency presentations and reduce cancer deaths. This message applies to Canada, Europe and Oceania, as well as the UK,” says Professor Georgios Lyratzopoulos, lead researcher from University College London.

This is the first time we have seen figures for the UK nations alongside data from comparable countries and we are calling for government to act on this worrying picture.

Michelle Mitchell, our chief executive, said “For months we have been warning that cancer survival could go backwards due to the pandemic. The UK is already lagging behind when it comes to cancer survival – this study helps us understand why, showing that countries with higher levels of emergency presentations have lower survival. If we want to build a world-class cancer service, we need to learn from comparable countries and ensure fewer patients are being diagnosed with cancer after an emergency referral or trip to A&E.

“We’d like to see governments across the UK take bold action on this within their cancer plans – so that by 2032, fewer than 10% of cancer cases are diagnosed through emergency routes.”

The importance of monitoring the data

Unlike statistics like incidence and mortality rates, information on the route through which cancer is diagnosed is not widely collected and available. ICBP researchers are now calling for wider collection of this measure globally, for use in official cancer surveillance statistics. More regular collection of these data will also help to iron out the wrinkles of the different definitions and make it easier to draw comparisons.

In the UK, and other countries with high rates of emergency presentations, improving diagnoses via non-emergency routes is critical to improving overall cancer survival.

Prof Mark Lawler, Queen’s University Belfast and Chair of the ICBP says: “This work emphasises the importance of the collaborative use of data to deliver the critical intelligence needed to improve cancer outcomes. It resonates strongly with Cancer Research UK’s recently refreshed strategy, in particular its focus on early diagnosis, and illuminates the path that ICBP is taking to empower a data-informed approach to improve patient survival. Data really can save lives.”


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