20 INSIGHT ‘The way we diagnose cancer has to be reorganised’ Deputy editor Angela Sharda assesses how feasible the long-term plan’s early diagnosis cancer targets are for the NHS s many as one person in three will be diagnosed with cancer in their lifetime, according to data from NHS England, and it’s expected that by 2030, 3.4 million people will be living with the disease. The NHS long-term plan was published in January and included new clinical targets for cancer. How realistic are these ambitions and what must be done to diagnose cancer earlier? A ‘Challenging aspiration’ The plan outlines that by 2028, the NHS will diagnose 75% of cancers at stage 1 or 2. In real terms, this means that an additional 55,000 people a year will survive for at least five years after diagnosis. Healthcare leaders are naturally eager to improve the low levels of early cancer diagnosis. ‘If we could diagnose patients with cancer at an earlier stage, we could make sure people have the best chance of a cure,’ says Professor Chris Harrison, NHS England national clinical director for cancer and medical director of strategy for the Christie NHS Foundation Trust in Manchester. The long-term plan states: ‘The plan will build on work to raise awareness of symptoms of cancer, lower the threshold for referral by GPs, accelerate access to diagnosis and treatment, and maximise the number of cancers that they identify through screening.’ ‘To achieve 75% by 2028 is a really challenging aspiration, but it’s a goal that we need to meet if we are going to close the gap in survival between England and similar countries,’ Professor Harrison says. NHS England confirms that the long- term plan introduces a new and faster diagnosis standard from 2020, to help patients either receive a definitive diagnosis or rule out cancer within 28 days of referral from a GP or from screening. ‘Although this is a very challenging aspiration, test sites for the new standards Healthcare Leader 2019 Issue 10 have shown it can be achieved, but the way we diagnose cancer has to be reorganised,’ says Professor Harrison. ‘This means we need to challenge traditional ways of doing things and organise tests more efficiently.’ This is a view mirrored by Cancer Research UK policy manager Matt Case. ‘The plan’s commitment to early diagnosis is really ambitious – a potentially transformative change. But to make it happen, a number of changes must be made. This includes supporting primary care to make more effective referrals for suspected cancer, improving our existing screening programmes and making sure there is enough capacity in diagnostics services to support these changes,’ he says. ‘Communication is very poor’ In 2007, founder and chief executive of Pancreatic Cancer Action Ali Stunt was diagnosed with pancreatic cancer. Ms Stunt’s illness was detected early enough to allow a life-saving operation that just 10% of people are able to have. Since that procedure, her scans have shown ‘no evidence of disease’. She says one of the biggest flaws in the NHS is the lack of communication between different departments. ‘Communication is very poor between primary and secondary care, and sometimes between different outpatient departments such as oncology and surgery,’ she comments. However, Ms Stunt says the inefficiencies lie within the NHS as a whole, not with the individual consultants. ‘It’s not the specialist who is falling down. It is the system that is failing specialists and their patients,’ she says. ‘It’s not happening right now, but I like the ambition of the 28-day diagnosis. It’s a tricky one – 28 days should be achievable, but we need to make sure we have the right imaging. The volume of MRI scans has increased by 220% and CT scans by 160% over the past 10 years, and we need to increase that investment in diagnostic capacity,’ Ms Stunt says. The new faster diagnosis standard will be set by a refit of the way diagnostic services are delivered. The start of this year saw the rollout of new rapid diagnostic centres across the nation to upgrade and bring together the latest diagnostic equipment and expertise. It expands on 10 models piloted with Cancer Research UK, which focused on diagnosing cancers where patients often present with non-specific symptoms and go to their GP several times before being sent for tests. ‘We have failed against other systems’ Cancers are not all the same and many health experts feel that a variety of approaches is needed. ‘Cancer cannot be seen as a whole. A lot of the targets in the plan do not apply to all cancers,’ Ms Stunt says. In fact, the long-term plan does not have targets for the less common cancers, such as pancreatic and ovarian. Experts also believe early diagnosis may be difficult for some cancers. ‘It’s very hard to diagnose cancers such as pancreatic or ovarian. To do so will require us to understand genetic risks and develop new tests based on blood samples,’ Professor Harrison says. Ms Stunt believes that diagnosing a significant percentage of pancreatic cancers at stage 1 or 2 by 2028 is not realistic. ‘Some 80% of our patients are diagnosed at stage 4, which has a terminal prognosis.