During the current crisis, many routine medical appointments have had to be postponed or delayed, as all arms of the NHS focus on providing urgent care. In many cases, this has also included postponing screening appointments, including those made as a follow-up to an abnormal result. While a necessary measure, there remains the need to resume these appointments, and encourage people to take them up, as soon as possible – not least to prevent a spike in another major illness. Back in 2014, we looked at the fall in women attending cervical cancer screenings, and found that it not only saved lives, but had a positive impact on reducing the cost of the disease to individuals, hospitals and the state. As we begin to think about how to safeguard the NHS against future crises, encouraging people to take up these kinds of appointments seems an obvious step in the right direction.
Read Behind the Screen here, and the introduction below.
What is cervical cancer?
Cervical cancer is the most common form of cancer among women under 35 in the UK, and the twelfth most common cancer among women in the UK as a whole. Every year, there are around 3,000 new cases of cervical cancer diagnosed in the UK, and around 970 women die of the disease. (1)
Cervical cancer affects the neck of the womb – and is especially common in younger women of reproductive age (there is a spike in incidence between the ages of 30 and 34) (2). It is caused in virtually all (99.7 per cent) cases by infection with the human papillomavirus (HPV) – a sexually transmitted infection that causes mutations in the cells of the cervix, which can lead to cancer. Women with the disease often display no symptoms until the cancer reaches a comparatively advanced stage, at which point more intensive treatment may be required and survival rates are significantly reduced.
And yet cervical cancer is one of the only cancers that can be prevented – as it can be detected and treated in the pre-cancerous stage. The presence of either cervical cell abnormalities, or the presence of HPV, can act as a precursor for cervical cancer, and tests for either can allow a woman to be treated before cancer has a chance to develop. If cervical cancer does develop, as long as it is caught and treated at an early enough stage, treatment is relatively straightforward, and survival rates are good. Cervical cancers diagnosed at stage 1a – the earliest possible stage (see chapter 1 for an explanation of cervical cancer staging) – have a cure rate of between 95 per cent and 99 per cent. However, once the cancer spreads, the prognosis quickly deteriorates. Only 20 per cent of women diagnosed with a stage 4 cancer survive for more than five years. (3)
Cervical cancer is therefore a prime candidate for early intervention – and one does exist, in the form of the NHS Cervical Screening Programme, introduced in 1988. The Programme invites all women between the ages of 25 and 64 for regular screening tests, which look for pre-cancerous abnormalities in the cervix. If these are found, they are removed, and a case of cervical cancer could have been prevented. In the 20 years following its introduction, cervical cancer incidence fell by over a third – from 15.0 to 9.8 cases per 100,000 women. (4)
Yet cervical screening suffers from similar problems to other early intervention measures in public health: it requires pro-activity on behalf of the public to avoid an intangible, future ill, but may involve inconvenience, discomfort and embarrassment for those being screened in the short term. Healthcare providers therefore need to work doubly hard to ensure that people take advantage of preventive measures on offer.
Coverage of cervical screening – the number of women regularly attending a screening appointment – peaked at around 82 per cent in the late 1990s, and is now on the wane. The proportion of eligible women screened at least once in the past five years fell from 78.6 per cent in 2010/11 to 78.3 per cent in 2011/12.
This is a worrying trend: fewer women being screened means that more cancers that could be prevented will not be, and so the number of women being diagnosed with cervical cancer will rise. This is already beginning to happen – except for 2009 (when many more women were diagnosed in the wake of Jade Goody’s death from cervical cancer), incidence in 2011 (3,067 cases) was the highest it has been in the UK since 1999 (when 3,276 women were diagnosed). As cervical cancer is often symptomless in its early stages, it is also likely that many more cancers will go unnoticed until they reach a more advanced stage, where survival rates are lower.
Despite the overwhelming evidence of the benefits of cervical screening, it appears that women are still discouraged by the inconvenience and embarrassment of the screening test – a survey by Jo’s Cervical Cancer Trust found a quarter of women put off screening because of embarrassment, while 35 per cent agreed they would attend if GP appointments could be more flexible. (5) Ethnic minority women, women from more disadvantaged communities and older women all have persistently lower rates of cervical screening than average. It is clear, then, that to reverse this downward trend in screening rates, awareness of the importance of screening needs to be raised and steps need to be taken to make it easier, more convenient and less awkward for women to undergo a smear test. This, invariably, will cost money. In this report, we tackle this issue head-on by demonstrating the financial implications of cervical cancer and show, clearly, how increased investment not just saves lives, but makes sound financial sense.
In our report Paying the Price Demos highlighted the under-recognised financial side-effects of cancer – income lost during time off work or having to stop work altogether, and extra costs accrued in the course of treatment and recovery, which can include higher bills, additional travel costs, replacement clothing and medical costs (6). We argued that cancer is viewed primarily as a healthcare issue, but following fantastic improvements in diagnosis, treatment and survival rates, wider socio-economic issues are also becoming apparent. People who have survived cancer are increasingly returning to work, having families and carrying on with their lives, but they also have to recover from the drastic financial loss experienced during illness and treatment (estimated by Macmillan Cancer Support to be on average £570 a month) as well as make a physical recovery. Banks, insurers, employers and people surviving cancer themselves all need to adapt to the new reality of cancer survival.
This is especially true for those who have had cervical cancer, given the preventable nature of the illness, and the high survival rates for early stage cancers. Early stage cancers and pre-cancers can be treated quite quickly and easily with surgery (chemotherapy and radiotherapy, and more debilitating surgeries tend only to be used for more advanced cancers), so a woman can be back on her feet reasonably quickly and financial effects will be minimal.
Preventing cervical cancer, or diagnosing and treating it at an earlier stage, therefore, is likely to be cheaper for the woman involved, allowing her to get on with her life much more easily post-recovery. It also delivers cost savings to the NHS, through less costly treatment, and to society in general, through keeping more women healthy and either in work or caring for their families.
In this report, we are aiming to demonstrate:
- the cost savings that the NHS can achieve by increasing screening rates to 80 per cent, 85 per cent or even 100 per cent of all eligible women; these savings are likely to more than offset the extra spend required to boost uptake
- to women themselves how some of the costs associated with cervical cancer can be minimised or avoided altogether by ensuring that cervical cancer is either prevented entirely or picked up at the earliest possible stage through regular screening.
A more detailed methodology can be found in the methodological appendix to this report (page 97).
Demos carried out semi-structured interviews with ten specialists working in the fields of cervical cancer screening and treatment, which explored their perceptions of the links between changes in cervical cancer screening rates, stage of diagnosis, and the costs of illness to the NHS and the individual. We then looked at the costs of cervical cancer in three broad categories: costs to the NHS (chapter 2), costs to the state (chapter 2) and costs to the individual (chapter 3).
To model the costs to individuals and the state (through loss of tax revenue when people stop work), we surveyed 182 clients of Jo’s Cervical Cancer Trust, all of whom had previously been (or were currently being) treated for cervical cancer. The survey asked women who had been diagnosed at different stages and ages what extra costs and loss of income they had experienced post-diagnosis.
The team at the Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London provided data on cervical cancer incidence and mortality in England, and a breakdown of the treatment given to women according to their age and stage of diagnosis. More limited data (without the treatment information) were provided for Scotland, Wales and Northern Ireland. Using these data, we modelled what would happen to cervical cancer incidence and mortality in the three countries if cervical screening coverage was increased to 80 per cent, 85 per cent and 100 per cent nationally. We also modelled the implications of screening coverage falling to 70 per cent.
For England, we were also able to attribute costs to the treatments received by women at different stages and ages, using unit costs from NHS Reference Costs 2012–13. (7) This allowed us to compare the overall cost to the NHS of treating cervical cancer currently, and in each of the four screening scenarios.
To calculate the costs to the state, we looked at the loss of tax income to the state when somebody stops work altogether, or reduces their working hours – both of which were reported by women in our survey. We based our calculations on somebody earning the median salary, and where women switched from full-time to part-time work when they reduced their working hours.
Finally, we interviewed three women who had been treated for cervical cancer; their stories about how cervical cancer affected them financially appear throughout this report, to illustrate the costs associated with different cancer experiences.
(1) 2011 figures; Cancer Research UK, ‘Cancer statistics key facts, cervical cancer’, Jan 2014, http://publications.cancerresearchuk. org/downloads/Product/CS_KF_CERVICAL.pdf (accessed 7 May 2014).
(2) Cancer Research UK, ‘Cervical cancer incidence statistics – by age’, 2014, www.cancerresearchuk.org/cancer-info/cancerstats/ types/cervix/incidence/uk-cervical-cancer-incidence- statistics#age (accessed 8 May 2014).
(3) Cancer Research UK, ‘Cervical cancer statistics and outlook’, 2014, www.cancerresearchuk.org/cancer-help/type/cervical- cancer/treatment/cervical-cancer-statistics-and-outlook#stage (accessed 7 May 2014).
(4) NHS Cancer Screening Programmes and Trent Cancer Registry, Profile of Cervical Cancer in England: Incidence, mortality and survival, 2012, www.cancerscreening.nhs.uk/cervical/profile- cervical-cancer-england-report-october2012.pdf (accessed 14 May 2014).
(5) Jo’s Cervical Cancer Trust website, ‘Charity calls for more to be done as test which could mean the difference between life and death is increasingly ignored’, 6 Jun 2011, www.jostrust.org.uk/ news/articles/2011/06/06/charity-calls-for-more-to-be-done-as- test-which-could-mean-the-difference-between-life-and-death-is- increasingly-ignored (accessed 19 May 2014).
(6) Wind-Cowie and Salter, Paying the Price.
(7) DoH, NHS Reference Costs 2012–13, Department of Health, 2013, https://www.gov.uk/government/publications/nhs-reference- costs-2012-to-2013 (accessed 16 May 2014).