HC Deb 13 June 2003 vol 406 cc999-1006

Motion made, and Question proposed, That this House do now adjourn.—[Joan Ryan.]

2.32 pm
Dr. Vincent Cable (Twickenham)

I am grateful for the opportunity to introduce an Adjournment debate on the rather broad issue of cancer screening, but my interest is somewhat narrow and is prompted by two considerations. The first is a constituency interest, as the leading bowel cancer charity is located in Twickenham. I met those at the charity recently, and they expressed their frustration about the fact that thousands of people die unnecessarily because the disease was not picked up sufficiently early. They urged me to do what I could at a political level to draw attention to a disease that is not particularly fashionable or that people enjoy talking about, but which deserves more attention, especially in respect of early detection and screening.

The second reason why I feel motivated to raise this subject is a personal one. My wife died of breast cancer two years ago, and we lived with the disease for 13 years through all its stages. That left me with the very strong feeling that nobody should have to go through the same experience if at all possible. I am also left with a lingering doubt; although my wife was wonderfully cared for by the NHS, she was diagnosed in her early 40s. One is always left with the thought that, if there had been screening and early detection for women in their 40s, she might still be here. One is bound to have that thought in the circumstances.

For those two reasons, I have a personal motivation for pursuing the issue. I approach it in a positive spirit. I acknowledge that in Britain, certainly in relation to breast cancer and cervical cancer, we probably have the most ambitious and long-standing, and arguably the most successful, approach in the world. That is certainly the British reputation and we must be proud of it, so I approach the matter in that upbeat spirit. One reason for that success is a general popular understanding of why screening is important—that screening leads to early diagnosis and early diagnosis saves lives; it is as simple as that.

I was a little concerned to read a couple of months ago the conclusions of Professor Baum, one of the leading cancer specialists, who argued against cancer screening on the grounds that it raises anxiety and leads to what I believe are called in the trade "false positives": people who are falsely diagnosed with various forms of cancer, thereby leading to unnecessary operations. I hope that that has not led to confusion or doubt—certainly in the Government's mind—about the virtues and importance of cancer screening. It is important that public confidence be restored.

Having made those general points, I want quickly to discuss the main cancer screening areas for which there are outstanding and important questions about Government policy, and to seek reassurance from the Minister. In many ways, the breast cancer programme is the best-established, best-understood programme. The mammography programme deals with some 1.3 million women a year aged 50 to 64. By common consent, it has a demonstrable and proven record in saving lives; indeed, there has been a sharp decline in mortality rates. In 2001, 13,000 women died of the disease, but that constituted a 20 per cent. reduction on the figure for a decade earlier.

There are also some very simple comparisons that can be made. Of a sample of women diagnosed with breast cancer in the mid-1990s, 76 per cent. survived for five years. However, the rate for those who had been screened rose to 93 per cent. So over the years, some 80,000 cases have been detected and very many lives saved as a result of this programme. I appreciate that the Government have indicated that they are willing to extend breast cancer screening to 70-year-old women, thereby removing a rather arbitrary element of age discrimination, and that in the process they will make the tests more comprehensive and less liable to faults.

I have three questions for the Minister on breast cancer specifically. First, as a result of research carried out in Sweden in particular, empirical proof has emerged in just the past few months that the lives of a substantial number of women in their 40s could be saved if screening were extended to them. Indeed, an article in the April edition of The Lancet reached a very strong conclusion to that effect. Are the Government aware of that finding, do they accept it and do they propose to act on it?

The second question is a related one. There have been worrying reports that in some parts of the country, particularly in the London boroughs, the cancer screening programme had to be stopped—it happened last year—because there simply was not the personnel capacity to cope with the number of women involved. I seek some reassurance from the Minister that that problem will not recur, and that the capacity will be available to cope with the expanded numbers if we quickly move to including 70-year-old women. Indeed, if the programme is also extended to 40-year-olds, will the system be able to cope with such numbers? Will it be held back, if it is clinically necessary, by lack of capacity, personnel and equipment?

My third question relates to a group of women who came to see me at my constituency advice surgery two weeks' ago. They had been diagnosed early—the system had worked—but they were extremely alarmed to discover that treatment was being very seriously delayed as a result of difficulties in getting appointments at, in this case, Charing Cross hospital. My understanding is that under National Institute for Clinical Excellence guidelines, nobody should have to wait more than a month for cancer treatment at any stage. However, one woman who had already had a mastectomy in one hospital and was referred for radiography at another was told that she would have to wait six months for that treatment—way beyond the NICE guidelines. I seek reassurance from the Minister that such incidents are extremely rare, and perhaps she could tell us how serious and widespread these slippages are. Of course, this issue does not relate to the screening programme, but it would be tragic if people's expectations were raised by good screening and diagnosis, only for it not to be followed up by appropriate treatment.

My second set of questions relates to cervical cancer screening, which is an even bigger programme. As the Minister knows, it deals with 3.5 million women a year, from a much wider age group: 20 to 65. It has a clear scientific rationale, based on the fact that early detection in this area is crucial to cure and the evidence that has emerged from past work that something of the order of 1,000 lives a year are being saved specifically as a result of the smear test system—in other words, it is one of the great success stories of the NHS.

However, there are several specific problems surrounding the programme. Seventeen per cent. of women who are entitled to screening do not come, mainly for sociological reasons—ethnic minorities and those from certain social classes—and many of these women die, needlessly because the screening is there. About 10 per cent. have to be recalled and experience all the anxiety associated with that. About 20 per cent. are simply missed because the test is not sufficiently accurate. Of those, there are significant numbers—perhaps half of the 1,200 who die every year—who were screened and passed, but were missed by the test. It is that inaccuracy which gives so much rise to so much anxiety and the necessity for moving on to improved technology.

New technologies are available. The new liquid-based cytology has been extensively trialled and I believe is now available broadly in Scotland, A few weeks ago, I attended an all-day medical conference where the leader of that programme in Edinburgh described the efficiency with which that system now operates in Scotland. The simple question that I put to the Minister is, since it has now being extensively trialled and proven, appears to have few negative side effects and has positive outcomes, when will it be rolled out through England and Wales? When may we realistically expect comprehensive cervical cancer screening, using that new technology?

The other question that I have on cervical cancer relates to the fact that some women report that their results are being seriously delayed. I have had anecdotal evidence of this and surveys suggest that 15 per cent. do not get their results within 10 weeks, which is way outside the guidelines. I should be grateful for some reassurance on that.

The third category to which I wish to refer specifically is bowel cancer, which was where I started. There is increasing anxiety that it is growing rapidly. It has become the second cause of deaths among cancer victims; 35,000 a year are diagnosed, of whom 16,000 die. But there is now effective screening technology, and evidence from trial studies suggests that 2,500 of those who die could be saved if they were screened satisfactorily. I am delighted to read that the Government have now accepted that conclusion and are proceeding to a national screening programme. That is very good news. However, most of the people with whom I have discussed the subject—the action groups and those in the profession—are not sure how the Government's programme will work. Perhaps the Minister would be good enough to tell us as much as possible about how that screening programme will work, and particularly how long it will be—one year, two years or longer?—before most of the men and women who have anxiety on that score can be screened. Are the resources available? Are the nurses and specialists being trained for it?

In conclusion I shall refer to two other types of cancer, in connection with which the screening process and the technology are less advanced, but where there is a growth of cancers and growing anxiety. One is prostate cancer. I was horrified to discover that by the age of 80, half of all men will have prostate cancer. Very few will die of it because they have other things, but obviously it is a major source of anxiety for any man, and it is a growing source of death.

Tests are available. There is the prostate specific antigen test, but it is a very primitive testing system. Even the leading prostate cancer action group, the supporters of the charter for action, are not pressing for screening based on that technology because they acknowledge that it has major errors. Two thirds of all men show raised PSA levels when they are tested and 20 per cent. of men with prostate cancer are not picked up by the test, so it is an imprecise system. No one is currently calling for a national screening programme based on the test. None the less, there is a strong desire for the Government to do what they can to promote research on screening technologies and to advance the situation so that we are not quite as helpless in the face of the disease.

My final comments relate to another woman's cancer: ovarian cancer. I know from women who have been affected by the disease that it is a growing source of anxiety because the death rate is so high. Only about 30 per cent. of women affected survive for longer than five years and the problem seems to be growing. There is a worry that the scanning process in the NHS is highly inconsistent. Some parts of the country have ultrasound equipment and actively encourage screening. Some parts of the country offer screening if it is sought, yet it is simply not available in some areas. That reflects the different distribution of resources and differences among health professionals about whether the procedure is useful. Will the Government give clear guidance on whether screening is useful? If it is useful, will there be a consistent approach in the NHS? That information would help the pressure groups and the general public. There seems to be much confusion and uncertainty, although research at Barts and in Cambridge may cast light on the situation.

I have covered a wide spectrum from established programmes for cervical and breast cancers to programmes in which screening and research are at an early stage. The Government and the country can be proud of the programmes but much remains to be done. Enormous numbers of people are dying, but they might not do so if better technology were being better applied. I would be grateful for as much encouragement as the Minister can give me.

2.47 pm
The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)

I congratulate the hon. Member for Twickenham (Dr. Cable) on securing the debate. The measures in the NHS cancer plan on early screening, early diagnosis and better treatment are beginning to be significantly beneficial in the field. We have a genuinely good story to tell about screening but there is also more to do to extend the programmes.

Reducing the incidence of cancer is vital to long-term efforts to reduce cancer mortality. If we can screen early, we can reduce the number of deaths. Vigilance against the onset of disease is absolutely crucial. When screening is possible, it is an important method to detect abnormalities at an early stage, which allows treatment when the cancer is most likely to be curable or, in some cases, even before it develops. That is why the cancer plan proposes a major expansion of screening programmes that is absolutely based—this is not quite a caveat—on the fact that they should be used when it is clear that screening can reduce mortality. We want to use screening when there is evidence that it works and has a proper effect.

The UK was the first country in the European Community and one of the first in the world to launch a nationwide breast cancer screening programme based on computerised call and recall services in 1988. Women aged between 50 and 64 are invited for breast screenings every three years and women aged over 65 may request free three-yearly screenings. In 2001–02, 1.3 million women were screened at an estimated cost of £52 million. More than 8,500 cancers were detected, many of which were small and could not be detected by hand because they had not developed into a lump. The breast cancer screening programme can help to save lives. We funded pilot studies that showed that extending screening to women aged between 65 and 70 is feasible and cost-effective.

The hon. Gentleman asked whether we might be able to extend screening to women under 50. The Forrest report, on which the whole breast cancer screening programme is based, recommended further research to assess the clinical and cost effectiveness of offering routine screening to women under 50, and that research is under way. The study began in February 1991. Recruitment to the trial has stopped, but 160,000 are now on it. It costs about £1 million to run, and looks primarily at mortality benefits. Interim results are expected late this year, with full results expected in 2005. We are extremely interested in using it to decide whether such a programme is feasible and cost-effective.

The hon. Gentleman asked about work force capacity in breast screening programmes. I am delighted to be able to tell him that we have run several pilot programmes in trying to get a greater skill mix among the various professions involved and trying to ensure that radiotherapists and radiographers can perform tasks that previously only radiologists could perform. Those pilots have been evaluated, with an extremely successful outcome. Practitioners are now able to put markers on to X-rays to show where cancers are, and some are able to do basic radiotherapy. That frees up consultants to carry out the work that they should properly be doing, and perhaps which only they can do, and enables us to get more people through the programme. We have increased training places for radiographers by some 55 per cent. since 1997: we are getting more people into training, changing the skill mix and increasing capacity. I entirely accept, however, that there is tremendous pressure in this field, because as we get more equipment and do more screening, we create more demand, and rightly so. We need to keep on top of that.

The hon. Gentleman asked about time between diagnosis and treatment. In the cancer plan, we said that it would be a maximum of one month for breast cancer. I can tell him that the latest figures that we have for 2001–02 show that 96.5 per cent. of women with diagnosed breast cancer received treatment within that month. I am pleased to reassure him that the example that he gave relates to a very small minority. Early treatment is absolutely key, especially after a diagnosis, because a great deal of distress and worry can be caused at that time.

Moving on to cervical screening, the national computerised call and recall system was, again, introduced in 1988. Again, it was the first such programme. Women aged 20 to 64 are invited for a free cervical screening test every three to five years, and women aged over 65 are invited for screening if their previous two tests were not clear or if they have never been screened. In 2001–02, 3.9 million women were screened in England. Research has shown that death rates from cervical cancer fell by 43 per cent. between 1988 and 1997. Lives are being saved by the screening programme.

On 6 June 2000, we announced that we would pilot the introduction of new technology—liquid-based cytology, or LBC, along with the use of human papilloma virus, or HPV, testing—as part of the NHS cervical screening programme. LBC techniques offer a new way to prepare cell samples for examination in the laboratory. The National Institute for Clinical Excellence has suggested that introducing LBC could increase the sensitivity of slides, reduce the number of inadequate screening tests—an area of concern—and improve the speed with which slides can be read. The report of the independent evaluation has been sent to NICE, and final appraisal guidance is due in August. If that is positive, LBC techniques will be introduced across the NHS in England, as promised in the NHS cancer plan.

The hon. Gentleman mentioned that the system is being adopted in Scotland. Obviously, it will be a much bigger programme in England and Wales if we decide to adopt it nationwide: there will need to be a phased transition in terms of work force capacity and changes in laboratories. We are working with the NHS Purchasing and Supply Agency to examine ways in which we can procure the new technology in a cost-effective way to ensure that a programme can be established across the country, if that is what NICE recommends in its final guidance.

HPV is a group of more than 80 viruses that are known to be implicated in 99 per cent. of cases of cervical cancer, but in most women those viruses are cleared naturally by the immune system. The HPV arm of the pilot study tests women if they have a mild or borderline screening test result. That evaluation report is due this autumn. As yet, there is no evidence to support the use of HPV as a primary screening tool.

Professor Henry Kitchener, at St. Mary's hospital in Manchester, is co-ordinating a study to investigate whether it could be used in that way in the future. The study began in January 2001: it will take six years, involving 28,000 women, and we are keen to press on with it.

The hon. Gentleman mentioned bowel cancer, which he is right to say has not received a huge amount of attention in the past, partly because of the difficulties we have in talking about the subject. It is the second largest killer, with 14,000 lives lost a year, so it is an important area for us to concentrate on. We now have breast and cervical cancer screening programmes, and we are sometimes accused of being sexist, because there are no screening programmes for cancers that affect men. In men's health week, I should like to put it on the record that we are absolutely not sexist. We want screening where it is effective: evidence is key. One area where evidence is increasingly good is in relation to colorectal and bowel cancer.

In a speech to the Britain Against Cancer conference in November last year, the Secretary of State reaffirmed his commitment to introduce a national screening programme for bowel cancer for both men and women, and the national cancer director, Professor Mike Richards launched the programme on 4 February this year. There are three main strands: developing the screening programme, streamlining the care for patients who already have symptoms, and improving treatment.

One important subject of current debate is the best screening methodology to adopt. Much research and discussion is taking place about the respective merits of faecal occult blood testing and flexible sigmoidoscopy. In order to take that forward, the screening working group will examine those complex issues and make recommendations about the most appropriate way to make progress. The faecal occult blood testing has a research base, but flexible sigmoidoscopy is becoming increasingly important as a good way of detecting cancer.

On prostate cancer, we are committed to introducing a screening programme if and when screening and treatment techniques are sufficiently well developed. Trials have shown that there is no conclusive evidence from any country that screening for prostate cancer would reduce the death rate, which is our objective. The prostate-specific antigen test, a blood test, is not always accurate. Some men with high PSA will not have prostate cancer, and some with low PSA will have prostate cancer. There is also no clinical consensus on the best way to treat prostate cancer. We need more serious and extensive research in that area—exactly what we are doing. We are on target to spend the promised £4.2 million on research into prostate cancer this year—something like a 20-fold increase on the research carried out in previous years.

However, the fact that there is insufficient evidence for a screening programme does not help men who are worried about prostate cancer, which is why we introduced the prostate cancer risk management programme. Those who go for a PSA test should have good information about the benefits, limitations and risks associated with that test. Evidence-based resource packs were sent to all general practitioners in September last year. They included information leaflets for patients, and doctors were encouraged to have discussions with their patients when they seek the test and ensure that they have the fullest information available to them.

The hon. Gentleman also mentioned ovarian cancer screening. As more technology becomes available, more screening will be a possibility. The health technology assessment programme has undertaken a systematic review of the evidence for introducing ovarian screening. Currently, there is insufficient evidence to reach a firm conclusion, but the UK collaborative trial of ovarian cancer screening began in 2000. About 200,000 post-menopausal women aged between 50 and 74 are being randomised in 12 UK centres. Half the women will be screened, either by annual blood test or annual trans-vaginal ultrasound, with the remainder as the control group. The study is funded by the Department of Health, the Medical Research Council and Cancer Research UK. It is expected to cost some £20 million and will continue until 2010. We are keen to examine further evidence on ovarian screening, which, as the hon. Gentleman said, is an increasing problem and rightly a proper matter of concern.

We are also examining the possibility of lung cancer screening. Recent research has shown that low-dose spiral computer tomography scanning can identify lung cancer in asymptomatic individuals at high risk. That suggests that CT scanning might be a useful screening test for lung cancer. The outcomes for lung cancer are very poor indeed in terms of five-year survival rates, so screening could be useful there.

Finally, I should like to emphasise that no screening programme is perfect. Those who seek it need to understand the potential benefits and limitations, and then make informed choices about them. That is why we said that we would produce national leaflets. We have done so for breast and cervical screening, and they are sent out to all women who take part in the programmes. It is important—in every area of health care, not just in screening—that patients are able to participate in the decisions about their health and feel some ownership of the process of managing their own clinical conditions.

I am delighted that we have had the debate today, and wish to place on record my personal thanks to all the staff who are involved in the screening programme. They work incredibly hard and do a fantastic job. They have contributed enormously to the good health of thousands of people in this country, and they have helped to save lives, too.

Question put and agreed to.

Adjourned accordingly at Three o'clock.