New cancer strategy: consultation

Section B: Introduction

The Purpose of this Consultation

17. The current National Cancer Plan 'Recovery and redesign: an action plan for cancer services'^[4] comes to completion in March 2023. This superseded the previous cancer strategy 'Beating Cancer Ambition and Action', and was developed in response to immediate challenges presented by the COVID-19 pandemic. We have started the process of developing a new cancer strategy for Scotland and want to seek wide ranging views on what should be prioritised as we recover from the pandemic and beyond.

18. It is important that our vision, aims and principles reflect a long-term ambition and guide where we want to go. We need to decide what aspects of cancer prevention, management and care are the most important. We want to be comprehensive but will also need to focus on the most important areas for action, particularly in the shorter-term.

Cancer in Scotland

19. Over the last decade to 2019, the numbers of cancers in Scotland increased in both sexes, from an overall total of over 30,600 in 2010 to more than 34,100 in 2019 – an increase of 11%.^[5] The increase in numbers reflects the increasing size of the older population and our success in increasing survival rates from other diseases. By 2027 this is expected to reach 40,000 a year – 110 people being diagnosed with cancer every day.^[6] To understand the implications of these trends over time, each cancer needs to be considered separately.^[7]

20. With effective population-based screening programmes, earlier detection, better diagnostic methods and advances in treatments, more people in Scotland are surviving cancer than ever before. Cancer mortality rates (age adjusted) in Scotland have reduced by 11% over the last 10 years (13% for males, 7% for females).

21. Lung cancer continues to be the most common cause of death from cancer in Scotland (3,874 deaths in 2020), which is more than double that of colorectal cancer, the next most common cause of death. Meanwhile, liver cancer had the biggest increase in mortality rates in the last decade (38%). Survival from liver cancer is poor in most cases. The main risk factors for liver cancer are obesity, alcohol and infection with hepatitis B and C viruses^[8].

22. Smoking, obesity, alcohol, physical inactivity and diet are among the largest modifiable risk factors for cancer in Scotland. Up to 40% of cancers can be prevented through modifiable risk factors^[9] in line with Scotland's wider public health priorities.^[10]

23. We know that health inequalities are the result of fundamental inequity in the distribution of power, money and resources. This has an impact on the opportunities for good quality work, income, education, social inclusion, housing and access to quality public services. In turn, these determinants shape individual experiences and health throughout life, including cancer.

24. The most deprived areas have incidence rates that are 34% higher than the least deprived areas. Lung cancer is three times more common in the most socio-economically deprived areas compared with the least deprived areas in Scotland. Cervical cancers are also more common in more deprived areas. In contrast, female breast and prostate cancers are more common in less deprived areas^[11].

25. Socio-economic inequalities lead to unequal access to healthier environments and quality health and community resources including screening services. There is convincing evidence that socio-economic deprivation increases the likelihood of being diagnosed with more advanced cancers of the bladder, bowel, cervix, female breast, head and neck, melanoma and prostate. For these cancers, people were more likely to have cancers that had spread to other parts of the body (metastatic disease) in the most deprived groups compared to the least deprived groups^[12]. This situation is not inevitable and can be improved.

26. The earlier a person is diagnosed with cancer, the more likely they are to have a good outcome. From 2000-2019, four out of five breast cancers (79%) were diagnosed at an early stage (I or II). In contrast, almost half of lung cancers (47%) and a fifth of colorectal cancers (20%) were diagnosed at a late stage (Stage IV)^[13].

27. During the five-year period 2013-17, overall, two thirds of men (67%) and women (71%) diagnosed with cancer survived for at least one year, while 2 in 5 men (43%) and 1 in 2 women (51%) survived for at least five years. However, an individual's chance of survival depends largely on which cancer they have, with 1-year survival ranging from around 20% to almost 100%, for different types of cancer. After taking account of changes in the population age structure over time, survival from all cancers (excluding non-melanoma skin cancers) improved, at both one and five years, by around 2% between 2008-12 and 2013-17, for both men and women^[14].

28. Although this is good news, this increase in the number of people surviving cancer will result in an increased use of specialist and primary care services and, due to the increasing age-profile, people using these services will most likely be presenting with multiple health conditions and complex health needs.

29. Considering all cancers combined, mortality rates were 78% higher in the most deprived areas compared with the least deprived. This suggests that a combination of higher incidence and poorer survival from cancer in more deprived areas contribute to the excess mortality from the disease^[15].

30. A key challenge will be for health, social care and third sector services to develop sustainable and innovative approaches to cancer care which meet the changing requirements of people with cancer to support them to live healthy lives at home. But we can only rise to this challenge if we are willing to be ambitious in the change that can be realised and consider the whole pathway from prevention to screening, diagnosis, treatment and care. Tackling inequalities in cancer incidence and care will be complemented by wider place-based action to enable communities, third, public and private sector organisations to work jointly to drive improvements in health locally. We will create the conditions that will support people to have a better quality of life, making sure that there are fair opportunities for everyone to have an active and healthy life.

Policy Context

31. In 2016, 'Beating Cancer Ambition and Action', was published with a 5-year horizon. The strategy set out a number of key ambitions for cancer services. In order to ensure services continue to improve, the former Cabinet Secretary for Health and Sport commissioned an update to the 2016 strategy. The 'Beating Cancer: Ambition and Action (2016) update: achievements, new action and testing change', was subsequently published in April 2020. The strategy update was published just after the first national lockdown and was written with a pre-pandemic lens.

Coronavirus (COVID-19) impact and response

32. Health protection measures, as well as wider pandemic impacts, including workforce isolation, impacted on cancer pathways including, for example, scope-based diagnostic tests. We recognise the significant pressure that the NHS continues to experience and cannot underestimate the risks from COVID-19 and its knock-on effects, which are likely to remain with us for some time to come.

33. To account for the new ways of working and the impact of the pandemic, a short-term action plan was developed by a multi-disciplinary group. The current National Cancer Plan, 'Recovery and Redesign: an action plan for cancer services' was published in December 2020^[16]. The plan detailed 68 actions that were designed to both redesign cancer services to benefit people diagnosed with cancer, and to increase our services' overall resilience to future rises in COVID-19 prevalence.

34. The National Cancer Recovery Group was established^[17] to provide national oversight of cancer services during the recovery phase and to drive forward the actions set out in the National Cancer Plan, alongside other governance groups for, amongst others, different types of cancer treatment.

35. Limiting the impact of COVID-19 on people diagnosed with cancer has remained a top priority throughout the pandemic. NHS Scotland continues to prioritise new people being referred with a suspicion of cancer, and this is closely monitored through weekly performance meetings with officials and reflected in Boards' Remobilisation Plans.

36. The majority of cancer treatments have continued throughout the pandemic. The framework for the maintenance of cancer surgery^[18] and national Systemic Anti-Cancer Therapy (SACT) prioritisation framework^[19] provide guidance ensuring people diagnosed with cancer are treated in order of clinical priority consistently across NHS Scotland.

37. The Scottish Government published the NHS Recovery Plan on 25 August^[20]. This set out plans for health and social care over the next 5 years. This restated our commitment to recovering and renewing cancer services.

38. The Scottish Cancer Registry^[21] has been collecting information on cancer since 1958. Data collected by the Registry are published by PHS. This information is used for a wide variety of purposes including: public health surveillance; health needs assessment, planning and commissioning of cancer services; evaluation of the impact of interventions on incidence and survival; clinical audit and health services research; epidemiological studies; and providing information to support genetic counselling and health promotion. New developments in the Scottish Cancer Registration and Intelligence Service will make cancer data more readily available and will make data on waiting times, screening, diagnosis and treatment more easily linked to the Registry.

Where we are now – successes and remaining challenges

39. The National Cancer Plan actions continue to progress well. To date, the plan is on track. The current status of the 68 actions are as follows:

• 14 actions are completed
• 35 actions are unchanged and progressing
• 17 actions have changed in scope or timeline but are progressing
• 2 actions have been superseded by new emerging work

40. The National Cancer Plan consists of 4 flagship actions, which are large, novel and new innovations being implemented across cancer services in Scotland. An overview of each flagship action and their progress can be found below.

i. A Single Point of Contact (SPoC) supports people diagnosed with cancer to:

• Have a single point of contact for discussing questions or anxieties related to their clinical care from the point of diagnosis
• Receive timely and accurate advice on their appointments, test and results
• Have the chance to discuss what non-clinical support may be available for them and their family following a cancer diagnosis
• Understand their treatment plan and expected timelines for treatment delivery
• Self-manage (aspects of) their condition and access available services as appropriate following discharge

ii. Early Cancer Diagnostic Centres (ECDCs) provide primary care with access to a new fast-track diagnostic pathway for people with non-specific symptoms that can be suspicious of cancer, such as weight loss and fatigue.

iii. Cancer prehabilitation can support people to better cope with cancer treatment whilst also improving clinical and service outcomes. The Scottish Government has committed to invest in prehabilitation and to test and evaluate the concept for delivery across Scotland.

iv. NHS National Services Scotland is hosting the Scottish Cancer Network. This is a dedicated national resource to support and facilitate a 'Once for Scotland' approach to cancer services, which will assist in enabling equitable access to care and treatment across Scotland. Its main aims are to:

• Develop and operate a system for the production, review, and hosting of National Clinical Management Guidelines.
• Oversee and drive improvement of existing National Managed Clinical Networks and adopt similar national network approaches for other areas, for example areas with low volume activity that may benefit.

41. While the NHS remains under pressure as a result of COVID-19, we've treated more people diagnosed with cancer within the 62 day standard in the quarter Q4 2021 compared to pre-COVID (3,273 in Q4 2021 compared to 3,115 in Q4 2019). However, the latest published figures have demonstrated that no boards have met the 95% target.

42. The number of monthly SACT patients continues to increase over time across all three cancer regions, with the latest figures showing 11,781 in January 2022, an increase of 12% since January 2020. This increased demand on services in conjunction with the increasingly complex treatment options is having an impact on overall capacity within the existing workforce^[22].

43. The Scottish Government have been working to ensure the voices and experiences of people affected by cancer are at the heart of policy. By utilising stories published on Care Opinion, and listening to stories told during engagement activities, it is evident that experience is positively associated with timely, compassionate and proactive care and communication. Whilst previous versions of the Scottish Cancer Patient Experience Survey (2015 and 2018) and Care Opinion tell us that the majority of experiences of cancer services in Scotland are positive (95%), we know that when things could be better, communication is often at the heart of those experiences.

Development of a new cancer strategy

44. A core design group has been established within the Scottish Government to take forward the development of a new cancer strategy and plan, consisting of officials from several departments. The group has initiated thinking on the aims and scope of a new strategy or plan and the engagement process for its development.

45. These early proposals have been discussed with the National Cancer Recovery Group and, through its membership of the NCRG, representatives of the Third Sector and clinical staff.