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CANCER IN SCOTLAND: ACTION FOR CHANGE

03. DETECTING AND TREATING CANCER EARLY

SCREENING FOR CANCER

OUR STRATEGY FOR PREVENTING AS MANY CANCERS AS POSSIBLE FROM OCCURRING IS SET OUT IN CHAPTER 2. THE NEXT BEST STRATEGY IS TO DETECT AND TREAT CANCER EARLY AND NATIONAL POPULATION SCREENING PROGRAMMES AIM TO DO THAT.

By identifying cancer very early in its development treatment can begin at a much earlier stage than might otherwise be the case.

New screening programmes are introduced only after rigorous assessment to ensure that they are effective in doing what they set out to do, according to nationally agreed criteria. The UK National Screening Committee was established in 1996 to advise UK Health Ministers about the introduction of new screening programmes and on the need for modification and/or extension of existing ones. The advice of the Committee is taken into account in the Scottish Executive's consideration of screening issues.

Screening is offered to apparently healthy people so that a small number (who may develop cancer or who may, unknown to them, already have cancer at a very early stage) can be identified and be offered early and effective treatment. While most people welcome this opportunity, we know that attending for screening and waiting for results can cause additional anxiety and may increase the period during which people must live with the possibility that they may be suffering from cancer.

EXISTING SCREENING PROGRAMMES

Cervical cancer

The cervical screening programme in Scotland is well established. Scottish Health Statistics for 1999 show that as a result of cervical screening, up to 250 cases of cervical cancer are prevented each year. This apparent success does not mean that the programme cannot continue to be improved. For example, existing information systems have been in place for a number of years during which time significant developments have taken place in information technology. We want to take advantage of these developments to improve the systems and processes which support the screening programmes, making them even more robust and reliable.

• A new nationally co-ordinated IT system will be developed by late spring 2003 which will secure real improvements in the call/recall arrangements for cervical cancer screening.

Alternative ways of processing smears are now available. One such example is liquid based cytology. However, so that women may have confidence in the technology being used, any new system must be tried and tested before it can be made available universally.

Breast cancer

The Scottish Breast Cancer Screening Programme (SBSP) was established in the late 1980s. Its aim is to contribute to the Government's headline target to reduce the age standardised mortality rate from all cancers in people under age 75 by 20% by 2010. Scottish Health Statistics show that SBSP regularly exceeds its 70% target uptake by women. With this level of attendance for screening the programme is well placed to contribute to this target.

Even although SBSP has met or exceeded its overall target uptake, in some areas improvements require to be made in the numbers of women presenting for screening. Health Boards promote a number of initiatives to improve uptake, particularly among women from ethnic minorities and deprived areas. These include working with GPs to increase awareness of the value of breast screening, localised media campaigns allied to the mobile screening programme and more mobile screening in inner city deprived areas.

• The new NHS Boards must continue to target areas of low screening uptake.
• The upper age limit for the Scottish Breast Cancer Screening Programme will be raised from 65 to 70 years commencing in 2003/04.
• The extension will be implemented over one 3 year round of screening.
• Women over the age of 70 can continue to be screened on request.

Colorectal cancer

Following the National Screening Committee's recommendations on colorectal cancer screening, the Scottish Executive established a Demonstration Project - The Cancer Challenge - to see if screening for colorectal cancer is feasible and whether it is publicly acceptable. This project is now underway in Tayside, Fife and Grampian Health Board areas, where everyone aged 50 to 69 is invited to participate. This pilot is due to end in mid-2002. It will be evaluated by an expert team, including epidemiologists, from the University of Edinburgh.

• If this pilot is shown to have a significant impact, and its adoption is recommended by the UK Screening Committee, the Scottish Executive will plan to introduce colorectal cancer screening for people aged 50 to 69.
• We are studying the resource implications for NHSScotland of a national screening programme for colorectal cancer.

Prostate cancer

Many men who develop prostate cancer do not die of it. Indeed, a great many men are never actually aware that they have it, and live long lives before dying of other, unrelated conditions.

The level of prostate specific antigen (PSA) in the blood is one of a range of investigations which may be undertaken to help confirm a diagnosis of prostate cancer. However, the currently available test cannot differentiate between those men whose prostate cancer will grow rapidly and aggressively and those in whom it will remain localised to the prostate for the rest of their lives. PSA levels may also be raised in a number of conditions unrelated to cancer.

As with other cancers, none of the treatment options for prostate cancer is without side effects. The unwanted side effects of surgery and radiotherapy in men receiving treatment for prostate cancer can be significant.

For these reasons PSA testing as a means of population screening for prostate cancer is not currently recommended by the UK Screening Committee. However the situation is kept under review and once the final results from screening trials are available, for example, the European Randomised Study of Screening for Prostate Cancer (ERSSPC), they will be considered by the National Screening Committee.

If and when new research leads to screening and treatment techniques being sufficiently developed to support it, the Scottish Executive will plan to introduce a population based prostate cancer screening programme.

A multi-centre trial is being undertaken in England which will provide valuable information on the reliability of the PSA test and on the clinical and cost effectiveness of alternative approaches to diagnosis and treatment of prostate cancer.

• The Scottish Cancer Group set up a multi-disciplinary Prostate Cancer Working Group to review the referral, management and treatment of people with prostate cancer in Scotland. This Group was also asked to make recommendations for modernising and improving services. Their report will be considered by the Scottish Cancer Group in the first instance.

Ovarian cancer

A UK trial has been set up but will not report on the feasibility and effectiveness of screening for ovarian cancer until at least 2010. Possible screening tests include ultrasound and blood testing for an ovarian cancer related protein.

Lung cancer

Previous attempts at screening for lung cancer were unsuccessful, but with improvements in technology over time it is possible that imaging systems may now allow the detection of early tumours.

• A (UK randomised controlled) trial of screening by CT scan has recently been approved and funded by the Medical Research Council (MRC). There will be one pilot site in Scotland, based in Dundee.

Oral cancers

Opportunistic screening for oral cancers has previously been recommended by the Scottish Needs Assessment Programme (SNAP) which suggested this should be carried out by dental practitioners during the course of dental check-up or by general practitioners for at risk groups, such as heavy smokers and drinkers.

• Proposals for opportunistic screening are currently being developed in line with the Action Plan for Dental Services in Scotland.

GENETIC SCREENING

There is increasing evidence that genetic predisposition plays a significant role in the development of some of the more common cancers, including breast, ovarian and colorectal cancer, although only a small proportion of such cancers are inherited. However, in those who inherit the genetic susceptibility the life-time risk of cancer can be very high. Thus, it is important that anyone who is concerned that they may be at increased risk due to family history has access to counselling, assessment and, where indicated, follow up surveillance.

For most people who are worried and seek advice, the first point of contact is likely to be their GP. However, on average a GP is unlikely to see more than a few individuals each year who have concerns relating to a family history of cancer, and the issues involved can be complex. Advice and guidance is therefore available for GPs as well as for people who may be worried that they are at increased risk of developing cancer because of their family history.

To ensure that this service is readily accessible throughout the country, the Scottish Executive has already provided funding for genetic nurse associates working alongside GPs but with their base in each of the Regional Genetics Units in Aberdeen, Dundee, Edinburgh and Glasgow. These associates provide advice and counselling through primary care services throughout Scotland.

• To maintain continuous improvements in advice and care, these services will be subject to regular evaluation by the Genetics Sub-Group of the Scottish Cancer Group.

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