Download Cancer and health inequalities

“We need not, then, accept the present size of the social
gradient in health as fixed. If it can change, and we
can understand why, action is possible to reduce it”
Cancer and
health inequalities:
An introduction to
current evidence
Michael Marmot, 2006
Vanessa Gordon-Dseagu BSc, MSc
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Contents
Executive summary
3
Inequalities in cancer incidence and mortality
5
Inequalities in lifestyle factors
7
Tobacco consumption
7
Poor Diet
9
Physical activity
9
Weight and obesity
10
Alcohol consumption
10
Sun and Ultraviolet (UV) exposure
11
Perceptions of cancer risks
12
Inequalities in symptom recognition and awareness
14
Inequalities in the use of health services
16
Information
16
Screening
17
Diagnosis
20
Primary care services
20
Cancer treatment
22
Palliative care
23
What is Cancer Research UK currently doing to reduce health inequalities?
24
Annex 1: Differences in cancer survival rates between most and least
deprived groups for 1986-1990 and 1996-1999* (England and Wales)
Annex 2: References
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Cancer and Health Inequalities
Executive summary
The health of the UK population has been gradually
improving since the Second World War. Life
expectancy is at an all time high, and is expected to
continue increasing. Analysis of cancer survival by
Cancer Research UK1 found that:
• Cancer death rates began to fall in the late 1980s
and since then they have dropped by more than
17 per cent.
• More people than ever before are surviving cancer; the
proportion of patients surviving beyond five years has
increased from only 28 per cent in the early 1970s to
around 50 per cent today.
• Survival rates have improved for almost all of the 20
most commonly diagnosed cancers.
The overall picture is therefore positive, but at the same
time there are some groups who do not have access to
the information, resources and services required to take
full advantage of these improvements in health.
The focus of this report is inequalities as they relate to
cancer, with the inequalities of a range of groups being
discussed; although most attention is given to those
communities experiencing deprivation and BME groups.
In part this is due to the availability of evidence, but
also illustrates the focus of our ‘Goals’ up to 20202. The
overarching areas covered within the report are:
Cancer incidence, mortality and survival
Evidence given supports an inverse correlation between
socioeconomic status and cancer incidence and mortality
(with particular focus upon the impact of tobacco
consumption) and evidence of differing rates of cancer
among Black and Minority Ethnic communities, other
harder to reach groups and the general population.
Lifestyle factors
This section focuses upon those lifestyle behaviours which
have been found to have a positive impact upon cancer
incidence and mortality and gives evidence of differential
levels of engagement in such behaviours between
socioeconomic (and some harder to reach groups) and
the general population
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Perceptions of cancer risk
Cancer Research UK’s Reduce the Risk survey found that
there was a socioeconomic gradient to knowledge of all
the major risk factors relating to cancer; with the wealthier
more likely to have knowledge of cancer risk factors
compared to those lower down the socioeconomic scale.
There are also differing levels of awareness between BME
communities and the general population.
Levels of cancer symptom recognition
Early diagnosis of cancer is a critical factor which
determines the types of treatment available to an individual
and their chances of survival. Awareness of cancer
symptoms is a crucial factor in early diagnosis as people
who recognise that their symptoms may be serious are
more likely to visit their GP. There is evidence of lower
cancer symptom awareness amongst those experiencing
deprivation and those from BME communities.
Awareness and uptake of health services
A range of harder to reach groups have unmet need
relating to information, support and cancer services.
There is evidence of inequalities at each stage of the
patient pathway, from information provision through to
palliative care.
The report concludes with a look at the work that
Cancer Research UK is currently doing to reduce health
inequalities and how the introduction of our ‘Goals’ will
affect our work in this important area.
Our Goals
In order to support our vision ‘together we will beat
cancer’ Cancer Research UK created ten ambitious
new goals that, together with our partners, we are
aiming to achieve by 2020.
The goals are wide ranging and seek to clarify our
priorities and enable us to demonstrate our progress
and impact in a range of areas including reducing
cancer incidence, ensuring patients have access to
the information they need and reducing cancer
inequalities (for more information about the goals
that relate to cancer inequalities please see the final
chapter of this report).
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Cancer and Health Inequalities
Recommendations
There are currently gaps in our knowledge relating to
potential inequalities within cancer and harder to reach
groups. It is therefore essential that work is undertaken to
increase our knowledge of the communities and groups
who are experiencing such inequalities; in order that we
can develop methods of effectively meeting their needs
and improving health outcomes. Included at the end of
each chapter are recommendations for taking forward this
work. These are:
• Smoking is a major cause of inequalities in cancer
incidence and mortality. Further work should therefore
be undertaken to reduce the inequalities in tobacco
consumption rates between groups and communities.
Research should also be undertaken which aims
to understand which interventions are effective at
producing behaviour change. A further consideration
is to ensure that policies and interventions do not
exacerbate inequalities.
• Health information and support should be targeted
at those groups, with the worst cancer incidence and
mortality rates, to ensure that their service needs
are met.
• Research should be undertaken which explores how
sociodemographic and socioeconomic information
could be collected within cancer services. This would
enable a national picture of cancer incidence and
mortality, within harder to reach communities. This could
then form the basis of further work to address existing
cancer inequalities.
• Appropriate and targeted service provision is central
to the reduction of cancer inequalities. It is therefore
essential that information and support is provided which
effectively meets the needs of harder to reach groups.
• The Equality Act 2006 makes it unlawful to discriminate
on the grounds of race, age, gender, sexual orientation
and religion in the provision of goods, facilities and
services. Research should be developed to better
understand how discrimination, and inequalities in the
provision of services, impacts upon the experiences
of harder to reach groups within such services and
how inequitable access to services influences cancer
incidence and outcomes.
• Health care professionals should, as part of their
ongoing career development, receive training in
communication skills (with a focus upon harder to reach
communities and groups).
This report is accompanied by Equal and Inclusive:
Government policy targeted at reducing health inequalities
and social exclusion which focuses upon government policy,
aimed at reducing health inequalities, relevant to cancer.
The aim of both reports is to give an idea of the range of
issues that are relevant to Cancer Research UK’s ongoing
work to reduce inequalities within cancer. It is our intention
for this report to be used as a reference for those wishing
to better understand cancer inequalities within the UK.
Cancer Research UK would like to thank Paul Haezewindt,
for the extensive initial research he carried out for this
report and a number of Cancer Research UK staff whose
input has been invaluable.
• The evidence contained in this report shows that those
from harder to reach groups are more likely to adopt
lifestyle behaviours which could positively impact upon
cancer rates. Targeted health information and support
should be developed that increases knowledge of
healthy lifestyles and encourages healthy behaviour.
• Programmes should be developed and evaluated which
seek to create sustained behaviour change within
communities and groups with poorer cancer outcomes
than the general population.
• Levels of symptom recognition have been found to relate
to cancer outcomes. It is therefore essential that services,
through the provision of appropriate information, meet
the needs of the UK’s diverse population.
• Good practice, in terms of increasing cancer awareness,
should be developed using examples from successful
campaigns in cancer and other disease areas.
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Cancer and Health Inequalities
Inequalities in cancer incidence and mortality
Introduction
Life expectancy, at birth, in the UK has increased steadily to
reach an all time high of 76.96 years in men and 81.29 years
in women.3 While the upward trend is positive there remain
underlying inequalities; for example the gap in life expectancy
between the highest and lowest socioeconomic groups is
increasing in the UK. For men the gap increased from 5.5
years in 1972/76 to 7.4 years in 1997/99 and for women
the gap increased from 5.3 to 5.7 years.4 At an international
level, although cancer survival rates increased during the
1990s, the UK failed to close the gap with the European
countries with the best cancer outcomes. In response to this
trend the NHS Cancer Plan5 (2000) was published and since
this time mortality rates have been moving more in line with
the rest of Europe and other developed countries.
Cancer is a major cause of illness with more than 280,000
people diagnosed each year in the UK. It is also the biggest
cause of death in the UK, accounting for 1 in 4, or around
125,000 individuals a year. There are significant inequalities
in cancer incidence, mortality and survival. The risk of being
diagnosed with certain cancers is greater among the
most deprived families and communities and, for most
types of cancer, survival rates for the most deprived
patients are worse.
Survival rates for most types of cancer have risen steadily
since the 1970s. However, because rates have increased
faster among more affluent groups the survival gap between
the least and most deprived patients has increased.6
There are a range of ‘harder to reach’ groups who are not
benefiting as much as the general population from improved
cancer outcomes.
Annex 1 illustrates differences in survival rates between
most and least deprived groups, by cancer type, between
1980 and 1999.
Socioeconomic
The relationship between deprivation and cancer is
complex and multifaceted. Certain types of cancer - such
as lung, mouth and oesophagus – are more likely to be
diagnosed in the most deprived groups. For other types
of cancer – such as breast and prostate – death rates are
higher among the most deprived despite the fact that
incidence rates are lower.
Cancer mortality rates are higher for deprived groups.
Unskilled workers are twice as likely to die from cancer
as professionals, and while mortality rates vary widely
across the country, they tend to be highest in areas
with significant levels of deprivation.7 Much of these
inequalities relate to higher smoking prevalence among
the most deprived populations which leads to a greater
incidence of smoking related diseases including cancer.
Jarvis and Wardle estimate that smoking accounts for over
half of the difference in the risk of dying early between
socioeconomic groups.8
Before the dangers of smoking were widely known,
smoking prevalence varied little by socio-economic group.9
Today there are clear differences due to the differential
decline in smoking by social class that occurred in the
1970s and 1980s.10 By 2005, 29 per cent of adults in
manual occupations smoked compared to only 19 per cent
of those in non-manual occupations.11 Diabetes UK found
that individuals in lower socio-economic groups were
fifty per cent more likely to smoke compared to those in
higher groups.12 The result is that premature death, from
lung cancer, among unskilled workers is five times higher
than their professional counterparts13 and higher rates
for other smoking related cancers are also found in lower
socioeconomic groups14.
Around 90 per cent of lung cancer cases in the UK are
caused by tobacco smoking and, in addition, the 2002
IARC Working Group concluded that tobacco smoking
can also cause cancers of the following sites: upper
aerodigestive tract (oral cavity, nasal cavity, nasal sinuses,
pharynx, larynx and oesophagus), pancreas, stomach,
liver, lower urinary tract (renal pelvis and bladder), kidney,
uterine cervix and myeloid leukaemia.15
Lung cancer incidence and mortality rates are associated
with socio-economic deprivation. The differences in
survival between the most and least affluent, while only
being one per cent, is considerably when the number
of patients involved is taken into account.16 In the early
1990s incidence rates were around 2.5 times higher in
the most deprived male groups compared to the least
deprived – the difference for women was even greater at
three times.17 However, more recent data from the West
Midlands records that between 1981-2004 lung cancer
rates for the most affluent men remained stable, while in
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Cancer and Health Inequalities
the most deprived male group, they dropped by 56 per
cent. While the deprivation gap remained substantial it was
reduced from 1981 (from 200 per cent to 50 per cent
greater).18 In women, lung cancer incidence increased more
for affluent women than deprived women between 1981
and 2004.
In addition to a greater likelihood of being diagnosed
with certain cancers, people from the most deprived
communities have poorer outcomes once they have been
diagnosed.19 The biggest gap in survival rates for patients
diagnosed 1996-99 was for laryngeal cancer: for every 100
patients there were 16 more deaths in the most deprived
patients compared with the least deprived group. For some
cancers, such as lung cancer, even very small differences in
survival rates are of concern because of the large numbers
of patients involved. If survival rates across all socioeconomic groups matched those of the most affluent
patients then around 3,200 deaths would be avoided every
year in England and Wales.20
Between 1986-90 and 1996-99 the gap in survival rates
between most and least deprived groups increased for 19
out of 33 cancer types and stayed the same or decreased
for the remaining 14 cancer types.21 For men 12 out of 16
cancers experienced an increase in the survival gap, while
for women this occurred for nine out of 17 cancers.
Other groups
As ethnicity has not been systematically recorded by
cancer registries in the UK there are no reliable data
on patterns of cancer incidence, mortality and survival
specific to Black and Minority Ethnic (BME) communities
living in the UK. However there is growing evidence, often
from smaller scale studies, that BME communities may
experience differing rates of some cancers.22 For example:
• Breast cancer in South Asian women appears to be
lower than the rate found in the general population23
• Prostate cancer among Black Caribbean and African
men appears to be higher24
• Mouth cancer among South Asians appears to
be higher. 25
It is often the case that BME communities are composed
of more people in the younger age groups. It may be
therefore be the case that cancer rates will increasingly
resemble those of the general population as these
individuals age.
cancer on average 21 years earlier than their white
counterparts. Further to this, the type of cancer that was
being diagnosed within this group was more likely to be an
aggressive form of the disease which was unresponsive to
newer drug regimens and had poorer outcomes.
Cancer mortality among those with learning disabilities
is, generally, similar to the general population. There is
evidence of differing rates of cancers of the oesophagus,
stomach and gallbladder which are thought to be linked
to increased rates of related illnesses such as gallstones
and oesophageal reflux among those with learning
disabilities. 27 Howells28 and Wilson and Haire29 identified
high rates of unmet need and poorly managed conditions,
including cancers, among those with learning disabilities.
Horwitz et al. supported the finding that a range of
health conditions were not being properly addressed and
that those with learning disabilities were not receiving
preventative services.30
There are a number of factors related to inequalities
in cancer outcomes, discussed above, between groups
within the UK population. The following chapters of this
report will focus upon the available evidence regarding the
presence of such lifestyle factors.
Recommendations
• Smoking is a major cause of inequalities in cancer
incidence and mortality. Further work should therefore
be undertaken to reduce the inequalities in tobacco
consumption rates between groups and communities.
Research should also be undertaken which captures
smoking rates, and other lifestyle factors which
increase the risk of developing cancer, within harder
to reach communities and which identifies those
interventions are effective at producing behaviour
change in this regard.
• Health information and support should be targeted
at those groups with the worst cancer incidence and
mortality rates to ensure that their needs for such
services are met.
• Research should be undertaken which explores how
sociodemographic and socioeconomic information
could be collected within cancer services. This would
enable a national picture of cancer incidence and
mortality, within harder to reach communities, which
could then form the basis of further work to address
existing cancer inequalities.
In some instances it also appears to be the case that
specific cancers affect BME communities at different
ages. Rowen et al.26 found that women of African and
West Indian descent were being diagnosed with breast
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Inequalities in lifestyle factors
Cancer Research UK estimates that around half of all
cancers could be prevented by changes to lifestyle.
Differential levels of exposure or engagement in risky health
behaviours are the most significant cause of inequalities in
the likelihood of developing cancer. The following section
details the behaviour and exposures that contribute to
inequalities in cancer incidence and mortality.
Rates (percent) of smoking by social group
40
35
Management
Intermediate
Routine / Manual
30
25
20
Tobacco consumption
There are large differences in smoking rates within
the UK. Tobacco causes around nine out of ten cases
of lung cancer in the UK as well as a range of other
cancers including mouth and oesophagus. Inequalities in
smoking rates therefore impact cancer rates in different
communities. The following section details smoking rates
among such groups.
5
0
5
0
All
Male
Female
Source: Office for National Statistics (2005) Smoking related behaviour
and attitudes 200536
Socioeconomic
Smoking is the main cause of differences in illness and
death between the poor and wealthy.31 Gruer et al. (2007)
found that:
• If smoking as a factor is removed the differences in
survival between the wealthiest and those living in
deprivation is relatively small
• Those in the lowest socioeconomic group have better
survival than the most affluent smokers.
• In order to reduce health inequalities policy must
aim to enable the less well off to stop smoking or
never start.32
The mapping project for Securing Good Health for the
Whole Population found that overall 26 per cent of the
general adult population smoked but that rates differed
enormously by ward.33 For example, in the Princess ward
of Knowsley, one of the most deprived areas of the UK, 52
per cent of the population smoked. This compared to a
smoking rate of 12 per cent of the population in Keyworth
North, one of the least deprived wards in England.
The Director of Action on Smoking and Health (ASH)
concluded that “Smoking is the biggest killer in England,
and it kills more people in poorer communities than in
richer ones”.34 A further study looking at the contribution
of smoking to socio-economic inequalities in male death
rates concluded that “most, but not all, of the substantial
social inequalities in adult male mortality…were due to the
effects of smoking”.35
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While the desire and motivation to give up smoking
appears not have a socioeconomic gradient,37,38 people
from the most deprived areas have lower smoking
cessation rates.39 Jarvis also found smoking cessation
rates of around 55 per cent in the most affluent smokers
compared to 5 per cent in the most deprived.40 A 2003
study found that “Deprivation was negatively associated
with cessation at four weeks”.41 If this situation continues
health inequalities related to smoking may widen further.
BME
The table below illustrates the varied rates of smoking
among the different communities within the UK population.
Rates among ‘Other White’, ‘White’ and ‘Black African’,
‘Other Mixed’ and ‘Bangladeshi’, ‘Chinese and Other’ groups
are considerably higher among men compared to the
‘White British’ population. Rates among ‘Indian’, ‘African’
and ‘Other Black’ men are much lower. Among women,
smoking rates tend to be lower among BME communities,
apart from the ‘Mixed’ sub-group.
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Rates (percent) of smoking by Black and Minority Ethnic status
Ethnic Group
Men
Women
Total
White British
27
25
26
Other White
34
26
30
White and Black
Caribbean
25
29
28
White and black African
38
26
33
White and Asian
31
33
32
Other Mixed
39
26
31
Indian
17
4
10
Pakistani
25
6
16
Bangladeshi
45
7
26
Other Asian
26
9
17
31
18
19
19
5
16
24
11
17
Chinese
34
8
Other
33
19
21
27
White
Mixed
Asian or Asian British
Black or Black British
Caribbean
African
Other Black
Chinese or Other ethic group
Source: General Household Survey 2005: ONS, 2006
A further issue for some BME groups is the chewing of
tobacco and related products. Although overall UK rates
are very low, among the Bangladeshi population it is
estimated that around 9 per cent of men and 16 per cent
of women chew tobacco.42 A small scale study also found
that Paan, a mixture of ingredients that often includes
tobacco, was chewed by 78 per cent of Bangladeshi adults
and that women were more likely to add tobacco to their
Quid/Paan and chew more frequently than men.43 Further
to this the study concluded that there were a number of
barriers preventing those from the Bangladeshi community
using dental practices to access oral cancer screening and
oral health services. These included the attitudes of the
community towards asymptomatic use of such services
and language issues.
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Higher smoking rates among some BME communities
may be related more to their economic status within the
wider UK population than their BME status. This may also
explain the high rates of tobacco consumption among
Black Caribbean and Bangladeshi communities; within these
groups around half of the former and two thirds of the
latter were found to be living in low income households,
compared to 21 per cent of the White population.44
There is evidence of under-reporting of smoking behaviour
among some BME communities. The Health Survey for
England (2004) used saliva cotinine samples and estimated
that around 60 per cent of men and 35 per cent of
women from the Bangladeshi community personally
consumed tobacco.45
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Mental health
Smoking rates are higher among those with mental health
problems. The presence of a neurotic disorder was found
to double the chances of an individual being a smoker in
a national study. Among those with schizophrenia smoking
rates have been found to be as high as 80 per cent,46 while
Meltzer et al.47 found that over 70 per cent of those living
in an institution with a psychotic disorder were smokers.
Other groups
It is estimated that a higher percentage of gay and lesbian
teenagers and adults are smokers compared to the general
population and that among the latter a high proportion are
heavy smokers.48,49,50,51,52 Current estimates put smoking
rates at between 41 and 25 per cent among lesbians and
gay men.53,54
Research suggests that smoking rates in people with
learning disabilities are similar to the general population.55
Around 80 per cent of prisoners smoke56, as well as 75 per
cent of lone parents on state benefits57 and over 90 per
cent of homeless individuals.58 These groups make up some
of the ‘hardest to reach’59, in terms of traditional methods
of healthcare provision, and it is likely that intensive
information and support is required if cessation rates are
to be improved within these communities.
Poor Diet
Around a third of all cancer deaths have been linked to
diet. Diet can have an impact upon the risk of cancers of
the bowel, stomach, mouth, larynx and oesophagus –
plus breast and prostate cancer60. Diets rich in fat and
excess sugars, combined with non-active lifestyles, have
resulted in greater prevalence of obesity in nearly all
developed countries.
Socioeconomic
The significant differences in food consumption between
more and less affluent groups are linked to the availability
and cost of food61,62 and knowledge of healthy eating. The
result is that “Higher income families tend to consume
healthier versions of most foods compared to lower
income families” (National Food Alliance, 1997, p.2).
Lower income households are less likely to meet
government guidelines for eating fruit and vegetables.
Around forty per cent of women in the highest income
quintile group consume five or more portions of fruit and
vegetables compared to only 17 per cent in the lowest
income group. For men, 27 per cent consumed at least five
portions a day in the most affluent group compared to 14
per cent in the lowest income group63.
People from lower income groups eat less white meat and
oily fish64 and fibre65. Overall, only 28 per cent of British
men and 13 per cent of women meet the recommended
daily intake of fibre.66,67
BME
In 2004 the Health Survey for England68 found higher
rates of fruit and vegetable consumption among BME
communities. Compared to rates in the general population
of 23 per cent of men and 27 per cent of women eating
5+ daily portions, the rates were nearly 40 per cent
among Indian and Chinese men, 42 per cent in Chinese
women and 36 per cent in Indian women. For some
communities consumption rates were lower; for example,
Irish men (26 per cent) and Bangladeshi women (28 per
cent). The survey also found that fat intake was higher
among the general population, but that the use of salt in
cooking was higher among all ethnic groups.
Physical activity
Ten top tips
Cancer Research UK, in partnership with Weight
Concern, has developed ‘Ten Top Tips’ to help
people maintain a healthy weight. The tips encourage
individuals to make lifestyle changes that include
consuming fewer calories and burning more
through exercise. The tips are also aimed to be
simple habits that everyone can permanently fit
into their daily lives; as well as being provided in
easy-to-understand language.
A lack of physical activity increases the risk of a number of
cancers such as colon and breast cancer and is linked to
cancers of the womb, lung and prostate. Inactive lifestyle is
estimated to account for around five per cent of all cancer
deaths.69 Low levels of physical activity combined with
a poor diet can also lead to obesity which is thought to
increase cancer risk.
For further information see: http://info.
cancerresearchuk.org/healthyliving/reducetherisk
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Cancer and Health Inequalities
Socioeconomic
Men involved in manual employment tend to be more
active than those in non-manual jobs, mainly due to the
physical nature of their occupations. At the same time,
participation in physical activity outside of work, such
as involvement in sports teams or clubs and walking, is
strongly related to household income, with those in higher
income households more likely to participate.70 This may
combine with the healthier diets of those from higher
socioeconomic groups to counterbalance the effects of
sedentary employment.
BME
Low levels of activity (defined as participation in less than
one 30 minute moderate or vigorous activity session a
week) were found to be more common among those
from some BME communities, particularly Bangladeshi and
Pakistani men and women.71
Children
Brodersen et al. (2006) found higher rates of sedentary
behaviour among children from lower socioeconomic
groups; and that a reduction in physical activity occurred
between the ages 11-12 and 15-16.72 A study of Italian
children also found a positive relationship between
socioeconomic group and physical activity73; these findings
are backed up by a number of American studies which
indicate increased inactivity among children from lower
socioeconomic groups (as well as more children from
the highest socioeconomic group falling into the highest
category of physical activity).74 This is matched with higher
rates of television watching among those from lower
socioeconomic groups.75
Weight and obesity
It is estimated that 12,000 cases of cancer could be
avoided if the population maintained a healthy body
weight.76 For non-smokers, a key avoidable or modifiable
risk factor for cancer is obesity.77 Being obese increases the
risk of cancer of the womb, kidney, colon and oesophagus
and is linked to breast cancer in post-menopausal
women.78 The Million Women Study79 found that in middle
aged and older women around five per cent of all cancers,
around 6000 cases, were caused by being overweight or
obese. And that for 10 of the 17 types of cancer studied
an increase in Body Mass Index was associated with an
increased risk of developing the disease.
Obesity levels have tripled over the last twenty years.80 In
1980, six per cent of men and eight per cent of women
were obese. By 2002, 22 per cent of men and 23 per cent
of women were obese. For children, obesity levels have
risen from three to almost six per cent in boys from 1995
to 2002, and from five to eight per cent in girls over the
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same time. If these trends continue, by 2020 a third of
adults and half of all children will be obese.81
Socioeconomic
Adult obesity is strongly related to social class (with the
strongest association in women). Thirty five per cent
of women from routine occupations were obese in
2002, compared to 16 per cent from managerial/
professional occupations.82
Obesity in childhood is linked to social class for girls
(ranging from five per cent for girls from managerial/
professional backgrounds to eight and nine per cent
for girls from intermediate and routine/semi routine
backgrounds respectively). There is no statistically significant
variation for boys.83 Research indicates that the likelihood
of adult obesity is already established by the age of 11. Few
children move into overweight or obesity between the
ages of 11 and 16, while equally few overweight or obese
children lose weight between these ages. Highest rates of
obesity were found among black girls84 (38 per cent)
and children from deprived backgrounds in general
(31 per cent).85
BME
Obesity rates vary by BME group, particularly for women.
Black African (38 per cent), Black Caribbean (32 per cent)
and Pakistani (28 per cent) women are more likely to
be obese than women from the general population (21
per cent). Differences were less marked for men, though
Bangladeshi (five per cent) and Chinese (six per cent) men
are much less likely to be obese compared to men from
the general population (19 per cent).86
Other groups
Higher rates of obesity and overweight have been found
in those with learning disabilities and mental health
problems.87 Among lesbians there is mixed evidence
relating to overweight and obesity, with a number of
studies finding increased rates within this group, one
American study found that lesbians had twice the odds
of being overweight, while others found no correlation
between sexual orientation and overweight/obesity.88,89,90,91
Conversely among gay men there is evidence of higher
rates of eating disorders, such as bulimia, compared to
heterosexual men.92,93
Alcohol consumption
Excessive alcohol consumption can cause a range of
diseases including liver diseases such as cirrhosis, heart
disease and strokes. Alcohol has also been linked to
increased risk of cancer of the mouth, larynx, oesophagus,
liver, breast and bowel.94,95,96
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Cancer and Health Inequalities
The Government has set benchmarks of the
recommended safe maximum amount to drink in a day:
three-four units of alcohol for men and two-three units for
women. Cancer Research UK further recommends that
men should be drinking a maximum of three units a day,
while women should drink no more than two.
Socioeconomic
Excessive drinking does not follow the pattern of smoking
or obesity by being more prevalent in poorer groups.
People from managerial and professional occupations are
more likely to report exceeding government benchmarks
for safe drinking than those from routine and manual
households (32 per cent compared to 29 per cent
respectively). Findings from the General Household Survey
(2005) found that those who were in employment were
more likely to report having drunk in the previous week
compared to the economically inactive (for men 77 per
cent and 62 per cent respectively and for women 67 per
cent and 47 per cent)97. Frequency of drinking was also
found to be related to income; with those earning more
than £800 more likely to report having drunk on five or
more days in the previous week than those on less than
£200 a week (32 per cent of men and 24 per cent of
women in the former group compared to 21 and 13 per
cent of the latter group).98
The cumulative cancer risk of combining smoking and
drinking has been found to be greater than the sum
of each separate risk factor.99 While there are no large
socioeconomic differences in terms of overall drinking,
there are marked differences in those who participate
in both smoking and drinking; with those from lower
socioeconomic groups most likely to do both.
BME
Almost all BME groups are less likely to binge drink
than the general population,100 except those from the
Irish community. Among Irish men 71 per cent exceed
recommended drinking levels, while for women the
figure is 53 per cent.101 The table below illustrates the
percentage of those who are non-drinkers for different
BME communities; among the general population 7 per
cent of men and 12 per cent of women fall into this group.
This indicates that, apart from the Irish community, those
from BME communities are far more likely to report being
non-drinkers.
Non-drinkers among BME communities compared to the
general population (percent)
Group
Men
Women
General population
7
12
Irish
5
10
Black Caribbean
13
18
Chinese
30
41
Indian
33
64
Pakistani
91
N/A
Bangladeshi
96
99
Source: Alcohol Concern, Acquire, 2003
Other groups
Men tend to drink more than women; with a higher
percentage exceeding the government benchmarks for
safe drinking in the previous week compared to 48 per
cent of women.102 Among the lesbian and gay community
evidence suggests a higher rate of alcohol consumption
than the general population;103,104 as well as greater levels
of difficulties related to alcohol consumption.105,106 For
example Creith107 found over 37 per cent of lesbians drank
over the recommended level compared to 11 per cent of
women in the general population.
Sun and Ultraviolet (UV) exposure
Sunlight is the most important preventable cause of skin
cancer. Incidence rates have increased dramatically since
the 1970s.108 Incidence is expected to triple over the next
30 years if people continue to sunbathe and use
sun beds.109,110
SunSmart
SunSmart is Cancer Research UK’s national skin
cancer campaign (funded by UK health departments).
Part of the campaign is the SunSmart code which is:
Spend time in the shade between 11 and 3
Make sure you never burn
Aim to cover up with a t-shirt, hat and sunglasses
Remember to take extra care with children
Then use factor 15+ sunscreen
It is also recommended that individuals report any
mole changes or unusual skin growths to their doctor.
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Cancer and Health Inequalities
Socioeconomic
Historically skin cancer has been linked to more affluent
groups, probably due to higher frequency of foreign
holidays. While evidence shows that wealthier individuals
are still more likely to develop skin cancer,111 the overall
pattern is changing as increasing numbers of people can
afford to holiday abroad or use sunbeds.
People from disadvantaged groups are less knowledgeable
about skin cancer prevention, practice less protective
behaviour, and are less likely to check their skin112. As a
result of poor awareness and lower levels of protective
behaviour, people from disadvantaged groups are more
likely to be diagnosed with advanced stage tumours and
have poorer survival outcomes.113,114
There is concern that sunbed salons, particularly coinoperated sunbeds, are predominantly located in deprived
areas and therefore most often used by people from
disadvantaged groups. This may contribute to cancer
inequalities. Cancer Research UK has funded research
to further explore the link between sunbeds and
social deprivation.115
Results from Cancer Research UK’s SunSmart survey116
indicated that age of leaving fulltime education, as a proxy
for deprivation, was a strong indicator of sun awareness
and protective behaviour (i.e. leaving school at an early
age is linked to higher levels of deprivation). Those who
stayed in education beyond age 19 mentioned, on average,
awareness of 2.4 protective behaviours compared to 1.8
behaviours among those who left school before the age of
14. Only 21 per cent of those who had left school before
age 14 reported using high factor sunscreen (SPF 15+)
compared to 45 per cent of those leaving school between
19 and 25.117
People working outdoors are more at risk of sun
exposure. Outdoor workers receive on average three to
four times more UV exposure each year than those who
work indoors.118 People from lower social class groups,
particularly men, are more likely to work outside and are
therefore, more at risk for certain skin cancers than those
from higher social class groups.119
Perceptions of cancer risks
A Cancer Research UK survey of 4000 people found that
cancer was feared most among a list including Alzheimer’s
and terrorist attacks.120 People’s health behaviours are
based on a combination of their perceptions/ knowledge,
attitude and intentions.121 Perceptions of risk allow people
to make informed choices about their health behaviour.
For example, when tobacco was shown to cause lung
cancer in the early 1950s, those most informed of the risks
(largely those from higher social classes) were the first to
quit smoking.122
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Results from the 2004 Cancer Research UK Reduce the
Risk Survey show that large numbers of people were not
aware of the risks associated with developing cancer. For
example, two-thirds of adults aged over 15, were unaware
of the risks concerning alcohol consumption, diet and
being over weight/obese. While awareness of risk factors
for smoking and getting sunburnt were higher, still almost
a tenth and a quarter of adults respectively claimed to be
unaware of those risks.123
Key messages
Cancer Research UK believes that half of all cancers
could be prevented by changes in lifestyle. Our key
messages relate to five ways that individuals can lower
their risk. These are:
• Stop smoking
• Stay in shape
• Eat and drink healthily
• Be SunSmart
• Look after number one (know your body and
see your doctor about anything unusual)
Socioeconomic
For all the main risk factors, the wealthier an individual, the
more likely they are to be aware of its link to cancer (see
the graph below). The biggest difference was for fruit and
vegetable consumption, with twice as many affluent people
being aware of the link between this and cancer compared
with the most deprived.
Awareness of cancer risks by socioeconomic
group (percent)
Smoking
Sunburn
Close relative
Fruit & veg
Bodyweight
Age
Alcohol
Exercise
Least deprived (%)
Most deprived (%)
Sexual partners
0
20
40
60
80
100
Source: Reduce the Risk Survey (2004) Cancer Research UK
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Cancer and Health Inequalities
Those living in deprivation were found to be less willing
to make lifestyle changes in order to reduce their risk of
cancer.124 Overall, around half the population would be
willing to make some changes to their lifestyle to reduce
the risk of cancer, and a quarter would change all their
unhealthy habits for healthy ones. People from the most
deprived group were twice as likely as those from the least
deprived group to report that they were not willing to
make any changes to their lifestyle.
Willingness to make lifestyle changes by socioeconomic
group (percent)
60
Least deprived (%)
Almost a third of overweight people describe themselves
as having a normal weight. Obese and very obese people
tend to be least able to describe their correct body
weight. Only eight per cent of obese people correctly
described themselves as obese (92 per cent of obese
people underestimate their weight and consequently
the risks associated with being obese).126
Unsurprisingly, people who already engaged in a healthy
lifestyle were more likely to be knowledgeable about
reducing their cancer risk through changes to lifestyle. For
example, people who ate more than five portions of fruit
and vegetables were more likely to know that half of all
cancers can be prevented by lifestyle choices.127
Most deprived (%)
50
Recommendations
• The evidence above shows that those from harder to
reach groups are more likely to undertaken lifestyle
factors which could negatively impact upon cancer rates.
Targeted health information and support should be
developed that increases knowledge of healthy lifestyles.
40
30
20
10
0
Make some
changes
Change all
risky behaviour
Take a
daily pill
Unwilling to
do anything
• Programmes should also be developed and evaluated
which seek to create sustained behaviour change within
communities and groups with poorer cancer outcomes
than the general population.
Source: Reduce the Risk Survey (2004) Cancer Research UK
Other groups
Hill125 found differing rates of awareness of risk factors
among BME communities. Knowledge on the risks of
smoking and not taking exercise was poor, while there
was found to be greater knowledge of, and desire for
further information, related to healthier diets. Interestingly,
the study also found that among
some South Asian and Caribbean communities there was a
belief that cancer was a disease
of white people.
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Cancer and Health Inequalities
Inequalities in symptom recognition and awareness
Introduction
For the majority of cancers, early diagnosis is a critical
factor which determines the type of treatment received
and the responsiveness of the cancer to such treatment;
and ultimately the likelihood of surviving the disease.
Being aware and recognising potential cancer symptoms
is very important, in terms of encouraging individuals
to seek early medical attention. Research indicates that
awareness of cancer symptoms in the general population
is low, for example:
• Older women had poor levels of breast cancer
symptom recognition, even though their risk of
developing breast cancer was higher than
younger women.128
• 24 per cent of respondents could not identify any
warning signs for colorectal cancer.129
• A survey of men found that only a quarter
considered that they knew ‘a lot’ or a ‘fair amount’ about
prostate cancer.130
Socioeconomic
Cancer Research UK’s Reduce the Risk Survey shows low
awareness of cancer symptoms; particularly among people
from the most deprived groups and communities.131 Twice
as many people from the most deprived group could not
name any cancer symptoms (20per cent) compared to
those from the least deprived group (9per cent). People
from the least deprived group were three times more
likely to mention ‘blood in urine/stools’ and twice as likely
to mention ‘change in moles’ and a ‘pain/ache’ than those
from the most deprived group.
Awareness of cancer symptoms by socioeconomic
group (percent)
Symptom
Least
deprived
Most
deprived
Difference
(% points)
Lump/bump
53
46
7
Weight loss/gain
21
14
7
Moles/change
in moles
18
9
9
Pain/ache
16
8
8
Blood in stools/urine
13
4
9
Tiredness/fatigue
12
5
7
Don’t know
9
20
11
Source: Reduce the Risk Survey 2005, Cancer Research UK
BME
Breast Cancer Care (2005) found that 43per cent of
BME women indicated that they had never practised
breast awareness, compared to 11per cent of the general
population. Among this group 53 per cent of BME women
said that they had not done so because they were
unsure what to look for. The survey also found a higher
proportion of BME women believed that a lump was the
only symptom of breast cancer, 38 per cent compared to
22 per cent of the general population.
Hill132 in interviews with cancer outreach and information
workers, found low levels of knowledge relating to cancer
signs and symptoms among their clients. Most were
aware that a lump could be caused by cancer, but were
unsure of other potential signs or symptoms. The workers
interviewed also commented on the low levels of body
awareness among their clients, often due to cultural factors
which discouraged the building of body awareness through
touching and looking.
For all groups, lower knowledge of cancer signs and
symptoms may be related to a lack of support and
information. The next chapter explores potential
inequalities in the provision of such services.
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Cancer and Health Inequalities
Open Up to Mouth Cancer campaign pilots
Cancer Research UK has been running a targeted
campaign aimed at raising the profile of mouth cancer
among those groups most at risk of developing the
disease. We have been providing information to health
professionals and the public through our website,
leaflets and posters.
Two pilot projects were based in communities
with particular issues relating to mouth cancer.
The first, in Tower Hamlets in London, sought to
raise awareness amongst the Bangladeshi community.
This involved providing bilingual information, working
with community leaders and networks and providing
mouth cancer check up sessions.
Recommendations
• Levels of symptom recognition have been found
to relate to cancer outcomes. It is therefore
essential that services, through the provision of
appropriate information, meet the needs of the
UK’s diverse population.
• Good practice, in terms of increasing community
level cancer awareness, could be developed using
examples from successful campaigns in cancer
and other disease areas.
The second in Gateshead targeted older men and
women who were heavy smokers and drinkers.
This provided mouth cancer check ups through the
use of a free voucher system.
For further information please go to:
http://info.cancerresearchuk.org/healthyliving/
openuptomouthcancer/
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Cancer and Health Inequalities
Inequalities in the use of health services
Introduction
There is a substantial amount of evidence relating
to the impact that a range of socioeconomic and
sociodemographic factors have upon uptake of cancer
services, from screening through to palliative care. The
following chapter details this research.
Information
The UK population is diverse and includes a range of
communities with varied needs for information. Even within
a specific community or group there can be considerable
variation in the type of information that individuals are
able to utilise. The unavailability and/or inappropriateness
of health information is a critical driver of risky health
behaviour, poor use of health services and poorer
health outcomes. Many people have additional
communication needs, which can act as a barrier to
accessing written information and hamper
communication with health professionals.
Health information is crucial for people to be able to
raise their awareness of cancer risks and symptoms, make
informed lifestyle choices, identify and navigate health
services and act upon treatment advice. Information can
help empower people and improve wellbeing by reducing
anxiety about health problems.
Socioeconomic
People from disadvantaged groups can face difficulties
in communicating with health professionals. Difficulties
reading official letters from service providers can mean
that letters are often ignored or action delayed until
a friend or relative can help. This could lead to missed
hospital appointments.133 40 per cent of cancer patients
received no written information at the time of their
diagnosis; while 16 per cent of those who received written
information did not fully understood it.134
Among disadvantaged groups there is a perception
that voluntary and community sector organisations are
more trusted and provide information more effectively,
particularly among ethnic minorities and disabled people.135
However, awareness about what Cancer Research UK
does among people from disadvantaged groups is lower
than among more affluent groups.
Literacy
The majority of health information is text based. Letters,
leaflets, and websites are sometimes produced in small
print and written in complex language that people find
difficult to understand. Research suggests that one in six
patient information leaflets produced by hospices and
palliative care units can only be read by 40 per cent
of the population,136 and that only 30 per cent of GPs
surgeries have accessible information for people with
learning disabilities.137
A key factor in the low take up of financial benefits is a
lack of information. Research indicates that around three
quarters of cancer patients report not being given
benefits information by anyone. A third of cancer patients
– likely to be those most in need and least able to get
information themselves – stated that they would have
liked such advice. 138
BME
Language can be a significant barrier to accessing cancer
services for many people from BME groups, particularly
(but not limited to) asylum seekers and refugees. The
report Focus on social inequalities found that 41 per cent
of people with additional language needs had no one to
help with interpreting when visiting a GP or health centre
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Cancer and Health Inequalities
(43 per cent relied on relatives or friends and
16 per cent on staff at the surgery or health centre).139
Perhaps as a result of this lack of information and support
a further study found that cancer patients from BME
groups were less likely to understand their diagnosis and
treatment options.140
Among older generations in BME communities low literacy
may be a barrier to accessing information;141 this is
likely to be compounded when an individual is not fluent
in spoken English and therefore cannot talk about their
concerns with a health professional without the use of
translation support.
Word of mouth as a means of communication has both
advantages and disadvantages. It is an important
source of information, but information passed on may
be limited, incorrect or out of date. In close-knit
communities such as certain minority ethnic communities,
misconceptions and misunderstandings about cancer and
cancer services can be widespread and reinforced through
community networks.142
Many hospitals outside large urban areas reported that
they did not hold information in other languages and relied
upon ad hoc solutions.143 Translating leaflets does not
always solve the problem, as they are sometimes of poor
quality, or inappropriate for people who cannot read their
mother tongue or have a culture of oral communication.144
Documents written in plain English have been found, in
some situations, to be more beneficial than translated
material, particularly where languages are difficult to
translate effectively.145
It is also important to remember that BME communities
contain a diverse array of individuals with information
needs ranging from those similar to the general population
to those requiring more specialised support in order to
utilise health information.
Other groups
Research indicates that a third of deaf or hard of hearing
patients are unclear about their condition (not specifically
cancer) and are unclear about medication or have taken
the wrong dose because of communication problems with
their GPs and hospital staff.146,147
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Screening
Screening Matters Campaign
Cancer Research UK is currently undertaking a
campaign asking UK governments to commit to:
• Screen at least three million more people over the
next five years
• Reduce the variation in screening across the UK
• Reach out to people eligible for screening who
aren’t taking part
• Provide the best possible screening programmes
through funding, staffing and measuring success.
Members of the public who sign up to support to
the campaign also pledge to attend screening when
invited and encourage those close to them to do
the same.
For more information about our campaign please
go to: http://info.cancerresearchuk.org/cancercampaigns/
screeningmatters/
Early diagnosis of cancer is likely to increase an individual’s
chance of surviving the disease, for example women who
are diagnosed at the earliest stage of breast cancer are 26
times more likely to survive than those diagnosed at the
latest stage.148 Screening is one such way that this can be
achieved. It is estimated that:
• Around 1,400 lives are saved each year by the NHS
breast screening programme149
• The bowel screening programme, when fully rolled
out, will reduce mortality from the disease by an
estimated 16 per cent (preventing one in six deaths
from bowel cancer)150
• Since 1988 the cervical screening programme has saved
around 5,000 each year.151
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Cancer and Health Inequalities
Socioeconomic
Cancer Research UK’s (BMRB) annual UK survey indicates
that women from more deprived areas are less likely
to attend screening. For cervical screening 34 per cent
of women with manual/routine occupations reported
irregular or non attendance; this compared to 17 per cent
of women with professional or managerial occupations. For
breast screening the figures were 31 per cent and 12 per
cent respectively.
International findings
Lorant et al159 undertook a study in Belgium160 and found
that women from lower socioeconomic groups were less
likely to have had a test for cervical cancer. Reasons for
these differing uptake rates were felt to be related to:
Baker and Middleton152 found reduced uptake of cervical
screening among lower socioeconomic groups and those
living in deprived areas in England 1991-1999. Target levels
of 80per cent uptake were reached by a higher proportion
of providers in wealthy, as opposed to deprived, areas.
• Behaviours (support and information seeking)
Henley et al153 found that uptake of breast screening in
Glasgow was lowest among those groups who were
experiencing socioeconomic deprivation. This finding is
supported by a range of research carried out both within
the UK and internationally.154,155,156
The Social Exclusion Unit157 reported that disadvantaged
groups were less likely to take up discretionary health
services, such as screening, compared to wealthier cohorts.
This was especially the case when admission to the
services was dependent upon a referral by a gatekeeper,
for example a GP.
The table below indicates awareness of current cancer
screening programmes and illustrates the differing levels
between socioeconomic groups; with the most deprived
having the least awareness. Interestingly a fairly large
minority from both groups indicated a belief that there
were screening programmes in prostate, lung, and ovarian.
Awareness of cancer screening programme among most
and least deprived (percent)
NHS Cancer
screening
Least
deprived
Most
deprived
Difference
(% points)
Breast
94
84
10
Cervical
57
40
17
Bowel/colorectal
16
18
-2
Ovarian
14
12
2
Don’t Know
3
9
3
Prostate
33
23
10
Lung
21
26
-5
• Cost (financial and psychological)
• Beliefs (attitudes of both patients and physicians)
• Importance of asymptomatic screening for those dealing
with day to day concerns.
Victora et al161 attempted to explain health inequalities by
proposing the ‘inverse equity hypothesis’.They postulated that
when new public health programmes are introduced they
are initially taken up by those from the higher socioeconomic
groups and this (temporarily) increases health inequalities.
Following this initial phase these groups reach a plateau of
improved health, while at the same time those from lower
socioeconomic groups begin to utilise the programmes at
increasing rates. At this stage the initial inequality begins to
narrow.This could go some way to explaining why, the Baker
and Middleton study mentioned above found that between
1991 and 1999 coverage of cervical screening services
improved at a faster rate, from lower levels, within deprived
areas compared to more affluent ones.
Age
There are differences in screening uptake by age. The
table below indicates lower uptake of cervical screening
at each end of the eligible age group. Among those who
are 25-34 or 55-64 coverage is six and five per cent lower
respectively compared to those who are 35-44.
Uptake of cervical screening by age (percent)
Great Britain
Percentages
1999
2000
20011
25-342
82
81
79
35-44
87
87
85
45-54
87
87
84
55-643
80
81
80
All aged 25-644
84
84
82
Age
1
Source: Reduce the Risk Survey 2004158
March 2002 for England.
20-34 for Wales and Scotland.
3
55-60 for Scotland.
4
20-64 for Wales and 20-60 for Scotland.
2
Source: National Statistics Statistical Bulletin: Cervical Screening Programme
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Cancer and Health Inequalities
The NHS Health and Social Care Information Centre162
found consistently lower levels of breast screening
uptake among women in the older age group. The table
below indicates that women in the older age group are
considerably less likely to attend for breast screening;
even though the chance of having breast cancer increases
with age.
Not understanding the purpose of preventative services,
such as cancer screening, is also a barrier to uptake among
some BME communities. The concept of screening for
disease before any symptoms, or of using health services
when well, is often not understood170. Fear can also stop
individuals from attending health services as they may not
want to know if they are ill. Other barriers include fear of
being stigmatised by being given a diagnosis of cancer, and
embarrassment regarding medical procedures/screening
practices.171,172,173
Uptake of breast screening by age (percent)
%
Coverage
100
Breast screening: coverage for women
53-64 and 65-70. England 2002 to 2005
53-64
65-70
80
60
40
20
0
2002
2003
2004
As at 31 March
each different community and GP staff, research such
as this is useful in terms of better understanding what
measures could be useful in increasing service use among
harder to reach communities. Gatrell et al and Majeed et al.
also found that the presence of a female GP could increase
cervical screening uptake.168,169
2005
Source: Breast Screening Programme, England, 2004-2005 NHS
Health and Social Care Information Centre, 2006
BME
A study focusing upon South Asian communities in the
UK found evidence of lower uptake of cervical screening
services, compared to the general population (although
they did find higher uptake rates among second and third
generation women). Further to this, while around 84 per
cent of the population now took part in the screening
programme, among those who were born overseas uptake
was below 60 per cent and one-third were recorded as
‘never screened’. They concluded that the current challenge
is to focus upon identifying and targeting services at those
groups who have lower uptake rates.163
Learning disabled
Women with learning difficulties have been identified
as a group with consistently low uptake of screening
programmes. Stein and Allen174 found that only 13 per
cent of women falling into this group had had a smear
test; while Biswas et al175 (2005) found that 16 per cent
were having regular tests. Evidence for the Cancer Reform
Strategy puts the figure even lower than this at around
3 per cent.176 An earlier study by Pearson et al.177 found
that around 24 per cent of eligible women with a learning
disability had undertaken a smear test in the past five years.
The studies indicated that the assumptions and attitudes
of health professionals towards individuals with learning
difficulties (for example that this group did not require
cervical screening services because they do not
participate in sexual intercourse) may be negatively
impacting upon uptake rates for this group. Other
contributing factors include (although they may not be
relevant for each individual):
• Low demand for services among this group
• Consent issues
Breast Cancer Care (2005) found that around three
quarters of the women in their study stated they had not
received an invite to attend breast screening; they also
found low levels of breast cancer awareness among this
group.164 Uk and internationally based studies have also
found that women from BME communities had lower rates
of uptake compared to the general population.165,166
Atri et al167 found that, among multiethnic communities,
a modest increase in breast screening uptake could be
achieved if GP receptionists were trained to contact
patients. The study found that the increase was most
marked when the receptionist shared the same linguistic
and cultural background as the potential attendee.
Although it would not be practical to create a ‘fit’ between
70708_CRUK_HEALTH_INEQ.indd Sec1:19
• Inaccessible appointment systems and waiting facilities
• Lack of ‘joined-up’ working combined with uncertainty
over service provider responsibilities
• Lack of communication training for health professionals
• Limited time/resources and pressures from other
groups of patients.
Although the evidence base in this area is limited, work is
often qualitative and small scale, breast screening uptake
rates for those with learning disabilities appears to be at
similar rates to the general population.178
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Cancer and Health Inequalities
Mental health
There are mixed findings for those with mental health
problems in terms of their uptake of screening services.
A study of three London boroughs found that patients
with a history of multiple detentions, relating to mental
health problems or psychosis, were significantly less likely
to attend breast screening.179 The study also found that
age and social deprivation were independent predictors of
non-attendance. Contradicting this work, Harris et al found
that measures of mental health were not independent
predictors of mammography uptake.180 There appears
to be a current lack of evidence surrounding uptake of
screening services for this group and further work is
required in order to understand the patterns of service
use, and information and support requirements, among
those with mental health issues.
Lesbians and women who sleep with women
Within the health community, and among lesbian women,
there is some confusion over whether or not this group
need to undergo routine cervical screening; with the result
that uptake of such services is often low in this group.
Although research in this area is limited, evidence suggests
that transmission of HPV (the main cause of cervical
cancer), is possible within this group and therefore that
regular cervical testing is required.181
Literacy
In the UK, 5.2 million adults have low literacy skills.182
The average reading age in the UK is nine years old (or
years 4/5 at school),183 and research into online health
information regarding other health matters found that
the majority of sites required an average reading age well
above this level. For example, the NHS Direct website was
found to require an average reading age of almost
17 years.
There is some evidence that those with low literacy are
less likely to attend screening184; with some commentators
arguing that this has a greater influence over health
behaviours than the factors discussed above (Garner,
2003). The Social Exclusion Unit found that those with
low literacy were six per cent less likely to attend cervical
screening than women with higher basic skills.185 Lindau
et al state that “Adult literacy is an independent and
important predictor of health behaviour”.186 They also
found that low literacy was a better predictor of cervical
screening knowledge than ethnicity or education; in
another study Lindau et al found that patients with low
literacy were also less likely to follow up after an abnormal
pap smear.187,188
70708_CRUK_HEALTH_INEQ.indd Sec1:20
Among women under the age of 65 Lagerlund et al found
that a range of factors were independent predictors of
mammography uptake.189 These included:
• Being employed
• Being married
• Having had a cervical smear
• Alcohol and/or tobacco consumption
• Regular contact with a doctor
Diagnosis
Socioeconomic
Neal and Allgar found that those from lower
socioeconomic groups had a longer delay for diagnosis of
prostate cancer. 190 They did not find any socioeconomic
differences in diagnosis delay in cancer of the colon, lung,
ovaries, breast, and non-Hodgkin’s lymphoma.
BME
The same study also found that BME status was a significant
factor in delay to diagnosis for breast cancer and that BME
status had a significant negative effect for delays within
secondary care. The researchers commented that this delay
may be caused by “primary care being slow to provide
accessible care appropriate to the needs of minority ethnic
populations”.191 An earlier study found similarities, in the use
of cancer services, between BME communities and those
from lower socioeconomic groups.192
Primary care services
Use of primary health care services, such as GP surgeries
and health centres, plays an important role in the diagnosis
of illness and as a gateway to referral for cancer services
and treatment. An individual’s involvement in primary care
also enables access to other services such as smoking
cessation, healthy eating advice, and counselling which may
aid the reduction of cancer risk.
Socioeconomic
Certain groups of people are less likely to visit a GP which
can delay a diagnosis of cancer. Take up of primary care
services can reflect either the extent of health problems
in a population or the extent to which populations are
seeking help for health problems. Disadvantaged groups
often use NHS services less in relation to need.193
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Cancer and Health Inequalities
People from disadvantaged groups are less likely to be
satisfied with their experience of health services and
outcomes. Satisfaction affects willingness to approach and
utilise services.194 People who report poor health are much
less satisfied with health services than those in good or
excellent health.195 Individuals experiencing deprivation
often feel that they do not get enough time with their GP.
Evidence suggests that for every point down a seven-point
scale of deprivation GPs spend 3.4 per cent less time with
their patient.196
People from disadvantaged groups are less likely to benefit
from reforms extending choice in accessing primary health
services.197 Disadvantaged groups tend to be less articulate
and less able to navigate the health system. They may also
be less aware of new services such as NHS Direct.198
Among disadvantaged groups there is evidence of
misunderstanding and fear about cancer. This could result
in people being reluctant to seek medical attention. People
from deprived groups are the most likely to delay seeking
medical advice and therefore more likely to present at
health services (and be diagnosed) when their cancer is
at a more advanced stage.199,200 A skin cancer study found
that 30 per cent of men reported that they would not go
to the doctor if they noticed changes to any moles.201
70708_CRUK_HEALTH_INEQ.indd Sec1:21
BME
For disadvantaged groups with transitory lifestyles such as Gypsies, Travellers, asylum seekers and refugees
- difficulty registering with a GP is a barrier to accessing
primary care.202 There is also some evidence that
health care providers, and staff working within primary
care settings, may restrict access to such services for
certain communities.203
GP consultation rates vary considerably by ethnic group.
Many people from minority ethnic groups visit their GP
more often than the general population. Particularly high
rates of GP contact are found for Pakistani women and
Bangladeshi men.204 Contact rates among ethnic groups
may reflect higher rates of general ill health among certain
BME groups. There are also differing rates of satisfaction
with primary care services among BME groups.205
For example, Pakistanis and Bangladeshis are less likely to
report getting an appointment on the day they wanted,
felt the doctor did not answer their questions and were
more likely to have been put off going to see a GP due to
inconvenient surgery hours.206
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Cancer and Health Inequalities
Cancer treatment
Inequalities in cancer treatment are quite difficult to
identify given the options available to people according
to the type of cancer they are diagnosed with,
the stage of disease at diagnosis and the way the
disease develops. It is perhaps for this reason
that there are mixed findings about the
relationship between socioeconomic or
sociodemographic factors and
cancer treatment.
Socioeconomic
People with the same cancer, at the
same stage of development, often
do not receive the same type of
treatment. Much of this can be
explained by the increased presence
of co-morbidities among those living
in deprived areas208 and the extent
to which other health and lifestyle
factors (e.g. poor diet, tobacco use
etc) render people less physically able
to face or survive cancer treatment.209
Downing et al focused upon women
with breast cancer and found that those
living in deprived areas were:
• More likely to be diagnosed with
advanced cancer
• More likely to have a mastectomy, rather than
breast conserving surgery210
• Less likely to receive radiotherapy
• Less likely to have surgical treatment
Other groups
For those with mental health problems the assumptions
made by health professionals, particularly ‘diagnostic
overshadowing’ (where symptoms are attributed to the
mental illness without further investigation) may make it
more difficult to get possible cancer symptoms recognised.
At the same time, communication difficulties make
incorrect diagnosis or unmet need for this group more
likely. Those with mental health problems have been found
to experience difficulties when attempting to re-register
with a GP, having previously been struck off.207
70708_CRUK_HEALTH_INEQ.indd Sec1:22
• Less likely to have survived five years211
Woods et al concluded that “Differences between
socioeconomic groups in the stage of disease at diagnosis
and in access to optimal treatment clearly explain at least
part of the association between social deprivation and
cancer survival”.212
Macleod et al found that women living in affluent areas
did not receive better treatment and care within the NHS,
but that women from deprived groups had increased rates
of hospital admission and GP consultations related to the
presence of co-morbidities.213 They therefore concluded
that any differences in cancer mortality were due to
increased rates of co-morbidities, and other negative health
outcomes, in deprived groups rather than differences in
breast cancer management. In support of this work, Henley
et al found that, in Glasgow, women from deprived areas
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Cancer and Health Inequalities
were more likely to receive a mastectomy than
women from affluent areas but that this was related
to women from the former areas having larger and
symptomatic tumours.214
Older Patients
There is some evidence that older patients receive differing
care to their younger counterparts. Evidence, given in
the Cancer Reform Strategy, found that older women
were less likely to receive standard management, such
as radiotherapy, for their breast cancer even after taking
account of tumour type215 and that older patients with lung
cancer were less likely to receive radical treatment for their
disease.216 At the same time, even though cancer incidence
is higher with older groups, it is often the case that clinical
trials are focused upon those under 65 years. Therefore
less is known about the efficacy of newer drugs on older
cancer populations and lack.
Palliative care
There is evidence to suggest that people from deprived
areas are less likely to use palliative services217 and those
who do are less likely to do so in their own home. Causes
of inequality in access to palliative care include: shortages
of specialist staff, increased demand for services and lack
of knowledge about the needs of patients from deprived
areas or BME communities.218
BME groups are less likely to be referred and use hospice
cancer services.219 A number of studies have found that
BME cancer patients and their carers were not using
available palliative services because they were less likely
to meet their needs.220,221 They also found that there was
a need for palliative services to be provided in more
culturally sensitive ways in order to meet the needs of
BME patients.
Other factors relating to health service use
Rural/Urban inequalities
Access to services is often worse for those living in rural
areas which can lead to poorer outcomes for these
communities.222 This could relate to a lack of infrastructure
in rural areas. For example public transport facilities are
often lacking (around 50 per cent of rural households are
more than a 13 minute walk to a bus stop and 29 per cent
of rural settlements have no bus stop).223 These factors
could pose particular problems for older or disabled
individuals. There is also some evidence that those living in
rural areas are more likely to have co-morbidities which
could affect their eligibility for particular forms of treatment
which in turn decrease their chances of survival.224
70708_CRUK_HEALTH_INEQ.indd Sec1:23
Individuals living in rural areas often take longer to present
for treatment of health problems and as a result have
been found to be diagnosed at a later cancer stage; this in
turn has an impact on the mortality of those living in rural,
as opposed to urban, areas.225,226,227,228 Jack et al. found
inequality in the treatment given to lung cancer patients
and postulated that this could be a consequence of
variations in access to oncology services.229
Campbell et al. found that patients living in rural settings
were more likely to delay seeking medical attention
because they did not want to be an inconvenience to
their GP. 230 The study undertaken in Scotland also found
that urban dwellers were more experienced at asking for
what they wanted and dissatisfied with delays.
Patient experience
Research indicates that there is little difference in patient
experience of cancer services between more and less
affluent groups. However, people from minority ethnic
groups have lower levels of satisfaction.231
People from minority ethnic groups are more likely to
have negative experiences of waiting times, understanding
explanations, trust in doctors and nurses, being treated
with respect and dignity, and help with pain relief.232
South Asian cancer patients are twice as likely to report
being in pain during their first hospital treatment.233
Patients from BME communities are also less likely to feel
involved in decisions about their care.234
Recommendations
• Appropriate and targeted service provision is central
to the reduction of cancer inequalities. It is therefore
essential that information and support is provided which
effectively meets the needs of harder to reach groups.
• The Equality Act 2006 makes it unlawful to discriminate
on the grounds of race, age, gender, sexual orientation
and religion in the provision of goods, facilities and
services. Research should be developed to better
understand how discrimination, and inequalities in the
provision of services, impacts upon the experiences
of harder to reach groups within such services and
how inequitable access to services influences cancer
incidence and outcomes.
• Health care professionals should, as part of their
ongoing career development, receive training in
communication skills (with a focus upon harder to reach
communities and groups).
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Cancer and Health Inequalities
What is Cancer Research UK currently doing to reduce health inequalities?
As the largest charity in the UK, Cancer Research UK has a
role to play in contributing to the health inequalities policy
agenda, especially when such policies are likely to impact
upon cancer incidence and outcome. The following section
details the work the charity is undertaking in this regard and
what our aims are for the coming years.
Our health inequalities goals
In 2007 Cancer Research UK launched ten goals to
measure our success in beating cancer over the years
up to 2020. A number of these relate to or will have
an impact upon health inequalities and the work that
Cancer Research UK will be undertaking in this area. Our
commitment to achieving these goals means that the
charity will work hard to keep cancer related inequalities
on the policy agenda. Although these goals are specifically
influencing the work of the charity, we have shared
them with the wider cancer community and will work
collaboratively to achieve them.
The goals with particular relevance to cancer and health
inequalities are:
We will especially tackle cancer in low-income
communities
The differences in the risk of dying from cancer between
the most affluent and the least affluent will be reduced
by half.
People will know how to reduce their risk of cancer
Our goal is that three-quarters of the UK public will be
aware of the main lifestyle choices they can make to
reduce their risk of getting cancer.
The number of smokers will fall dramatically
Four million fewer adults will be smokers, preventing
thousands of new cases of cancer every year.
People with cancer will get the information they need
At least nine out of ten patients will be able to access
the information they need at the time of diagnosis and
during treatment.
Cancer will be diagnosed earlier
Two-thirds of all cancer cases will be diagnosed at a stage
when the cancer can be successfully treated.
70708_CRUK_HEALTH_INEQ.indd Sec1:24
Our work so far
Increasing uptake of health services
As well as providing information about cancer to groups
with traditionally low uptake of health services, Cancer
Research UK is carrying out a campaign to increase the
number of people accepting an offer to attend cancer
screening. For more information go to:
http://info.cancerresearchuk.org/cancercampaigns/
Information provision and awareness-raising
We aim to increase people’s knowledge of cancer through
a number of methods including our website CancerHelp
(www.cancerhelp.org.uk).
We have a contract with Language Line (which provides
a translation service) to ensure that those, who are more
comfortable communicating in a language other than
English, are able to take advantage of the information and
support we provide. Our free-phone number is accessible
free of charge to landlines and most mobile phones (unlike
traditional 0800 numbers). Deaf, and hard of hearing,
individuals can either use type talk operators or minicom
when they require our cancer information.
We also have guidelines relating to the provision of
information by email to ensure that, when using this
format, our health information is free from medical jargon
and written (and formatted) in an easy to understand
manner. Publicity materials, for our information services, are
available via our shops. Providing information in these ways
ensures that we reach a diverse demographic with differing
needs for information and support.
The anonymous nature of accessing health information
by telephone or email means that those who would not
normally access face-to-face information are more likely
to contact us for assistance. Because individuals can also
access our information from their own homes those with
mobility issues are able to contact us more easily than
traditional health services.
Cancer Research UK’s ‘Open Up to Mouth Cancer’
Campaign worked specifically in the North of England and
Tower Hamlets to increase knowledge of mouth cancer
among communities with both unmet need and increased
risk factors associated with mouth cancer. We are currently
looking at ways of increasing the areas this project covers.
As part of our cancer risk reduction work Cancer
Research UK introduced cancer awareness units, which
specifically aim to travel to areas with high proportions
19/5/08 13:05:34
25
Cancer and Health Inequalities
of the population from C2, D, E socioeconomic groups,
the units have also been found to be popular among men.
Offering advice about the avoidable risks of cancer and the
importance of taking part in the screening programmes
in this way enables us to offer information and support
to communities and individuals who may not be accessing
more traditional health services.
All our health information resources and campaigns aim to
preferentially target C2, D, E socioeconomic groups, who
tend to have lower levels of health awareness combined
with higher cancer incidence and mortality. Our Open
up to Mouth Cancer, SunSmart and Smoke is Poison
campaigns (as well as the majority of our websites and
cancer awareness leaflets) were all written using accessible
English. We will continue to work in this way in order to
ensure that our services can be accessed by the largest
percentage of the UK population possible.
Cancer Research UK has funded a research project which
created the PROCEED (Professionals Responding to
Cancer in Ethnic Diversity)235 training programme. The
resource is a multimedia training tool to be used by those
working to develop the communication skills of health
professionals so that they are able to respond to the needs
of diverse patient populations. By working closely with a
variety of health professionals the resource fits with the
training needs of those providing services.
In the last year we have made our resources available free
of charge to ensure our messages reach the people with
the greatest need for information about cancer prevention
and early detection.
Working in partnership
The complex nature of health inequalities means that in
order to tackle the problem a multi-sector, multi-agency
approach is required. Cancer Research UK is taking
the opportunities available to the charity to work in
partnership and influence government policy. Working in
this way also ensures that there is less replication of service
provision and will enable good practices to be developed
across all agencies. Presently we are involved in a strategic
partnership with the newly merged Cancerbackup and
Macmillan to develop information prescriptions (this
will enable greater individualisation of information which
could go some way to meeting the needs, information
and support needs of diverse populations). We are also
working with a wide range of health and social care
organisations to provide policymakers with information
about how best to tackle health inequalities.
70708_CRUK_HEALTH_INEQ.indd Sec1:25
Encouraging healthy lifestyles
Currently a higher percentage of people from lower socioeconomic communities, and some BME communities, are
tobacco users. Part of our work has been to lobby the
Government to introduce comprehensive smoke-free
legislation in public places which is now in place in England,
Scotland, Wales and Northern Ireland.
We run mass media anti-smoking advertising campaigns
with funding from the Department of Health to raise
awareness of the dangers of smoking. Most recently, we
have worked to raise awareness of the toxic content of
cigarette smoke. We are currently working with Channel
4 to encourage young people to share their ideas with
us about smoking and how to encourage other young
people not to smoke. This will involve the production of
six viral films for use on social networking sites such as
Myspace and Youtube. Evidence also suggests high smoking
rates among the gay, lesbian, bisexual and transgender
communities. In order to raise awareness of the cancer
risks related to smoking we have worked in partnership
with Gaydar radio to disseminate a positive message about
the smoke-free legislation. As with our other campaign
work, we are using tailored information and new media
techniques to reach our target audience.
We are also committed to supporting research and
clinical trials testing the success of cessation methods
and programmes.
Supporting research and new initiatives
At present there are gaps in our knowledge in terms
of the causes of health inequalities, as well as effective
methods of addressing them. Cancer Research UK aims
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Cancer and Health Inequalities
to enable research in these areas and use this to influence
government programmes. One particular area of interest
is in understanding which methods are most effective in
improving health among the least affluent. The setting up of
the Cancer Research UK Cancer Inequalities Group allows
us to combine our knowledge in related issues to more
effectively contribute to the development of policy.
We fund and commission an array of research, as well as
being involved in other work related to reducing health
inequalities. Recent projects include:
• Michel Coleman and his team undertaking research to
better understand why people living in deprivation have
lower cancer survival rates than the general population.
They are using a variety of analytical methods and
sources of information, including exploring the views of
patients, carers and health professionals regarding the
route to cancer diagnosis.
• A previous study by Michel Coleman sought to
understand socio-economic inequalities in
cancer survival through analysis of MRC clinical
trial populations.
• Neil Campbell and his team are running a programme
to explore the potential for primary care to tackle
cancer inequalities in colorectal cancer patients and
their quality of life and survival rates.
• An earlier project by Neil Campbell aimed to a)
assess whether inequalities in cancer survival, between
rural and deprived communities and the general
population could be explained by later presentation at
health services by the former b) what patient factors
are associated with such a delay and if these factors
influence GP behaviour.
• Anne Taylor’s work is an exploration of the needs
of patients with cancers of the head and neck, with
particular focus on the outcomes and experiences
of those from deprived communities. Interviews with
patients, carers and health professionals are being used
to explore the route to diagnosis and awareness, among
professionals, of cancer care referral guidelines.
• The Veronica Project, led by Sheila Hollins is seeking
to understand the experiences of those with learning
disabilities who have cancer. The project involves
interviews with individuals from this cohort and seeks
to detail the barriers to cancer and palliative care
services, and produce policy guidance to improve access
to these services for those with learning disabilities.
• Contributing to the Prostate Cancer Advisory
Group pilot study which seeks to raise awareness
of the disease among men over 50, with particular
focus on groups with increased risk (such as men of
African origin). A further intention of the pilot is to
raise awareness amongst groups experiencing health
inequalities and reduce the gap between areas with the
best and worst disease outcomes.
• Cancer Research UK has funded Warwick Medical
School to look at ways of improving the collection of
cancer statistics based around BME status. Currently
data is not routinely collected linking BME status
to cancer incidence and this project aims to gather
evidence, identify best practice and produce clear
recommendations in order to improve data collection
of this nature.
• Cancer Research UK funded a research project
which created the PROCEED training tool for health
professionals (see above for further information).
• In 2004 Cancer Research UK hosted the conference
‘Equality in Cancer Prevention’ in order to explore some
of the challenges in the provision of cancer prevention
to diverse communities (A full report of the conference
is available).236
We also frequently carry out qualitative research with our
C2, D, E target audiences to ensure that our resources and
campaign activities are appropriately targeted and address
their needs.
Lobbying government
As this report illustrates, a lot of policy has been developed
with the intention of tackling health inequalities. Cancer
Research UK continues to play an active role in lobbying
UK governments and the EU to introduce policies which
address health inequalities as they relate to cancer.
Cancer Research UK will also be closely involved in
the work outlined in the Cancer Reform Strategy (the
current five year strategy for cancer in England which was
published in 2007). This includes the National Awareness
and Early Detection Initiative and the National Cancer
Equality Initiative.
Our work in all of these areas, and contributing to the
wider debate surrounding health inequalities, will enable us
to achieve our aim ‘Together we will beat cancer’.
• Funding Action on Smoking and Health (ASH). ASH is
a campaigning public health charity working towards a
sharp reduction, and eventual elimination, of the health
problems and inequalities caused by tobacco.
70708_CRUK_HEALTH_INEQ.indd Sec1:26
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Cancer and Health Inequalities
70708_CRUK_HEALTH_INEQ.indd Sec1:27
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Cancer and Health Inequalities
Annex 1: Differences in cancer survival rates between most and least
deprived groups for 1986-1990 and 1996-1999* (England and Wales)
CANCER type
Sex
1986-1990 Difference
(% points)
1996-1999 Difference
(% points)
% points change from
1986-1990 to1996-1999
Larynx
M
10.1
16.4
6.3
Multiple myeloma
F
-3.2
9.0
12.2
Rectum
M
4.4
8.6
4.2
NHL
M
5.1
7.7
2.6
Malignant melanoma
M
6.2
7.3
1.1
Rectum
F
3.3
7.1
3.9
Prostate
M
1.9
7.0
5.0
Colon
F
3.0
6.3
3.4
Bladder
M
3.8
5.9
2.1
Breast
F
5.8
5.8
0.0
Colon
M
2.9
5.4
2.5
Bladder
F
5.2
5.2
0.0
Cervix
F
3.0
4.8
1.8
Uterus
F
2.6
4.5
1.9
NHL
F
5.6
4.3
-1.3
All leukaemias
F
7.6
4.1
-3.5
All leukaemias
M
4.3
3.8
-0.4
Kidney
M
2.5
3.2
0.7
Multiple myeloma
M
-2.0
2.6
4.6
Brain
F
1.5
2.3
0.8
Oesophagus
M
-0.6
1.9
2.6
Lung
M
0.6
1.9
1.3
Testis
M
4.8
1.3
-3.4
Malignant melanoma
F
4.9
1.2
-3.7
Stomach
M
0.1
1.1
1.0
Pancreas
M
0.1
0.8
0.7
Lung
F
1.0
0.7
-0.3
Oesophagus
F
1.6
-0.4
-2.0
Pancreas
F
0.0
-1.3
-1.3
Ovary
F
2.8
-1.5
-4.3
Kidney
F
3.0
-1.7
-4.8
Stomach
F
0.1
-2.3
-2.5
Brain
M
1.5
-2.4
-3.9
* Table ranked according to deprivation gap in 1996-1999. Figures shown in bold indicate poorer survival rates for deprived groups,
while those underlined indicate poorer survival rates for affluent groups, or no difference.
Source: Cancer Research UK, see: http://info.cancerresearchuk.org/cancerstats/survival/survivaldeprivation
70708_CRUK_HEALTH_INEQ.indd Sec1:28
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Cancer and Health Inequalities
Annex 2: References
1
http://info.cancerresearchuk.org/cancerstats/survival/fiveyear/
2
For further information about Cancer Research UK’s ‘Goals’ please see the box below and the final chapter of this report.
Alternatively go to: http://www.cancerresearchuk.org/aboutus/whoweare/ourgoals/
3
ONS (2007) Male and female life expectancy at birth (years), United Kingdom:
http://www.statistics.gov.uk/downloads/theme_population/LE_UK_2007.xls
4
ONS (2004) Focus on Social Inequalities London: TSO
5
Department of Health (2000) The NHS Cancer Plan: A plan for investment, a plan for reform London: Department of Health
6
Coleman M et al (2004) Trends and socioeconomic inequalities in cancer survival in England and Wales up to 2001 British Journal
of Cancer, 90
7
National Audit Office (2004) Tackling cancer in England: saving more lives, p27
8
Jarvis, M. J. and Wardle, J (2005) Social patterning of health behaviours: the case of cigarette smoking. In: Marmot, M. and Wilkinson,
R. (eds) Social Determinants of Health Oxford: Oxford University Press, 2nd edition.
9
In 1958 the following per cent of men smoked manufactured cigarettes in each social class: 54% I, 58% II, 60% III, 54% IV, 61% V
and 45% VI. Source: Tobacco Advisory Council.
10
Crosier, A. (2005) Smoking and Health Inequalities: factsheet Public Health Research Consultant London: ASH
11
Goddard, E. (2005) General Household Survey 2005: Smoking and drinking among adults, 2005 London: Crown
12
Diabetes UK (2006) Diabetes and the Disadvantaged: reducing health inequalities in the UK Diabetes UK
13
Marmot et al (1999) Social determinants of health Oxford: Oxford University Press
14
Menvielle et al (2004) Smoking, alcohol drinking, occupational exposures and social inequalities in hypopharyngeal and laryngeal
cancer International Journal of Epidemiology; 2004: 33: 799-806
15
International Agency for Research on Cancer (2004) IARC Monographs on the Evaluation of Carcinogenic Risks to Humans:
Tobacco smoke and involuntary smoking. Volume 83; 2004, Lyon: IARC Press.
16
Cancer Research UK (2005) CancerStats: Cancer survival and deprivation statistics London: Cancer Research UK
17
Cancer Research UK (2007) CancerStats: UK Lung Cancer incidence statistics London: Cancer Research UK
18
Ibid
19
Cancer Research UK (2005) CancerStats: Cancer survival and deprivation London: Cancer Research UK
20
Ibid
21
Ibid
22
http://www.cancerbackup.org.uk/Healthprofessionals/Reachingmorecommunities/Backgroundinformation
23
Farooq, S. and Coleman, M.P. (2005) Breast cancer survival in South Asian women in England and Wales Journal of Epidemiology
and Community Health; 59: 402-406
24
Prostate Cancer Charter for Action (2005) The Prostate Cancer Equality Action Plan
25
Aspinall, P. and Jacobson, B. (2004) Ethnic disparities in health and health care: A focused review of the evidence and selected
examples of good practice London: London Health Observatory
26
Rowen et al. (2007) Early onset of breast cancer in a group of British black women British Journal of Cancer (2008) 98,
277-281
27
Patja et al. (2001) Cancer incidence among people with intellectual disability Journal of Intellectual Disability Research, 45,
4: 300-307
28
Howells, G. (1986) Are the medical needs of mentally handicapped adults being met? Journal of the Royal College of General
Practitioners; 36: 449-453
70708_CRUK_HEALTH_INEQ.indd Sec1:29
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Cancer and Health Inequalities
29
Wilson, D. and Haire, A. (1990) Health care screening for people with mental handicap living in the community BMJ: 301; 1379-1381
30
Horwitz, et al. (2000) The health status and needs of individuals with mental retardation Connecticut: Yale University
31
ASH (2001) Smoking and health inequalities London: ASH
32
Gruer, L. et al (2008) Smoking and health inequalities: new insights from Renfrew and Paisley http://www.ashscotland.org.uk/ash/
files/Laurence%20Gruer_Smoking%20and%20health%20inequalities.pdf (Presentation)
33
Wanless (2004) Securing Good Health for the Whole Population Norwich: HMSO
34
Deborah Arnott quoted in a Guardian Article by Sarah Boseley ‘Iron Chain’ links smoking and poverty: Guardian,
October 9th, 2006
35
Jha et al. (2006) Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates
in England, and Wales, Poland and North America Lancet 2006; 368: p.367
36
Taylor, T. et al (2005) Smoking related behaviour and attitudes London: Office for National Statistics
http://www.statistics.gov.uk/downloads/theme_health/Smoking2005.pdf
37
Jarvis, M. (2001) The challenge for reducing inequalities: analysis of the General Household Survey 1998 presentation to a
Department of Health seminar. January 2001
38
Goddard, E. (2005) General Household Survey 2005: Smoking and drinking among adults, 2005 London: Crown
39
Bauld, L. presentation at 2006 UK National Smoking Cessation Conference
40
Ibid
41
Bauld et al. (2003) Impact of UK National Health Service smoking cessation services: variations in outcomes in England Tobacco
Control 2003; 12: p.300
42
The Information Centre (2005) Health Survey for England 2004: The Health of Minority Ethnic Groups- headline tables
London: NHS Health and Social Care Information Centre
43
Williams, S. (1999) Dental services for the Bangladeshi community British Dental Journal, Vol. 186; 517-521
44
Department for Work and Pensions (2001) Households Below Average Income: Family Resources Survey (2000/01)
Department for Work and Pensions
45
Ibid
46
McNeill, A. (2001) Smoking and Mental Health: A review of the literature London: SmokeFree London
47
Meltzer et al. (1995) OCPS Surveys of Psychiatric Morbidity in Great Britain: Report 1 London: HMSO
48
Allday, E. (2006) Gay community has higher rates of smoking than other groups San Francisco Chronicle; August 6th, 2006
49
New Scientist (2004) Teenage lesbians have worst rates of smoking New Scientist; April 5th, 2004
50
Guardian (1999) Protect and survive: http://www.guardian.co.uk/society/1999/aug/11/gayrights.guardiansocietysupplement
51
Solarz, A. (1999) Lesbian Health: Current Assessment and Directions for the Future Washington, DC: National Academy
Press, p56-57
52
Harding et al (2004) Targeting smoking cessation to high prevalence communities: outcomes from a pilot intervention for gay men
BMC Public Health 2004, 4:43
53
DH (2007) Cancer Reform Strategy London: Department of Health
54
DH (2007) Healthy lifestyles for lesbian, gay, bisexual and trans (LGBT) people London: Department of Health
55
Nocon, A. (2006) Equal Treatment: Closing the gap London: Disability Rights Commission
56
HDA(2004) Smoking and patients with mental health problems. London: Health Development Agency
57
Marsh, A. and Mckay, S. (1994) Poor smokers London: Policy Studies Institute
58
Big Issue (2002) Coming Up from the Streets: What Big Issue Vendors Need to Escape Homelessness: Vendor Survey October 2002.
Cardiff: The Big Issue Cymru
59
‘Hardest to reach’ refers to those communities and groups within the population who may require either tailored and/or extra
information and support in order to be able to access health services or make healthy lifestyle choices.
70708_CRUK_HEALTH_INEQ.indd Sec1:30
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60
Cancer Research UK: http://www.cancerresearch.org.uk
61
Tackling inequality in obesity statistics http://www.nutraingredients.com
62
James, et al (1997) Socioeconomic determinants of health: The contribution of nutrition to inequalities in health BMJ; 314: 7093
63
Office for National Statistics (2006) Social Trends 36, p104
64
National Diet and Nutrition Survey 2003, see: http://www.food.gov.uk/science/101717/ndnsdocuments/printedreportpage
65
Bingham, S.A., et al., Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into
Cancer and Nutrition (EPIC): an observational study. The Lancet, 2003. 361(9368): p. 1496-1501, see: http://info.cancerresearchuk.
org/cancerstats/causes/lifestyle/diet/?a=5441
66
Department of Health, Dietary reference values for food energy and nutrients for the United Kingdom. Report of the panel on
dietary reference values of the Committee on Medical Aspects of Food Policy. Report on health and social subjects 41. 1991,
HMSO: London, see: http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/diet/?a=5441#source25
67
National Diet and Nutrition Survey 2003, see: http://www.food.gov.uk/science/101717/ndnsdocuments/printedreportpage
68
Department of Health (2004) Health Survey for England 2004: Health of Ethnic Minorities. See: http://www.ic.nhs.uk/statisticsand-data-collections/health-and-lifestyles/health-survey-for-england/health-survey-for-england-2004-health-of-ethnic-minoritiesheadline-tables
69
Colditz et al. (1997) Physical activity and reduced risk of colon cancer: implications for prevention Cancer Causes Control 1997; 8: p.
649-667
70
DH (1998) Health Survey for England London: Department of Health
71
Department of Health (2004) Health Survey for England 2004: Health of Ethnic Minorities London: Department of Health
72
Brodersen et al. (2006) Trends in physical activity and sedentary behaviour in adolescents: ethnic and socio-economic differences
British Journal of Sports Medicine: http://eprints.ucl.ac.uk/archive/00003316/01/3316.pdf
73
La Torre et al. (2006) Extra-curricular physical activity and socioeconomic status in Italian adolescents Bio Med Central Public
Health; 6:22
74
Gordon-Larsen et al (2000) Determinants of adolescent physical activity and inactivity patterns Paediatrics: 105 (6); 83
75
McMurray et al. (2000) The influence of physical activity, socioeconomic status, and ethnicity on the weight status of adolescents
Obesity Research (8) 2: 130-139
76
Cancer Research UK: http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/bodyweight/
77
Ibid
78
Ibid
79
Reeves, G.K. (2007) Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study
British Medical Journal; 335: 1134
80
Obesity is defined as individuals having a Body Mass Index of greater than 30 kg/m2
81
Weight Concern, see: www.weightconcern.org.uk
82
Unpublished analysis from the Health Survey for England 2002, by the National Centre for Social Research, 2004, cited in
Office for National Statistics (2004) Focus on Social Inequalities 2004, p75
83
Children aged 2 to 15 in 2001-02, from the Health Survey for England, cited in Office for National Statistics (2004) Focus on
Social Inequalities 2004, p75
84
The use of BMI may be a poor indicator of obesity among some BME communities, with indicators that take into account waist
measurements being more accurate.
85
Cancer Research UK, Pupils puppy fat leads to adult obesity, Thursday 4 May 2006, see: http://info.cancerresearchuk.org/news/
pressreleases/2006/may/150185
86
Department of Health (2000) Health of Minority Ethnic Groups, Health Survey for England London: Department of Health
87
Nocon, A. (2006) Equal Treatment: Closing the Gap London: Disability Rights Commission
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88
Boehmer et al. (2007) Overweight and obesity in Sexual-Minority Women: Evidence From Population –Based Data American Journal
of Public Health, 1134-1140, June 2007; Vol. 97, No.6
89
Bowen et al. (2008) A Review of Obesity Issues in Sexual Minority Women Obesity, 2008; 16, 221-228
90
Hughes, C. and Evans, A. (2003) Health needs of women who have sex with women BMJ, 2003;327; 939-940
91
Yancey et al. (2003) Correlates of overweight and obesity among lesbian and bisexual women Preventive Medicine, Vol. 36,
Issue 6, 676-683
92
Terence Higgins Trust (2007) GPs and Gay Men: 10 things to discuss with your gay and bisexual clients
London: Terrence Higgins Trust
93
Douglas Scott et al. (2004) Sexual Exclusion-Homophobia and health inequalities: a review London: UK Gay Men’s Health
Network
94
Cancer Research UK: http://www.cancerresearchuk.org
95
Malam, S. (2005) Health Education Population Survey: Update from 2004 Survey-Final report. Edinburgh: NHS Health Scotland
96
Bennicke, K. et al Cigarette smoking and breast cancer BMJ; 320, 6992, 1431
97
ONS (2005) General Household Survey 2005: Smoking and drinking among adults, 2005 London: ONS
98
Ibid
99
Boyle P et al (2003). European Code Against Cancer and scientific justification: third version, Ann Oncol, 2003. 14(7): p. 973-1005.
PubMed and Bagnardi V et al (2001) A meta-analysis of alcohol drinking and cancer risk. Br J Cancer, 2001. 85(11): p. 1700-5,
see: http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/diet/?a=5441#source4
100
DH (2004) Health Survey for England 2004 London: Department of Health
101
Ibid
102
Bromley, C. and Ormston, R. (2005) Part of the Scottish way of life? Edinburgh: Scottish Executive
103
Terrence Higgins Trust (2007) GPs and Gay Men: 10 things to discuss with your gay and bisexual clients
London: Terrence Higgins Trust
104
DH (2007) Healthy lifestyles for lesbian, gay, bisexual and trans (LGBT) people: Briefing 8 London: Department of Health
105
Alcohol Concern (2004) Acquire http://www.alcoholconcern.org.uk/files/20050907_104444_Acquire%20pull-out%20No40.pdf
106
Gruskin et al (2001) Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health
maintenance organization American Journal of Public Health 2001; 91 (6): 976-979
107
Creith (1994) Unpublished survey
108
Cancer Research UK: http://info.cancerresearchuk.org/cancerstats/types/skin/
109
Cancer Research UK: http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/sunlight/
110
Ibid
111
Hoey et al (2007) Skin cancer trends in Northern Ireland and consequences for provision of dermatology services
British Journal of Dermatology, Vol. 156: Issue 6, p. 1301-1307
112
Rainford L et al (2000) Health in England 1998: investigating the links between social inequalities and health.
London: The Stationery Office.
113
Geller, A., Koh, H., Miller, D. R., Lew, R.A. et al. (1996) Death rates of malignant melanoma among white men - United States
1973-88. Morbidity and Mortality Weekly Report 41 (2): 20-1
114
MacKie , R.M. and Hole, D.J. (1996) Incidence and thickness of primary tumours and survival of patients with cutaneous malignant
melanoma in relation to socioeconomic status. British Medical Journal 1996;312:1125-1128
115
SWPHO, Sunbeds and social deprivation in the UK, commissioned research by Cancer Research UK
116
www.cancerresearchuk.org/sunsmart
117
Office for National Statistics, 2003-2005 Sun Protection Survey, available at: www.sunsmart.org.uk
70708_CRUK_HEALTH_INEQ.indd Sec1:32
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118
Cancer Research UK, see: http://www.cancerresearchuk.org
119
Health Development Agency, 2002 (see GF email19/6)
120
Cancer Research UK (2007) Cancer is our number one fear but most don’t understand how many cases can be prevented
http://info.cancerresearchuk.org/news/archive/pressreleases/2007/april/316684
121
NICE Citizens council presentation, Mike Kelly, Why the fuss about health inequalities, (8/6/06).
122
International Union Against Cancer, Social inequalities in cancer, see: http://www.uicc.org/fileadmin/manual/6inequalities.pdf
123
Cancer Research UK, Reduce the Risk Survey 2004, see: http://info.cancerresearchuk.org/healthyliving/reducetherisk/
forprofessionals/campaignresearch/?a=5441
124
Cancer Research UK, Reduce the Risk, Perceptions of Risk Survey 2005: Summary, p5.
125
Hill, S. (2006) Ethnicity and Cancer Prevention Information (An Internal Report for Cancer Research UK
London: Cancer Research UK
126
Cancer Research UK (2005) Reduce The Risk: Perceptions of Risk Survey London: Cancer Research UK
127
Ibid
128
Grunfield et al. (2002) Women’s knowledge and beliefs regarding breast cancer British Journal of Cancer 86, 1373-1378
129
McCaffery, Wardle and Waller (2003) Knowledge, attitudes, and behavioural intentions in relation to the early detection of colorectal
cancer in the United Kingdom Preventive Medicine 2003; Issue 5: 525-535
130
National Audit Office (2004) Tackling Cancer in England: Saving More Lives http://www.publications.parliament.uk/pa/
cm200405/cmselect/cmpubacc/166/166.pdf
131
Cancer Research UK http://info.cancerresearchuk.org/healthyliving/reducetherisk/
132
Ibid
133
Ibid
134
National Audit Office (2005) Tackling cancer: improving the patient journey, p13
135
Social Exclusion Unit (2005) Improving Services, Improving Lives, p43 London: Social Exclusion Unit
136
National Consumer Council (2004) Health Literacy London: National Consumer Council
137
MENCAP (2004) Treat me right: better healthcare for people with learning difficulties London: Mencap
138
National Audit Office (2005)Tackling Cancer: Improving the Patient Journey
139
Office for National Statistics, (2004) Focus on Social Inequalities 2004 London: ONS
140
National Audit Office (2005) Tackling cancer: improving the patient journey,
141
Hill, S. (2006) Ethnicity and Cancer Prevention Information (Internal report) London: Cancer Research UK
142
Hill, S (2006) Ibid
143
National Audit Office (2005) Tackling cancer: improving the patient journey London: NAO/ DH
144
Central Office for Information (2003) Common Good Research: Ethnic Minority Communities Qualitative Research.
See: http://www.coi.gov.uk/documents/common-good-bme-exec-summ.pdf
145
Social Exclusion Unit (2005) Improving Services, Improving Lives London: Social Exclusion Unit
146
Royal National Institute for the Deaf (RNID), see: http://www.rnid.org.uk/mediacentre/press/2006/queens_uni_medics.htm
147
Social Exclusion Unit (2005) Improving Services, Improving Lives, p42 London: Social Exclusion Unit
148
Ugnat et al (2004) Survival of women with breast cancer in Ottawa, Canada: variation with age, stage, histology, grade and treatment
British Journal of Cancer 22; 90 (6) 1138-1143
149
NHSBSP (2006) Screening for Breast Cancer in England: Past and Future Advisory Committee on Breast Cancer Screening
NHSBSP Publication No. 61
150
Cochrane Database of Systematic Reviews, 2006. Screening for colorectal cancer using the faecal occult blood test: an update.
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151
Peto, J. (2004) The cervical cancer epidemic that screening has prevented in the UK The Lancet 2004; 364: 249-256
152
Baker, D. and Middleton, E. (2003) Cervical screening and health inequality in England in the 1990s Journal of Epidemiology and
Community Health; 2003: 57; 417-423
153
Henley et al. (2005) Does deprivation affect breast cancer management? British Journal of Cancer; 92: 631-633
154
Dinnes, J. and Smith, C. (1997) Breast cancer screening: factors which determine attendance and strategies to increase uptake
AMISTAHC: 156; 1997
155
Sutton et al. (1994) Prospective study of predictors of attendance for breast screening in inner London Journal of Epidemiology and
Community Health, 48, 65-73
156
Maheswaran et al. (2006) Socioeconomic deprivation, travel distance, location of service, and uptake of breast cancer screening in
North Derbyshire, UK Journal of Epidemiology and Community Health 2006; 60: 208-212
157
Social Exclusion Unit (2005) Improving Services, Improving Lives: Evidence and Key Themes London: ODPM
158
Comparison of social class groups A/B and E as proxy for affluence level, where A/B = least deprived and E = most deprived.
159
Lorant, V. et al. (2002) Equity in prevention and health care Journal of Epidemiology and Community Health 2002; 56: 510-516
160
Although findings from other countries are not entirely transferable to the UK screening situation, they do give an indication of
some of the issues that affect uptake rates among different socioeconomic groups and BME communities.
161
Victora et al. (2000) Explaining trends in inequities: evidence from Brazilian child health studies Lancet 2000; 356: 1093-98
162
NHS health and Social Care Information Centre (2006) Breast Screening Programme, England, 2004-2005 London: NHS Health
and Social Care Information Centre
163
Webb et al. (2004) Uptake for cervical screening by ethnicity and place-of-birth: a population-based cross-sectional study
Journal of Public Health, Vol. 26, No.3, 2004, p.293-296
164
Breast Cancer Care (2005) Same difference: policy briefing London: Breast Cancer Care (This figure is taken from the overall
group of women interviewed and may include those who are not eligible for breast screening).
165
Raja-Jones H. (1999) Breast screening and ethnic minority women: a literature review. Br J Nursing 10: 1284−1288.
166
Szczepura, A. (2005) Access to health care for ethnic minority populations Postgraduate Medical Journal 2005, 81: 141-147
167
Atri et al. (1997) Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice
reception staff to contact non-attenders BMJ 1997; 315: 1356-1359
168
Gatrell et al. (1998) Uptake of screening for breast cancer in South Lancashire Public Health; Vol. 112, Issue 5, 1998: 297-301
169
Majeed et al. (1994) Using patient and general practice characteristics to explain variations in cervical smear uptake rates BMJ 1994;
308: 1272-1276
170
Hill, S (2006) Ethnicity & Cancer Prevention: Internal report London: Cancer Research UK
171
Ibid
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Robb et al. (2008) Attitudes to colorectal cancer screening among ethnic minority groups in the UK
BMC Public Health 2008, 8: 34
173
Cancerbackup (2004) Why improve access to cancer information?
http://www.cancerbackup.org.uk/Healthprofessionals/Reachingmorecommunities/BeyondtheBarriers/Whyimproveaccess
174
Stein, K. and Allen, N. (1999) Cross sectional survey of cervical cancer screening in women with learning disability
British Medical Journal 1999; 318: 641
175
Biswas et al. (2005) Women with learning disability and uptake of screening: audit of screening uptake before and after one to one
counselling Journal of Public Health 2005 27 (4): 344-347
176
DH (2007) Cancer Reform Strategy London: Department of Health
177
Pearson, V. (1998) Only one quarter of women with learning disability in Exeter have cervical screening BMJ 1998; 316: 1979
178
Ibid
179
Werneke et al. (2006) Uptake of screening for breast cancer in patients with mental health problems Journal of Epidemiology and
Community Health 2006; 60: 600-605
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180
Harris et al. (2002) Mammography uptake predictors in older women Family Practice Vol. 19, No.6, 661-664
181
Bailey et al (2000) Lesbians and cervical screening British Journal of General Practice; 2000: 481-482
182
Department for Education and Skills (2003) The National Needs and Impact Survey of Literacy and Numeracy and ICT skills:
http://www.dfes.gov.uk/research/data/uploadfiles/RB490.pdf
183
Boulos M (2004) Readability Assessments of British Internet Information Resources on Diabetes Mellitus Targeting Laypersons,
University of Bath, see: http://www.bath.ac.uk/pr/releases/diabetes-survey.htm
184
Lindau et al. (2002) The association of health literacy with cervical cancer knowledge and health behaviours in a multiethnic cohort
of women American Journal of Obstetrics and Gynecology 2002; 186 (5): 938-943
185
Ibid
186
Lindau et al. (2001) Improving rates of cervical cancer screening and Pap smear follow-up for low-income women with limited
health literacy Cancer Investigation 2001; 19 (3): p.316
187
Lindau et al. (2002) The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic
cohort of women American Journal of Obstetrics and Gynecology
188
Lindau et al. (2006) Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study Journal of General
Internal Medicine 2006; 21 (8): 829-34
189
Lagerlund et al. (2000) Predictors of non-attendance in a population-based mammography screening programme; socio-demographic
factors and aspects of health behaviour European Journal of Cancer Prevention 2000; 9: 25-33
190
Neal, R.D and Allgar, V.L. (2005) Sociodemographic factors and delays in the diagnosis of six cancer: analysis of data from the
‘National Survey of NHS Patients: Cancer’ British Journal of Cancer 2005 92: 1971-1975
191
Ibid
192
Lodge, N. (2001) The identified needs of ethnic minority groups with cancer within the community: a review of the literature
European Journal of Cancer Care; Vol. 10: p.234
193
Coleman M et al (2004) Trends and socioeconomic inequalities in cancer survival in England and Wales up to 2001,
British Journal of Cancer, 90, p1372
194
Social Exclusion Unit (2005) Improving Services, Improving Lives, p38
195
Ibid
196
Social Exclusion Unit (2005) Improving Services, Improving Lives, p142
197
Ibid
198
Payne F et al (2003) Is NHS Direct meeting the needs of mental health callers? Journal of Mental Health, 12:1, p19-27
199
House of Commons Committee of Public Accounts (2005) The NHS Cancer Plan: a progress report, p15 London: HCCPA
200
Adams et al 2004) Are there socioeconomic gradients in stage and grade of breast cancer at diagnosis? Cross sectional analysis of
UK cancer registry data British Medical Journal Online 2004, June
201
Melanoma deaths in men soar, Cancer Research UK press release (15/5/06), see: http://info.cancerresearchuk.org/news/
pressreleases/2006/may/155887
202
Commission for Racial Equality (2005) Gypsies and Travellers: A Strategy for the CRE, 2004-07,
see: http://wwwcre.gov.uk/policy/gypsies_and_travellers.html
203
Messele, A. (2001) Access to health services for refugees and asylum seekers: Experiences and views of women refugees and asylum
seekers living in Redbridge and Waltham Forest - report of a focus group London: South Bank University
204
Health Survey for England 1999, cited in Office for National Statistics (2004) Focus On Social Inequalities 2004, p76
205
Census 2001, cited in Office for National Statistics (2004) Focus On Social Inequalities 2004, p77
206
Boreham R et al (2003) National survey of NHS patients, General Practice 2002,
see: http://www.dh.gov.uk/assetRoot/04/02/40/50/04024050.pdf
207
Buntwal et al. (1999) On Strike Open Mind: 100
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Macleod et al (2004) Comorbidity and socioeconomic deprivation: an observational study of the prevalence of comorbidity in
general practice European Journal of General Practice, Volume 10; March 2004
209
National Audit Office (2004) Tackling Cancer in England: Saving More Lives
210
This finding was supported by Thomson et al (2001) and Taylor and Chang (2002)
211
Downing et al. (2006) Socioeconomic background in relation to stage at diagnosis, treatment and survival in women with breast
cancer Leeds: University of Leeds
212
Woods et al. (2006) Origins of socio-economic inequalities in cancer survival: a review Annals of Oncology 17: p.16
213
Macleod et al. (2000) Primary and secondary care management of women with early breast cancer from affluent and deprived
areas: retrospective review of hospital and general practice records BMJ;320: 1442-1445
214
Henley et al. (2005) Does deprivation affect breast cancer management? British Journal of Cancer; 92: 631-633
215
Lavelle, K. et al. (2007) Non-standard management of breast cancer increases with age in the UK: a population based cohort of
women >65 years British Journal of Cancer, 96; 1197-1203
216
Peake, M. D. et al. (2003) Ageism in the management of lung cancer Age and Ageing, 32; 171-177
217
www.cancerbackup.org.uk
218
National Audit Office (2005) Tackling Cancer: Improving the Patient Journey
219
Ibid
220
Johnson, M. (2001) Palliative Care, Cancer and Minority Ethnic Communities: A Literature Review Leicester: De Montfort University/
Mary Seacole Research Centre
221
Gaffin et al (1996) Opening Doors: Improving access to hospice and specialist palliative services by members of the black and
minority ethnic communities. Commentary on palliative care British Journal of Cancer; 74, Supplement 24
222
Campbell et al (2000) Rural factors and survival from cancer: analysis of Scottish cancer registrations British Journal of Cancer; 82:
1863-1866
223
Social Exclusion Unit (2003) Making the Connections: Final Report on Transport and Social Exclusion
London: Social Exclusion Unit
224
Campbell, N. (2005) Tackling social inequalities in bowel cancer Science Update: Aberdeen: University of Aberdeen
225
Social Exclusion Unit (2005) Improving Services, Improving Lives
226
Liff et al (1991) Rural-urban differences in stage at diagnosis. Possible relationship to cancer screening Cancer 67: 1454-1459
227
Launoy et al (1992) Influence of rural environment on diagnosis, treatment and prognosis of colorectal cancer Journal of
Epidemiology and Community Health; 46: 365-367
228
Campbell et al (2002) Rural factors and survival from cancer: analysis of Scottish cancer registrations British Journal of Cancer; 82
(11), 1863-1866
229
Jack et al (2003) Geographical inequalities in lung cancer management and survival in South East England: evidence in variation in
access to oncology services? British Journal of Cancer; 88: 1025-1031
230
Ibid
231
National Audit Office (2005) Tackling Cancer: Improving the Patient Journey London: NAO
232
NHS Patient Surveys, General Practice (1998), Coronary Heart Disease (2000) and Cancer (2000) – cited by Commission for
Racial Equality website. See: www.cre.gov.uk/research/statistics_health.html
233
National Audit Office (2005) Tackling Cancer: Improving the Patient Journey London: NAO
234
Healthcare Commission (2006) Variations in the experiences of patients using the NHS services in England London: Health Care
Commission
235
Kai, J. (Ed) (2005) PROCEED: Professionals responding to ethnic diversity and cancer
University of Nottingham: Cancer Research UK
236
Cancer Research UK (2004) Equality in Cancer Prevention Conference Report
http://science.cancerresearchuk.org/reps/pdfs/fullrep.pdf
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