Can Lunchbreak Screening Make a Difference to Cancer Survival?

Prof Karol Sikora


October 21, 2019

Hello. This is Professor Karol Sikora here, talking about Prof Sir Mike Richards, former National Cancer Director's recent report: An Independent Review of Adult Screening Programmes in England .

The background to this is that cancer screening, in particular, costs a lot of money. It costs a lot of organisational skill, a lot of time and effort. And obviously, it causes a lot of time and effort for the customers, the patients out there, or the pre-patients. So is it worth it? What this report is doing is trying to see how we can really move forward, what's wrong with the screening programme today, how it can be improved and move forward. 

If a tax-based system like the NHS can't get this right, it's very difficult to see how any other healthcare system in the world can get screening so developed. We should be the best in the world.

We're pretty good, but we should be even better.

NHS Screening Programmes

If you take the adult screening, there are only five things we screen for:

  • Aortic aneurysms

  • Diabetes, eye checks in diabetic patients

Then the three cancer programmes:

  • Breast, with mammography

  • Colon with faecal occult blood or FIT (faecal immunochemical testing)

  • And the third one is of course cervical screening

There are two other screening programmes, one for pregnant women looking for neonatal problems and maternal problems.

And the other one is obviously neonatal screening, both physical and for biochemical abnormalities.

So that's the portfolio of NHS screening and what Mike was asked to do by NHS England and the politicians was to come up with some recommendations.

Screening Recommendations

He does this very well. Basically, he makes 22 different recommendations.

As you can imagine, most of these are not about technology. There's nothing anyone can do about where the future is and the technology of screening, and genomics, and circulating DNA, and all these things. These are all mentioned in the report, but it's more a report about the here and now. How can we make the NHS screening programmes better?

The 22 recommendations are mainly about organisation. The problem we've got is that no one's ultimately in charge. This is often the case within the NHS. There are several groups: NHS England who hold the purse strings, the Department of Health and Social Care, who ultimately have the political responsibility, and then Public Health England, who are responsible for implementing some of the services.

But at the end of the day, it's the people on the ground, the front line of the NHS, the people that staff the caravans in the supermarket car parks, or who run the cervical smear testing in laboratories up and down the country.

Organising Screening

So the first group of recommendations are really about organisation of services: who's going to be responsible, and the existing programme can't stop, it has to continue, whilst it's strengthened as it moves on. 

I think it's really all about oversight, the first 10 recommendations address who's actually running the programme.

Is it private sector or is it public sector? That's not really clear in there. And what are the incentives to those that are operating the system - not just financial what other incentives can you give [for example] general practices that have a very high rate of screening amongst their case load.

The next recommendations are all about information systems. And that clearly is the key to this programme. The key to success is having robust organisation systems. It's got much better in the last 5 years, but there's huge room for improvement: NHS Digital and NHSX, the IT arm of the NHS, really have to smarten-up the records of people's phone numbers, people's addresses, which ought to be done in a timely way.

Increasing Uptake

Then the next thing is how one can get better uptake and coverage.

We know the main problem is the 'worried well' over-use any service that's put forward; those that don't come forward or come forward with late symptoms don't use it. How can we change this?

We're in the world of social media, can we use social media? This is all discussed in the report - social media campaigns; encouraging links with faith leaders, and community groups, and trying to move more and more people to make screening the norm.

The other problem is capacity issues. So at the moment, breast cancer screening is every 36 months, but there's a lot of slippage. Should we make it 34 months and so on?

But the real thing is making it convenient for people.

How can you make screening, instead of being boring, very easy to do?

I think you have to take it to people and we've seen imaginative ways forward there. Indeed the headlines in the papers earlier on this week captured that, that it would be easier to go to screening.

If you take the main three cancer programmes, they all have inherent problems.

The breast programme, that inherent problem is mammography, which is not the greatest screening test, but it's the best we have.

If you take faecal occult blood or immunochemical testing, it's relying on the patient to take a faecal sample. Some people are appalled by doing that and they're just not going to do it. So how can you increase that?

The cervical programme, which is obviously the longest running programme, is midwife or nurse-led, and that is easier in a logistic sense, and the compliance rate is much higher because of it.

But the breast and the colon, we've got to get these programmes up and running in a smoother way for people that don't normally access health services too well. And that's the real challenge: getting over the hurdle of clogging the services with 'worried well', and not accessing those people that really need the screening test to pick up the cancers early.

Future Screening

The report's great, it looks at the future. It looks at lung cancer screening and looks at predicting high-risk groups by polygenic profiles.

If you take breast cancer, you can show quite clearly, and there's some good data in this report, where you have groups at very high risk of breast cancer and groups at very low risk based on genomic analysis, not for the common genes that we think about, such as BRCA 1 and BRCA 2, but the whole range of polymorphisms in multiple genes, and that's clearly the way forward.

If you knew you had an 80% chance of getting cancer, you would do something about it in terms of screening.

So picking up those that have a real incentive to get screened makes such good sense.

Implementation and Costs

So it's a very good report, but how's it going to be implemented? What will it cost to be implemented? We have to wait and see. One of the big problems still in our health system is the poor quality of the IT and the fact that although we have some great systems, they're all local or they're functional for a specific unit, such as PACS - picture archiving and communication systems. They are very good, but we don't have a good clinical database for patients. And that's going to be really what we need over the next 5 years for everything: genomics, artificial intelligence, circulating DNA: it requires very good IT if it's to succeed.

This is Karol Sikora talking about Mike Richards' report on adult screening and implementing a change in the way in which the NHS does it.

Thank you for listening.


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