Cancer strategy 2023-2033: equalities (records) impact assessment

3. Data and evidence gathering, involvement and consultation

Equality evidence finder

Health Inequalities in Scotland (Nov 2022)

Long-term monitoring of health inequalities: March 2022 report

Reducing health inequalities (PHS, 2021)

Cancer Incidence in Scotland (PHS, 2022)

[NOTE: Temporary pause of all adult National Screening Programmes on 30 March 2020; however they were resumed during Summer/Autumn 2020]

Characteristic: Age

Evidence Gathered and Strength/Quality of Evidence

• In mid-2021, the population of Scotland was estimated to be 5,479,900, with 4,568,378 aged 16 and over.^[1]
• Age-related risk:
  • Risk of cancer diagnosis increases with age in both sexes.
  • The overall number of cancers increased with age to a peak at 70–74 years, and declined thereafter as the size of the older population decreased.
  • For some cancer sites, risk differs by age group, eg. cervical cancer, where the highest risk is in the younger age groups.^[2]
  • There are no data gaps.
• Modifiable risk factors and age:
  • In 2019, the highest proportions of self-reported current smokers were recorded among those aged 25-54 (22%); the lowest smoking prevalence was among those aged 75 and over (7%).
  • In 2019, 66% of adults in Scotland (aged 16 and over) were overweight, including 29% of adults who are classed as obese.
  • 65-74 year-olds have the highest percentage of overweight individuals (79%) and obese individuals (37%).
  • The older a person is, the more likely they are to develop non-melanoma skin cancer – in 2016-2018, 48% of all new non-melanoma skin cancer cases in the UK were diagnosed in people aged 75 and over. In 2018-19, 918 deaths were attributed to non-melanoma skin cancer in the UK.
  • Whilst older age is the main risk for cancer, other risk factors in relation to melanoma include intermittent UV exposure (potential greater impact on young people and children), skin type, family history.^[3]
• Comments from consultation analysis (p73):
  • Younger people are disadvantaged throughout the cancer pathway as they are often less aware of symptoms
  • Older cancer patients are less of a priority when it comes to cancer care^[4]
• NHS Workforce:
  • At end September 2021:
    • 27.9% of the NHS Scotland workforce (WTE) were aged 34 years and under
    • 49.2% were aged between 35 and 54 years
    • 22.9% were aged 55 years and over^[5].

Were any Data Gaps Identified?

No data gaps identified – workforce can be broken down by specialism

Characteristic: Disability

Evidence Gathered and Strength/Quality of Evidence

Risk factors in 2019:

• smoking rates were higher (26%) among adults living with a limiting long-term health condition compared to those living with no such condition (13%).
• 38% of adults with a limiting long-term condition in Scotland were obese, compared to 31% of those with a non-limiting condition, and 23% of those without a condition^[6]
• Disabled people are more likely than non-disabled people to live with socio-economic deprivation.^[7]
• 1.1% of NHSScotland staff in 2021 reported having a disability.^[8]

Were any Data Gaps Identified?

No

Characteristic: Sex

Evidence Gathered and Strength/Quality of Evidence

• In mid-2021, of the 4,568,378 people in Scotland aged 16 and over:
  • 2,2054,79 were male
  • 2,362,899 were female^[9]
• Risk of incidence between sexes:

Were any Data Gaps Identified?

No data gaps identified

Characteristic: Pregnancy and Maternity

Evidence Gathered and Strength/Quality of Evidence

• Cancer during pregnancy is rare and rarely affects the growing foetus.^[13]
• While it is possible that being pregnant could delay a cancer diagnosis, due to commonality of pregnancy and cancer symptoms (eg. bloating, headaches, breast changes, rectal bleeding), it is also possible that antenatal care for pregnant women could uncover cancer (eg.an ultrasound could identify ovarian cancer).^[14]
• [Cervical screening is paused during pregnancy since it is more difficult to obtain a clear result]
• Breast cancer is the most common cancer found during pregnancy, followed by cervical cancer; gestational trophoblastic disease; Hodgkin/non-Hodgkin lymphoma; melanoma; thyroid cancer.

Were any Data Gaps Identified?

No data gaps identified

Characteristic: Gender Reassignment

Evidence Gathered and Strength/Quality of Evidence

• Participation in cancer screening for female and male cancers may be hard to access for transsexual persons.^[15]
• [In terms of s.7 of the Equality Act 2010, a transsexual person is a person who has the protected characteristic of gender reassignment, where the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person's sex by changing physiological or other attributes of sex.]
• In terms of gender identity, participation in cancer screening for (sex-based) female and male cancers may be hard to access for trans men and trans women respectively. This is also applicable to non-binary people.
• Regarding cervical cancer screening, Scotland’s National Cervical Screening Programme works closely with the National Gender Identity Clinical Network Scotland to improve access to cervical screening services for transmen and non-binary people who have a cervix. This work has included the development of dedicated information resources for trans and non-binary people on screening, and CPD modules training in sample taking for this group. Additionally, there has already been work to amend cervical screening recall processes to be gender inclusive.
• Comments from consultation analysis (p74):
  • transgender patients… disadvantaged due to a lack of resources and advice about screening …
  • may be reluctant to engage with cancer services^[16]

Were any Data Gaps Identified?

• Although research is limited, evidence so far suggests that, in general, being trans or non-binary should not affect diagnosis or treatment of cancer. Therefore no data gaps have been identified.
• Patients presenting with symptoms regardless of gender reassignment status or gender identity will be referred into the appropriate cancer pathway.
• The Scottish Cancer Referral Guidelines were updated in 2019 which supports GPs.

Characteristic: Sexual Orientation

Evidence Gathered and Strength/Quality of Evidence

• Scottish Surveys Core Questions 2019 showed around 95% of adults identified as straight in 2019, around 3% of adults self-identified as lesbian, gay, bisexual or other.^[17]
• In 2018, an estimated 94.6% of the UK population aged 16 years and over (53.0 million people) identified as heterosexual or straight^[18]
• Past experience of discrimination or poor treatment can mean that LGBTQ people are less likely to access some key health services, eg. GP services and screening programmes, but are more likely to use A&E and minor injuries clinics.^[19]
• 58.7% of NHS staff in 2021 reported being heterosexual; 2.1% reported being lesbian, gay bisexual or other; 39% declined to respond or were not known.^[20]

Were Any Data Gaps Identified?

• Although research is limited, the evidence so far suggests that, in general, sexual orientation should not affect diagnosis or treatment of cancer. Therefore no data gaps have been identified.
• Patients presenting with symptoms regardless of sexual orientation will be referred into the appropriate cancer pathway.
• The Scottish Cancer Referral Guidelines were updated in 2019 which supports GPs.

Characteristic: Race

Evidence Gathered and Strength/Quality of Evidence

• There are racial and racialised inequalities with disparities in cancer rates across different ethnicities.^[21] For example:
• In all broad ethnic groups, lung, bowel, breast and prostate cancers were the 4 most common cancer types.
• Asian and Black people as well as people with mixed ethnic backgrounds have lower rates of cancer for the majority of cancer types, compared with White people.
• A small number of cancer types are more common in certain ethnic groups compared with White people, such as myeloma and stomach cancer in Black people; gallbladder cancer in Black and Asian people; and prostate cancer in Black men.
• Black and Asian people have far lower rates of melanoma skin cancer than White people.
• People from minority ethnic groups are also more likely to be diagnosed at a later stage, in part due to poorer screening uptake, and have lower survival for some cancer types.^[22]
• Additionally, there is less awareness of genetic cancer services among some ethnic groups. A systematic review of what affects ethnic minority (Black African, White Irish, and South Asian) people’s access to genetic cancer services found that there was low awareness of these services amongst these groups.^[23]
• We know that cancer is more common in more deprived populations in Scotland. In 2017-20, people from non-white minority ethnic groups were more likely to be in poverty compared to those from white ethnic groups, and may be more at risk from cancer.^[24]
• Comments from consultation analysis (p73):
  • reluctancy to engage with cancer services and seek screening
  • mistrust of practitioners based on previous negative experiences
  • view cancer as a ‘taboo’ subject
• 68.3% of NHS staff in 2021 were white; 3.8% were mixed ethnicity, Asian, black or other; 27.9% declined to respond or were not known.^[25]

Were Any Data Gaps Identified?

There are no data gaps.

Characteristic: Religion or Belief

Evidence Gathered and Strength/Quality of Evidence

In March 2021, 35.9% of NHS staff reporting having a religion, 28.2% had no religion, 35.9% declined to respond or were not known.^[26]

Were any Data Gaps Identified?

Patients presenting with symptoms regardless of religious belief will be referred into the appropriate cancer pathway.

The Scottish Cancer Referral Guidelines were updated in 2019 which supports GPs.

Characteristic: Marriage or Civil Partnership

(the Scottish Government does not require assessment against this protected characteristic unless the policy or practice relates to work, for example HR policies and practices - refer to Definitions of Protected Characteristics document for details)