Cancer is the UK’s biggest killer, responsible for 1 death every 4 minutes.¹ Each year, it accounts for around a quarter of all UK deaths¹ and claims around 2 million years of life in the UK alone.² But this burden is not distributed equally across population groups, with inequalities across multiple domains.

For example, Cancer Research UK (CRUK) analysis shows that age-standardised cancer mortality rates are more than 40% higher in men compared with women in the UK,³ around a fifth higher in Scotland compared with England,³ almost a third higher in the most versus the least deprived areas in England;⁴ and, for a wide range of cancer sites, higher in the White ethnic group compared with most other broad ethnic groups in England and Wales combined.⁵

These inequalities in cancer mortality are the product of inequalities throughout the cancer pathway and across the UK. Inequality impacts the prevalence of key cancer risk factors in the incidence of the disease, the stage of diagnosis and access to treatment impacting survival.

Around 4 in 10 cases of cancer in the UK are preventable.⁶ Smoking contributes the largest number of cases, followed by overweight and obesity. In both, there are marked inequalities over a range of demographic characteristics.^7–11

Inequalities in preventable cancers

CRUK analysis suggests that almost 34,000 cancer cases in the UK each year are associated with deprivation, with incidence rates around a fifth higher in the most versus least deprived groups.¹² Smoking is the key driver of socioeconomic inequality in cancer incidence; for example, in England there are nearly twice as many cancer cases caused by smoking in the most deprived areas compared with the least. It is estimated that well over half of England’s deprivation-associated cancer cases are attributable to smoking.¹³

Smoking rates are more than 4-times higher in people with no qualifications versus those with a degree and almost 3-times higher among those in routine and manual jobs compared to managerial and professional workers.¹¹ White, Mixed and Other ethnicities (versus Black or Asian), gay, lesbian or bisexual sexual orientations, urban versus rural status, and living with a mental health condition are also associated with higher smoking prevalence.^10,11,14  

Smoking inequalities arise for a range of reasons, including social norms, tobacco product marketing that targets specific communities and stressful life circumstances.^14–16 CRUK wants more action and funds to prevent people from starting to smoke and to help them to quit. Sustainable funding for cessation support and services, ideally raised through a levy on the tobacco industry, is required to ensure comprehensive national, regional and local action can be delivered to reduce the impact of tobacco across the UK.

Obesity rates are almost twice as high in the most versus the least deprived areas,^7–10 and up to 20-times higher in Black African, Black Caribbean and Pakistani women compared with Chinese women (up to 2.5-times higher versus other ethnic groups).¹⁷ For overweight and obesity combined, rates are around a tenth higher in men than in women.^8–10,18

Inequalities in overweight and obesity prevalence may be linked with the food environment, including cost and marketing, and physiological factors.^19–21 To help address this, CRUK wants the UK government to implement legislation around high fat, salt and sugar foods no later than October 2025, UK-wide restrictions on TV and online advertising, and restrictions in England on volume-based price promotions (devolved governments are responsible for similar restrictions in Scotland, Wales and Northern Ireland).

Screening programmes

Bowel and cervical screening can prevent cancer and diagnose the disease earlier. Bowel screening uptake is around a third lower in the most deprived areas versus the least.^22–24 Some South Asian ethnic groups are around 50% less likely to be screened compared with the White ethnic group.²⁵

Cervical screening coverage is lower in GP practices in more deprived areas and in those with higher proportions of ethnic minority patients.^26,27 Other groups with lower bowel and/or cervical screening uptake include people with learning disabilities,²⁸ some religious communities²⁵ and women who have sex with women.²⁹

Variation in screening uptake may reflect practical barriers, social norms and understanding of personal risk (among both health professionals and the public).^25,28–30

People diagnosed with cancer at an earlier stage have higher survival rates than those diagnosed at a later stage,³¹ owing to the availability of a wider range of more effective treatments for localised disease. Stage at diagnosis varies markedly between cancer types and by demographic factors.

In England, among cases with a known stage, more than 8 in 10 cases of testicular, melanoma skin, breast and uterine cancers were diagnosed at stages 1 or 2, compared with fewer than 3 in 10 cases of non-Hodgkin lymphoma, lung, pancreatic, oesophageal and oropharyngeal cancers (this is based on 2018 data, as all data from 2019 onwards has been affected by COVID-19).^32,33 For some cancer sites, later stage at diagnosis is associated with higher deprivation,^33,34 being male,³⁵ and having Caribbean, African or Asian ethnicity.³⁶

Inequalities in routes to diagnosis underpin these stage differences. Overall, the proportion of cases diagnosed through screening – a route associated with earlier diagnosis – is more than a third lower in the most versus the least deprived areas.³⁷ Conversely, the proportion diagnosed through emergency presentation – associated with later stage at diagnosis – is almost 50% higher in the most versus the least deprived quintiles and up to 3-times higher in the oldest patients compared to the youngest.³⁷

Stage at, and routes to, diagnosis may vary by demographic characteristics. This is because of the attributes of the disease (e.g. some cancers present with non-specific symptoms until they are at a late stage), practical and emotional barriers to seeking help, and different levels of symptom recognition among both patients and health professionals.^38–40

Reducing barriers to access

CRUK’s Longer, Better Lives programme for the UK government calls for a paradigmatic shift in our ability to accurately detect and diagnose cancers at an earlier stage, which will require action on all fronts. Particularly for communities that face additional barriers, it is key to encourage help-seeking and informed screening uptake. To achieve this, we need a long-term commitment to fund national public awareness campaigns, with evidence-based targeting of the population groups that face inequalities.

There are also significant gains to be made in reducing late-stage cancer diagnoses by improving the existing cancer screening programmes, optimising diagnostic pathways and updating cancer referral guidelines to reflect the most up-to-date evidence. Achieving these improvements depends on the government ensuring that the NHS has sufficient capacity in diagnostic services, notably through addressing workforce shortages through a cancer-specific workforce plan and additional targeted capital investment in essential equipment, facilities and IT infrastructure.⁴¹

Waiting too long for cancer diagnosis and treatment causes additional worry for patients. Delays may affect stage at diagnosis and, ultimately, survival. Across the UK, cancer waiting time targets are routinely missed,⁴² but within this there are notable inequalities. For example, CRUK analysis in partnership with NHS England shows that patients living in the most deprived areas of England are a third more likely to wait over 104 days to begin treatment, compared with the least deprived. Patients starting treatment for lower gastrointestinal or urological cancer are the most likely to wait over 104 days.⁴³ The period between initial primary care presentation and diagnosis is 10–16% longer for Black and Asian patients versus White patients with certain cancers in England.⁴⁴

There is also inequality in the type of treatment received. The most deprived late-stage lung, oesophageal, stomach and pancreatic cancer patients in England were around a fifth less likely to receive chemotherapy, or chemotherapy and radiotherapy combined, compared with the least deprived.⁴⁵

Although there are legitimate reasons for why diagnosis can take longer or why some treatments may be inappropriate, these analyses are adjusted for age, sex, ethnicity, comorbidities and cancer site and stage, where relevant.

Given these inequalities in cancer diagnosis and treatment, it is unsurprising that there are also inequalities in survival. For most cancer sites, survival is lower in the most versus the least deprived areas. The relationship between survival and deprivation is roughly linear.^31,46,47 For some cancer sites, individual-level survival inequalities may be more pronounced than area-level; the survival experience of individuals may vary more in the most deprived areas compared with the least.⁴⁸ Evidence on other domains of inequality in cancer survival is sparse.

CRUK has set out 5 missions that together could reduce cancer mortality in the UK by acting strategically across the cancer pathway in biomedical research, public health and cancer care.⁴¹ Woven through these missions is the aim of reducing inequality. CRUK exists to beat cancer and beat cancer for everyone.

But the challenge is set to get even tougher. Deprivation gaps in smoking and obesity prevalence are set to widen, according to CRUK projections^49,50 This could worsen existing socioeconomic inequality in cancer incidence. Although the incidence of most cancer types is currently lower in non-White minority ethnic groups compared with the White population,⁵¹ this may change if risk factors become more common in these groups. If current trends continue, within 2 decades there will be more than half a million new cancer cases diagnosed in the UK each year, up from 385,000 annually now.⁵²

Improved collection of, access to, and analysis of inequalities data is vital.⁵³ A review of the data landscape, commissioned by a consortium of cancer charities including CRUK and Macmillan Cancer Support, reported that evidence is scant around cancer outcomes and gender identity, sexual orientation and mental health conditions, for example. Even domains where substantial evidence exists are marred by incomplete datasets and lack of granularity (e.g. many reports that describe inequality by ethnic group report only on ‘White’ versus ‘non-White’).⁵⁴ The interplay between domains of inequality is also poorly understood.

Inequalities in cancer are deep-seated and multifactorial. Some may be linked with the biology of the disease, but inequalities in outcomes are not inevitable. Where there is the will to address them, we can work towards a fairer future.

References available on our website.

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