Critically appraise the primary and secondary prevention (health promotion) elements of the NHS cancer plan.

Z0222143 Health Promotion Assignment

“Critically appraise the primary and secondary prevention (health promotion) elements of the NHS cancer plan. Include in your discussion how well these elements relate to known effective strategies for primary and secondary prevention of cancers and how they will contribute to a reduction in inequalities in health.”

Cancer patients in the UK face long delays before treatment and their survival rates compare badly to the US and many European countries (Kerr et al, 2002). To combat this well known fact, the highly ambitious NHS Cancer Plan was launched by the Government in September 2000, and has four main aims:

To save more lives
To ensure people with cancer get the right professional support and care as well as the best treatments
To tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals
To build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics revolution, so that the NHS never falls behind in cancer care again. (NHS Cancer Plan, 2000)

The plan sets out clear guidelines as to what this government expects to achieve, and how it will go about achieving their goal. It is through these health promotion methods that the main areas of tackling health inequalities and preventing the increasing incidence of cancer, that this work will focus on, highlighting areas that could be expanded or reconsidered, by referral to pertinent literature.

Cancer is a malignant neoplastic disease (Online Medical Dictionary). Cancer is not one disease, but many. There are over 200 types of cancer, but they all have similar features and all start in the same way (Cancer Research UK, 2003). Impaired control signals in mitosis results in abnormal and/or uncontrolled cell division, and is the source of mutated cells. The division of these mutated cells is the start of a tumour, of which there are two types: malignant and benign. Benign tumours are not cancerous, are generally harmless, and do not normally require treatment. Benign tumours are normally only treated on if the lump is encroaching upon surrounding tissue/organ/vascular structures impairing their normal function. Malignant neoplasm’s are formed in the same way as benign tumours, however as the tumour develops, the structure is unstable and invasive. Malignant tumours are particularly dangerous because their unstable structure can lead to the tumour ‘breaking up’ and spreading through the body via the bloodstream and lymphatic system. The transport and deposit of the smaller pieces of the tumour can lead to what are known as secondary growths. What causes cancer, how quickly the disease grows, and how quickly it spreads is different for every individual.

More than one in three people in England will develop cancer at some stage in their lives. One in four will die of cancer. Every year, over 200,000 people are diagnosed (600 people a day), and around 120,000 people die from the disease (NHS Cancer Plan, 2000). Colorectal cancer is a leading contributor to this number, with the disease taking around 20,000 lives each year (Dove-Edwin & Thomas, 2001). Sixty five percent of cancer diagnoses in the UK will be in people over 65 years of age (Cancer Research UK, 2003). It is estimated that one third of all cancer cases will have been caused directly by smoking and a further third are attributed to poor dietary habits (Cancer Research UK, 2003). Health inequalities have increased over the last 20 years; as observed by Sir Donald Acheson:

“We find that although the last 20 years have brought a marked increase in prosperity and substantial reductions in mortality overall, the gap between those at the top and bottom of the social scale has widened” (Acheson, in Mayor, 1998, pp. 1471).

People from deprived and less affluent backgrounds are more likely to get some types of cancer and overall are more likely to die from it once they have been diagnosed (Cancer Research UK, 2003). In the early 1990s 17 professional men out of 100,000 would die of lung cancer, while the rate was 82 per 100,000 for unskilled workers (NHS Cancer Plan, 2000). There are a number of reasons for these inequalities in cancer. While genetic factors may have some part in explaining ethnic variations in incidence of cancers, different levels of exposure to key risk factors for cancer – notably smoking and diet – are very important. The affluent are less likely to smoke and tend to have more fruit and vegetables in their diet. Lower awareness of the symptoms of cancer in some social groups, later presentation to GPs, lower uptake of screening services and unequal access to high quality services (known as the “postcode lottery”) also play a role (NHS Cancer Plan, 2003).

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A key part of the NHS Cancer Plan is to prevent the development and decrease the percentage of incidence in cancer. The health promotion interventions that will be the main focus in the reduction in incidence of cancer will be primary and secondary preventative methods. Primary prevention seeks to avoid the onset of ill health by the detection of high risk groups (such as unskilled workers who smoke) and the provision of advice and counselling (Naidoo & Wills, 2000). Examples of primary prevention for cancer would be smoking cessation campaigns, and information on how a healthy diet and taking part in regular exercise can prevent the formation of cancerous tumours. Secondary prevention seeks to shorten episodes of illness and prevent the progression of ill health through early diagnosis and treatment (Naidoo & Wills, 2000). Examples of secondary prevention would be the national breast screening campaign that the NHS is currently conducting, as well as the identification and symptoms of cancer. Secondary prevention allows for early and correct diagnosis, therefore leading on to much earlier treatment, thus increasing the likelihood of survival for victims.

Within the primary and secondary prevention (health promotion) elements of the NHS Cancer Plan (2000) there are areas of immediate concern. The need to address cancer prevention is high on the agenda, as the saying goes; ‘prevention is better than cure’. The primary prevention (health promotion) aspect of the cancer plan addresses certain key issues that cause/are linked to the causes of cancer in the UK, including: tobacco/smoking, diet, reducing weight/obesity, increasing physical activity, alcohol, and skin cancer prevention. As mentioned before, what causes cancer is different for every individual, therefore a wide range of potential causes were identified, and have been set milestones within the 10 year plan. As Melia et al (2000, pp. 702) claimed “Health education can be targeted at the whole population, or at different groups of the population” it is obvious in the plan that the government have taken this into account and are very clear in what they want to do.

In primary prevention the NHS plan aims to tackle the two main attributable areas of the causes of cancer: smoking and poor diet. Within these two areas, there have been inequalities recognised that give significant different incidence rates in different population groups as well as different socio-economic groups. The prevalence of smoking is higher among people in manual than non-manual social classes (31% compared with 23% in England in 2000). The widening of this gap over the past 20 years reflects a steeper decline in smoking prevalence among non-manual classes compared with manual classes (HDA Cancer Prevention, 2002). The social class differentials in smoking are reflected in the social gradients of deaths caused by smoking. Among men, smoking accounts for over half of the difference in risk of premature death between social classes (Jarvis & Wardle, 1999).

Cigarette smoking among minority ethnic groups is generally less than among the UK population as a whole (27%), but a more detailed examination reveals important differences between and within groups. The smoking rate among Bangladeshi men is particularly high (44%). Smoking rates are even higher among middle-aged and older Bangladeshi men (50% and 54% for men aged between 35-54 and 55+ years respectively). This same group of men also has high rates of chewing tobacco products. Tobacco chewing is particularly high among older Bangladeshi women: 43% of women aged 35-54 years and 56% of women aged over 55 years chew tobacco (HDA Cancer Prevention, 2002).

Traditional measures of social class tend to underplay the extent to which high smoking rates have not decreased in the poorest sections of society (HDA Cancer Prevention, 2002). Recent studies have shown that smoking levels have remained virtually unchanged among those in the poorest groups, and among lone mothers smoking levels have risen (Marsh & McKay, 1994; Dorsett & Marsh 1998; Jarvis, 1998). In a detailed study, lone parents living in rented accommodation and relying on social security benefits were found to have smoking levels in excess of 75% (Dorsett & Marsh, 1998).

The cancer plan has outlines that people have a right to smoke, and the Government reinforces the fact that they have no intention to outlaw smoking outright. However, they do say that if introduced today, smoking would never be made legal due to the addictiveness and harmful effects it has. The Government has therefore made it integral to the cancer plan that it will advertise the harmful effects smoking has, not only to smokers, but also to those who can be affected by other peoples smoke. The NHS Cancer Plan, in conjunction with the white paper Smoking Kills has set out a tobacco control strategy which pledges to:

Ban tobacco advertising
Increase new specialist NHS smoking cessation services
Make Nicotine Replacement Therapy (NRT) available through prescription from GP’s
Ask Committee on Safety of Medicines to consider whether NRT can be made available for general sale rather than only through pharmacies or on prescription
Make Zyban, a new treatment to help smokers give up, available on prescription from primary care
Update guidance on smoking cessation for health care professionals and commissioners from the Health Development Agency (HDA)
Enforce the best practice code, preventing the sale of tobacco products to under 16’s
Launch a new media campaign and an NHS smoker’s helpline (NHS Cancer Plan, 2000).

In these main aims the plan does not directly identify the need to tackle inequalities in smoking, however it does go on to mention the need to do this. The plan identifies the introduction of Zyban and NRT on prescription for those who want to quit smoking. The available evidence indicates that a comprehensive tobacco control programme as set out in Smoking Kills, if efficiently and fully implemented, would bring down smoking in both manual and non-manual social classes (HDA Cancer Prevention, 2002).

After smoking, what people eat is the next biggest contributor to cancer deaths, and as mentioned before, may be responsible for up to a third of all cancer deaths. A healthy diet is one that is high in fruit and vegetables and cereals, and low in fat, salt and sugar (NHS Cancer Plan, 2000). Diet is therefore a risk factor for the development of some of the most commonly occurring cancers in England. Improving people’s diets is an important public health measure, not only to reduce the rates of cancer but other diet-related chronic conditions such as coronary heart disease (CHD), stroke, type 2 diabetes and obesity (HDA Cancer Prevention, 2002).

Behind reducing smoking, increasing the intake of fresh fruit and vegetables is seen as the second most effective way to prevent the development of cancer (NHS Cancer Plan, 2002). Dietary recommendations to reduce the risk of cancer in the UK were first made by the Committee on Medical Aspects’ (COMA) working group on diet and cancer in 1998. The report recommends, on a population basis:

Increasing the consumption of a wide variety of fruits and vegetables
Increasing intakes of dietary fibre from bread and other cereals (particularly wholegrain varieties), potatoes, fruit and vegetables
Maintaining a healthy body weight (within the BMI range 20-25) and avoiding an increase during adult life
Avoiding an increase in the average consumption of red and processed meat, current intakes of which are about 90g/day
Avoiding the use of beta-carotene supplements to protect against cancer and being cautious in using high doses of purified supplements of other nutrients. (HDA Cancer Prevention, 2002).

The intake of a healthy balanced diet can prevent the development of certain cancers, such as colorectal cancer. Dove-Edwin & Thomas (2001) observed that “An inverse relationship between vegetable consumption and colorectal cancer has been reported in a number of case control and cohort studies”. While the aim is ultimately to increase the population average daily intake of fruit and vegetables to at least five portions of around 80g each, a recent trial has shown that increasing intakes by the equivalent of around one portion per day may be beneficial in reducing the rates of chronic disease (Khaw et al., 2001).

As it is generally accepted that having a healthy balanced diet can prevent such cancers as colorectal cancer, part of the NHS Cancer Plan (2000) is to introduce a national 5-a-day intake of fruit and vegetables. This scheme is currently in its pilot stage across 5 locations: Sandwell, Somerset, Airedale and Craven, County Durham and Hastings. The scheme aims to reach all areas of the community, particularly the economically deprived to make fresh fruit and vegetables readily available at reasonable prices. This strategy will hopefully reduce the inequalities in health regarding diet. Also the publication of how a healthy lifestyle will add to the primary prevention methods for cancer development. The most striking difference is the variation in amounts of vegetables and, particularly, in the amount of fruit eaten by people in lower socio-economic groups. In the UK, average consumption is about three to four portions a day, though there are marked differences between social groups with unskilled groups tending to eat around 50% less than professional groups (HDA Cancer Prevention, 2002). Improving knowledge alone is ineffective in improving people’s diets. Affordability and physical accessibility to foods such as fruit and vegetables have been identified as key barriers to eating a healthier diet. Interventions such as detailing what exactly is one portion of either vegetables or fruits have begun through supermarkets. For example; Tesco have started to label their fruit and vegetables with ‘stay healthy’ messages, and give examples of what a portion of fruit/vegetables is, as observed on a packet of Clementine’s:

“5-a-day:

Eat 5 portions of different fruit & veg to help prevent cancer
2 Clementine’s = 1 portion” (Cancer Research UK)

However, the effectiveness of this intervention is yet to be published. The ‘carefully monitored’ intervention has provided the start of the national “5-a-day” programme (2002) to assist the nation in improving their diet. The scheme’s main areas to target are hard to reach areas such as schools, prisons and hospitals.

The national School Fruit Scheme has been launched in conjunction with the 5-a-day campaign. There are clear links between childhood diet and risk of disease later in life, and eating patterns are established early in life. The aim of this strategy is to therefore reduce the likelihood of today’s children establishing bad eating habits later in life. Children’s consumption of fruit and vegetables is particularly low; one in five do not eat any fruit in a week, and three in five eat no leafy green vegetables. Children growing up in disadvantaged families are about 50% less likely to eat fruit and vegetables than those in high income families. The National School Fruit Scheme, announced in the NHS Plan, has made a free piece of fruit available to school children aged four to six each school day (NHS Cancer Plan, 2000).

The secondary prevention (health promotion) aspect of the cancer plan looks to catch cancer in or even before the early stages of development, increasing the rate of survival, thus decreasing mortality, and possibly reducing incidence by finding precancerous growths. This prevention is mainly done through screening; testing large groups of healthy people for early signs of disease (Cancer Research UK, 2003). Those who have a positive test can then be treated. Self identification of symptoms through distribution of grey literature can also contribute to the early detection of cancer, and the wider the knowledge base for this, the more likely cancers can be caught at an earlier stage. Screening is essential. National breast and cervical screening programmes are already saving lives, screening five million women each year. In 1998/ 1999 the breast screening programme detected nearly 8,000 cancers, over 40% of which were very small (less than 15 millimetres). The incidence of cervical cancer has fallen by 43% between 1988 and 1997 (NHS Cancer Plan, 2000).

There are ethical issues surrounding screening for cancer. Although screening can pick up cancers long before a person develops symptoms, it also has the potential to cause anxiety in people who are entirely healthy (Cancer Research UK, 2003). People invited to participate in screening programmes need to understand the potential benefit and harm in doing so to be able to make an informed choice about whether or not they wish to proceed. Screening needs to be accessible and sensitive to peoples needs (NHS Cancer Plan, 2000). Screening can also be seen as an invasive process, for example; in cervical screening many are reluctant to go through with the process as it is not only uncomfortable and invasive, but also some could see it as if they are being tested for sexually transmitted infections. The fact that screening results are never 100% accurate can lead to misdiagnosis and anxiety in patients, however, information provided to those invited must be honest, comprehensive and understandable to its audience.

The current screening facilities available in this country are for breast and cervical cancers, with a pilot screening service for colorectal cancer. The services look to mainly screen the over 50’s, or those most at risk to the disease. The NHS Cancer plan aims to vastly expand the screening service to a wider population group in all areas, as well as looking at the possibility to screen for prostate, ovarian and lung cancer. There are randomised clinical trials currently taking place, and if the Medical Research Council (MRC) see them as viable, and cost-effective the Department of Health will allocate the required funding needed for the service.

The accessibility to screening services is not egalitarian, as it should be. The cancer plan has identified thirteen health authorities (all deprived, inner city areas) that were not making the national target of 80% cervical screening coverage. This is very poor, considering that cervical screening has been available to the public since1988. These authorities were to have reached the national targets by 2002, but were only instructed to do so by increasing their accessibility to screening among deprived and minority ethnic groups. The examples given were only those from London, and although the actions taken are said to have a wider reach in the community, one begs to differ. For screening to be accessible to all, the number of screening units needs to be increased, and in order to do this, the number of clinical specialists and radiographers also needs to increase. The government have laid out how they aim to achieve this, in section 8 of the cancer plan, however it is highly ambitious, as between now and then there is a general election, and therefore that there is not guarantee that these plans will continue, or will ever happen.

To conclude; the government has laid out an ambitious, but otherwise sound plan to tackle the pressing issue of cancer in our society. The effectiveness of the plan can only be measured in time, but from the launch of the plan in 2000, the government have been keeping most of their milestone ‘promises’. In line with the white paper, Tackling Health inequalities: A programme for action, the government has achieved a lot since the launch of the cancer plan, yet still has a lot more to do, and many more milestones to reach.

References:

Department of Health, (1998a). Smoking Kills: A white paper on tobacco. London: The Stationery Office

Department of Health (2000a). The NHS Plan. A plan for investment, a plan for reform. London: The Stationery Office.

Department of Health (2000d). The NHS Cancer Plan. London: The Stationery Office. (http://www.doh.gov.uk/cancer/cancerplan.htm)

Dorsett, R. and Marsh, A. (1998). The health trap: poverty, smoking and lone parenthood. London: Policy Studies Institute.

Dove-Edwin, I. & Thomas, H. J. W. (2000). The prevention of colorectal cancer. Aliment Pharmacol Ther (15) Pp. 323-336. Middlesex: Blackwell.

Health Development Agency (2002). Cancer Prevention: A resource to support local action in delivering The NHS Cancer Plan.

Jarvis, M. (1998). Extra analyses of the General Household Survey, commissioned by the Health Education Authority. Unpublished.

Kerr, D., Bevan, H., Gowland, B., Penny, J., and Berwick, D. (2002). Redesigning Cancer Care. BMJ (324) Pp. 164-166

Khaw, K. T., Bingham, S., Welch, A., Luben, R., Wareham, N., Oakes, S. and Day, N. (2001). Relation between plasma ascorbic acid and mortality in men and women in EPIC-Norfolk prospective population study. The Lancet 357: 657-63.

Marsh, A. and McKay, S. (1994). Poor smokers. London: Policy Studies Institute.

Mayor, S. (1998). UK report calls for policies to halt growing inequalities in health. BMJ (317) Pp. 1471.

Melia, J., Pendry, L., Harland, C. and Moss, S. (2000). Evaluation of primary initiatives for skin cancer: a review from a UK perspective. British Journal of Dermatology (143) Pp. 701-708.

Naidoo, J. & Wills, J. (2000). Health Promotion: foundations for practice. 2nd Ed. Edinburgh: Bailliere Tindall.

Medical Dictionary Online. Accessed 04/02/2004

Cancer Research UK website, accessed 05/04/2004

World Health Organisation accessed o4/02/2004

Individuals who consume more than 140g/day of red and processed meat (cooked weight) should reduce their intake. Red meat is defined as beef, lamb and pork; processed meats are defined as meat products such as sausages and burgers. In practical terms, individuals should eat some foods from the meat, fish and alternatives food group each day, but should make a wide variety of choices (HDA Cancer Prevention, 2002)

Critically appraise the primary and secondary prevention (health promotion) elements of the NHS cancer plan.

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