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Cancer Screening

Volume 463: debated on Tuesday 17 July 2007

I am delighted to have the opportunity to introduce a debate on cancer screening, which is a continuation of an interest that I have had ever since I entered the House. I had debates on cervical cancer screening in 2001 and on screening in general in 2003. As the Minister may have guessed if she has had an opportunity to see the record, I want to use this debate to take forward the questions that I was raising at that stage. I have two reasons for wanting to do so. First, I am conscious that this issue is of very great concern to my constituents, particularly women. I discovered in 2001 that there was a major campaign in my constituency and 5,000 women wrote to me, specifically requesting that I raise in Parliament the issue of how to improve cervical cancer screening, as new technology was becoming available that would reduce the risk of omissions from the screening process.

As I explained in the previous debate, I also have a personal motivation: I lost my wife to breast cancer. She was diagnosed aged 43 and I have always been haunted by thoughts of whether, if screening had taken place for women in their 40s as opposed to 50s and 60s, her cancer would have been picked up at an earlier stage and she would have been saved.

In general, cancer screening is one of the great success stories of the NHS. It is more advanced than in almost every other developed country. It has been done on a mass scale, certainly for cervical cancer and breast cancer, for many years and many lives have been saved as a consequence, so it is a positive story, and big advances have been made in the past 10 years in respect of the big three cancers to which screening applies. I want to acknowledge that, while asking questions about the process.

It clearly appeals to elementary common sense to suggest that if we have screening, conditions can be picked up at an earlier stage, avoiding not just premature death but unnecessary surgery. I recognise, of course, that there are limits to that process. There are limits to screening technology, which mean, for example, that it is not applied in the case of some cancers. Prostate cancer is one for which there is not sufficient precision. I also recognise that there has to be a test of cost and benefits. We cannot just have indiscriminate screening of all age groups for all conditions.

Initially, I shall ask a few questions and pursue the issue of cervical cancer screening, in respect of which there have been major advances. There is a long history in Britain, through the smear test, of saving very large numbers of women from that condition. Some of the progress is recognised in the fact that we screen 3.5 million women annually; I understand that there is 80 per cent. coverage. Roughly 4,500 lives a year are saved as a result of the screening process, and I think that deaths have now come down to fewer than 1,000 a year. That is a major success story, with continually falling death rates since about 1990. The big transformation in recent years has been the introduction of the liquid-based cytology tests, which are much more accurate and avoid the 20 per cent. failure rate that occurred under the old testing system.

If the Minister does not have the answers to my questions to hand, I hope that she will write to me. First, since the new LBC system was successfully introduced in Scotland—I think that that was completed by 2004—why has it taken so long to spread it through England? Can she give us some clarity about when the roll-out is expected to be completed? I understand that we are talking about next year, but is it the beginning or end of next year? Is that known?

Secondly, there are substantial disparities between the home countries in respect of the age groups covered by the smear testing arrangements as enhanced by the LBC test. The age group is 20 to 60 in Scotland, 20 to 65 in Wales and 25 to 64 in England. There is nothing wrong with that at all—indeed, there is much to be said for experimentation and trying different approaches—but what lessons have been learned from those different age profiles? Does one work better than another? Can we learn from Wales and Scotland? Are there any proposals to adapt the age profile?

Thirdly, can the Minister confirm the worry that some cancer charities have expressed? One in particular, called Jo’s Trust, has written to me and I met representatives at a reception in the House of Commons. It is particularly concerned with young women and has pointed to the fact that there appears to be a serious tailing off in the number of young women in their late 20s who are going for the screening. Have the Government analysed that? Do they know the reasons for it and do they have any answers to it?

My final set of questions about cervical cancer screening relates to the new technology that is becoming available as a result of the understanding that, unlike other cancers, cervical cancer is caused by a virus—a sexually transmitted virus. I think that the science was developed in the mid-1990s, and out of the understanding of the human papilloma virus come various potentialities. The first is whether the knowledge of HPV is being incorporated in screening: is it being used as part of the new screening process with LBC?

Secondly, the technology now makes it possible to vaccinate against cervical cancer. The Government were right and, indeed, quite courageous to bring in the new programme, which involves vaccinating girls before they leave school. It is hoped that that will greatly reduce the incidence of the disease at an early stage in its transmission. However, the cancer charities that are following this issue have raised various supplementary questions about that and perhaps the Minister will reflect on them. First, it appears that the next school year will be missed. I do not know whether that is correct; perhaps the Minister will confirm it. If it will be missed because of the difficulties of introducing vaccination across the board, what will happen to that age group? Will there be a follow-up, with encouragement and support in getting GP referrals to catch up?

What plans do the Government have to deal with what we might call the missing age group? I am referring to those young women who are too old to have caught the new vaccination programme at school, but who are too young to have the smear test, because they will not get it until they are 25. There is a 10-year group of young women who are missing altogether. What are the plans to deal with that? Is there a system of enhanced GP referral, for example, which would enable them to be captured?

I also have some questions for the Minister about the progress being made in the breast cancer screening programme. That, too, is a major success story for the NHS. It has been going for a very long time, particularly for women aged 50 to 64, and the age group has now been expanded by five years, which is a very welcome step. The analysis shows that about 1,400 lives a year are being saved. As with cervical cancer, there is clinical evidence of a substantial disparity between the survival rate for those who are screened, which is about 95 per cent. over five years, and the survival rate for those who are not screened. The difference, however, is that breast cancer numbers are rising substantially, whereas cervical cancer numbers are falling, and I wonder whether that might have something to do with the difference in the take-up of screening.

One thing that I find difficult to understand is why the take-up of breast cancer screening is significantly lower than the take-up of cervical cancer screening. After all, we are talking not about young women, but about mature women, who are presumably very conscious of their health. We are also talking about the same obstacles in terms of information and literacy. Why, then, should the take-up for breast cancer mammographic screening be significantly lower than for cervical cancer screening? The figure for breast cancer screening is about 75 per cent. on average, as against 80 per cent. for cervical cancer screening. In my area, as the Minister will know because she lives close by and represents a constituency next to mine, breast screening take-up is well below the national average, even though people are generally fairly prosperous and well educated. I have asked the primary care trust to address some of the technical problems, such as the location of the screening site and so on, but the figure is still low, and I wonder how much work has gone into understanding why take-up rates are low and whether they can be improved.

The big issue on breast cancer screening is age, and as I explained to the Minister, I have a personal interest in pursuing this. Everybody welcomes the extension of screening to older women, but the outstanding question is whether there would be value in extending it down the age range to women between 45 and 50 or between 40 and 50. When I last asked that question four years ago, the Government felt that the evidence was not compelling. There have been some pilot studies since then, and I wondered whether there had been any rethink about the desirability of extending the age range to catch younger middle-aged women, substantial numbers of whom get cancer.

My final point on breast cancer screening is that, as with all cancers, screening is only as good as the subsequent cures and treatments. There is no point screening people if they are not promptly dealt with and there is a long-standing issue about the speed of treatment for breast cancer patients. Are the Minister and her officials aware of an article that appeared in the British Medical Journal in recent months, which was based on a case study in Bristol and pointed to the difficulties with the so-called two-week rule? Apparently, GPs are putting a lot of women in the non-urgent category, where cancer diagnosis is growing rapidly, so something is not working with the two-week rule and the other principles designed to get people quickly into treatment.

The third and final category about which I wish to ask the Minister is bowel cancer screening. It is a big step forward and very welcome that the Government have accepted that there is value in screening for bowel cancer, which is of course different from cervical cancer and breast cancer in that it affects men at least as much as—indeed, probably more than—women. There is a large number of fatalities—about 16,000 a year, or about half of those who are diagnosed—and the number is growing rapidly. An estimated 2,500 people a year could be saved if screening were effective, so it is very welcome that the Government have taken a step forward.

I speak on the issue with some local interest because one of the leading charities—Beating Bowel Cancer—is located in St. Margaret’s in my constituency. It is a strong advocate of the screening process, and some of us participate annually in its loud tie day, which is one of its gimmicks to make the subject more attractive. For obvious physical reasons, bowel cancer is not something that people particularly want to talk about, and the charity has done a brilliant job in overcoming some of that psychological resistance.

The screening programme is now being rolled out, which is very welcome, and the primary care trust in my area was one of the first in London to adopt it. However, I have some questions about how the process is working. First, the roll-out has been going on for a year, so do the Government have any preliminary conclusions? If so, when will they publish them? Secondly, some of the feedback from the work that has been done suggests that uptake is quite low and that only half of those who are tested return the kits, as they are required to do. Is anything being done to raise that problem and deal with it? Thirdly, do the Government have the funding to complete the envisaged three-year roll-out? Finally, are interesting conclusions being drawn as a result of different age ranges being applied in Scotland, Wales and England?

My final point about bowel cancer is that, as with other forms of cancer, the success of the Government’s programme depends entirely on whether those who are screened can get treatment. As the Minister will know, difficult and emotive issues have been raised as regards the drugs that are made available to bowel cancer patients once they have been screened and diagnosed. A constituent called Adam Griffin, who is only 30, has run up against the barrier that was created by the National Institute for Health and Clinical Excellence when it ruled that Erbitux and another bowel cancer drug, Avastin, could be made available only in exceptional circumstances, and several young people in their 20s and 30s in London are being denied those drugs because of that new ruling. I know the difficulties involved, and these drugs are expensive, but I wonder whether the Government take account of age in interpreting the phrase “in exceptional circumstances”. Common sense suggests that if people can be saved from premature death in their 20s and 30s, they would, quite apart from any humanitarian consideration, have a much longer life to live, so the value of the treatment would be much greater. How much flexibility is there in that respect? A lot of emotion has, rightly, been generated around Herceptin, but there are some equally dramatic and difficult issues around bowel cancer drugs.

That rather broader question takes us a bit away from screening, but I wonder whether the Government are responding to the rather critical study by the Swedish Karolinska institute. The study suggested that despite Britain’s screening record, which is second to none in the developed world, we rank among the worst in terms of the availability of cancer drugs. The study partly attributed the relatively low cancer survival rate in the UK to that limited availability.

My final point—I have just exceeded my 15 minutes, so it is my final point—is that some cancer conditions cannot be dealt with through screening because the science is insufficiently precise, and we are always told that prostate cancer is one of those conditions. It is increasing rapidly among men, which is not necessarily as insidious as it seems, because it is a condition of very elderly men, who have many other problems. I was recently invited to an MPs’ health check and I was very struck by the fact that I was offered a prostate cancer test, thereby becoming one of the 6 per cent. of men who are tested. I therefore have one simple question: if such tests are good enough for MPs and for 6 per cent. of the population, why can the other 94 per cent. not enjoy them?

I congratulate the hon. Member for Twickenham (Dr. Cable) on securing the debate. As he recognised, we have neighbouring constituencies and share the same acute trust—the West Middlesex University Hospital NHS Trust. He also mentioned the personal side of the debate, and I acknowledge that.

The earlier detection of cancer is vital to long-term efforts to reduce cancer mortality. Where screening for cancer is possible, it is an essential tool in detecting abnormalities at an early stage. That is why the NHS cancer plan proposed a major expansion of our cancer screening programmes, where it is clear that that can reduce mortality. The efforts of the service to deliver that expansion are now coming to fruition.

The hon. Gentleman mentioned breast cancer screening, and the NHS breast screening programme was the first such programme in the EU. It is regarded as one of the best screening programmes in the world and is estimated to save l,400 lives a year. I wish that our media would portray such things, rather than the negative issues that are usually associated with cancer and cancer screening.

In March 2005 we completed two of the objectives set by the NHS cancer plan. The screening age was extended to include women aged 65 to 70, and the service was fully upgraded so that two X-ray views of each breast are taken at all screening rounds. As a result of those changes, the breast screening programme screened more women and detected more cancers than ever before in 2005-06; 1.63 million women were screened and more than 13,500 cancers were detected, which implies a 62 per cent. increase since 2001; 40 per cent. of the cancers detected were small cancers that could not have been detected by a hand examination.

We cannot, however, be complacent, and we are always looking at ways of improving the service, as long as there is a clear evidence base. For example, the evidence to support inviting women aged over 70, on a population basis, is not clear. That is why research has been commissioned on behalf of the advisory committee on breast cancer screening. Women over 70 can still self-refer for breast screening every three years, and we have collaborated with Age Concern on a leaflet to remind women of that. I am sure that all hon. Members will welcome that, and actively encourage Age Concern’s involvement. In the areas that the hon. Gentleman and I represent it is important to look for ways to approach education in such matters for the ethnic minority communities.

The hon. Gentleman raised the matter of cervical cancer, which is the subject of the NHS’s other longest running screening programme; again, it was the first such programme in the EU. The introduction of cervical screening has prevented an epidemic of cervical cancer and is estimated to be preventing up to 5,000 deaths a year. In 2005-06, 79.5 per cent. of eligible women in England had had a test result in the previous five years, 3.6 million women were screened and laboratories reported 4 million tests. However, again, we are not complacent. Following the National Institute for Health and Clinical Excellence technological appraisal in 2003, we are rolling out the use of liquid-based cytology across the service. That will reduce the number of inadequate tests and speed up the reading of slides. It will mean that 300,000 women a year will not have go through the anxiety of being called back and retested because their slides could not be read.

For women under 25 screening is not a good idea and can do more harm than good, because the cervix is not properly developed. More research on that is taking place. The 2005 Labour party general election manifesto contained a commitment to speeding up cervical screening results. The LBC is a key aspect of that, and the commitment is being taken forward through the cancer reform strategy, which will be published at the end of the year. A more recent development in our battle against cervical cancer has been the advent of human papilloma virus vaccines. HPV is implicated in nearly all cervical cancers. The Joint Committee on Vaccination and Immunisation has recommended that an HPV vaccine should be routinely offered to girls aged around 12 years.

The hon. Gentleman raised a very new area of screening—that for bowel cancer. The NHS bowel cancer screening programme began in April 2006, and full national roll-out is expected by December 2009. It is one of the first national bowel screening programmes in the world, and it is the first cancer screening programme in England to invite men as well as women. Once it is fully operational, each year, around 3 million men and women in their 60s will be sent a self-sampling kit to use in the privacy of their homes. It is an ambitious project and, when fully implemented, will detect around 3,000 bowel cancers every year. I am pleased to say that those of the hon. Gentleman’s constituents who are in their 60s began to be invited to participate in the programme on 8 January.

We are committed to introducing a screening programme for prostate cancer if and when screening and treatment techniques become sufficiently well developed. I note the point that the hon. Gentleman made about what he was offered in the House. The Department of Health is supporting the development of screening technology for prostate cancer by way of a comprehensive research strategy. Prostate cancer is the only cancer with a departmental research funding target, and we continue to fund at least £4.2 million of prostate cancer research each year.

The hon. Gentleman and I both attended an Ovarian Cancer Action charity reception yesterday. The NHS cancer plan committed the Government to introducing ovarian cancer screening as and when research demonstrates that screening is appropriate and cost-effective. The research is well under way, and the UK collaborative trial of ovarian cancer screening began in 2000; results are expected in 2012. The cancer used to be called the silent killer, but we now have evidence to suggest that we can do more. I welcome the research, having taken an active interest in ovarian cancer for some time.

We need, of course, to screen for and monitor other cancers. However, participation is very important, and the hon. Gentleman raised the important issue of increasing participation in our screening programmes. We agree with him, but we must encourage people to attend for screening in a responsible way. People who are invited to participate in our cancer screening programmes need to understand the potential benefits and harms in doing so and to be able to make an informed choice about whether they want to proceed. That is why all people who are eligible to participate in the programmes receive a national information leaflet when they are invited for screening. Those leaflets have been translated into 19 languages; posters and CDs are also available in seven languages.

Cancer screening will form a major part of the cancer reform strategy. As part of the strategy we will be looking at new ways of encouraging people to make the decision to attend screening; that applies particularly to those from more deprived groups, whose uptake of screening has historically been poor. I hope that the leaflets in different languages and the way we approach education in communities where English is not the first language will help to improve constituents’ quality of life.

I pay tribute to all organisations and MPs who keep the issue of breast cancer in the public and Government eye. I hope that the hon. Gentleman will join me in thanking all the staff who have worked so hard in making our cancer screening programmes some of the best in the world, and particularly those in screening programmes in the areas that we represent. I congratulate the hon. Gentleman on bringing the debate to the House.

Sitting suspended.