Ala Szczepura wants to ensure better uptake

In the first study of its kind, research has revealed that members of the UK South Asian community are only half as likely to take up an invitation for bowel cancer screening, and 15 per cent less likely to attend breast cancer screening, than members of the non-Asian community.

Publication of the research coincides with the 20th anniversary of the NHS breast and cervical screening programmes. The NHS is committed to promoting access to its services and reducing inequalities in health, as formalised in the Race Relation Amendment Act 2000. This places a statutory duty on all public bodies to ensure that new policies do not disadvantage black and minority ethnic groups. A recent report from the NHS National Screening Committee also emphasises that nationally managed screening programmes should address the issue of race equality.

For all the common cancers – lung, breast, bowel, and prostate – survival figures in Britain have been well below the European average. Investment in a series of interlinked cancer centres and local units covering the entire country is helping to change this picture. A new NHS bowel cancer screening programme (launched in 2006) should also lead to improvements.

Minority ethnic communities comprise one in ten of the population in England and Wales, with just under half from the Indian Subcontinent. Funded by the NHS Cancer Screening Programmes, my research is based on a survey of 400,000 people over the period 1989 to 2005. 

Cultural differences and language needs probably lie at the heart of the reason why fewer South Asians are coming forward for cancer screening

Variation between groups

Establishing whether access to cancer screening programmes is equitable is difficult. The poor quality of recording of ethnicity in medical records is a major obstacle, often preventing even the most basic investigation. Recording is especially poor in general practice, from whose records cancer screening programmes draw their non-symptomatic populations. To circumvent this, Warwick researchers used name recognition software, refined to 97 per cent accuracy, to identify ethnic group. Statistical methods were also used to eliminate socio-economic status as a reason for any differences observed.

As well as observed inequalities for the South Asian community overall, there was also distinct variation between South Asian groups. The software divided the community into Hindu-Gujarati, Muslim, Sikh, and Other South Asian groups. 

Although one in three South Asian men and women participated in bowel screening, compared to two in three for the non-Asian population, for the Muslim community this figure fell to only one in four. Similar, although smaller, differences were evident for the long-established breast screening programme, with uptake one third lower for the Muslim population. In contrast, high breast screening uptakes were evident for the Hindu-Gujarati population, on a par with the non-Asian population and similar to those reported for African-Caribbeans. 

Explaining the differences

Cultural differences and language needs probably lie at the heart of the reason why fewer South Asians are coming forward for cancer screening. 

For bowel screening, the test must be undertaken by an individual at home and then sent to the laboratory for analysis. Clear instructions and support may be needed to help older people whose first language is not English, or who have problems with literacy, to perform this test. Literacy levels are known to be particularly low in the Muslim older generation.

For breast screening, women simply need to attend at a mobile mammography unit near their home. Low uptake here may be due to poor understanding of the role of screening, and the fact that breast self-examination, which many women in the Asian community undertake, cannot replace screening.
 
The five-year survival rate for abnormalities detected by mammography is 93 per cent, but only 76 per cent once women diagnosed symptomatically are included.

Although breast cancer rates are thought to be relatively low in the UK Asian population, there is no robust evidence. In the USA, Asian American women are now the only group for whom cancer is the leading cause of death. Incidence rates are also increasing, whereas they are stable or falling for all other populations. At the same time, breast cancer screening rates for this group of women have been recently shown to be the lowest for any ethnic group.

Two important messages emerge from this research. Firstly, the lack of an audit system for examining ethnic variations at a national level, either for screening uptake or for five-year survival, needs to be addressed. Secondly, methods for improving uptake need to be identified. Although one study has pointed the way, more still needs to be done.

Ala Szczepura is Professor of Health Services Research at the University of Warwick