Alastair Whitington summarises highlights from the Westminster Health Forum on cancer care in England
The Westminster Health Forum, Cancer Care in England—access to treatment, improving diagnosis and implementing the NHS Long Term Plan, was held on 17 September 2019 at Glaziers Hall, London Bridge.
Progress on the Cancer Drugs Fund
Professor Peter Clark, Clinical Lead, Cancer Drugs Fund, NHS England, reported progress on the Cancer Drugs Fund (CDF).1 NHS England spends £18 billion annually on medicines, of which chemotherapy accounts for £2.5 billion. As a result of acceleration of the cancer drug pipeline, chemotherapy expenditure is rising on average by 9–12% a year.
Views on NICE involvement
Professor Clark reminded the conference of predictions made by the pharmaceutical industry when NICE became involved in appraising all licensed cancer drug indications for the CDF. Although joined-up working between NICE and NHS England was welcomed, it was feared that the ‘old’ CDF drugs would be decommissioned, overall access to cancer drugs would fall, and there would be a lack of pharma engagement in the new process at NICE/NHS England. Professor Clark asserted that these fears have proven ill-founded.
The NICE appraisal process
The NICE drug appraisal process revolves around two simple questions: firstly, how clinically effective a drug is in comparison to drugs already in use; and secondly, how cost-effective it is—how much more life or quality of life is obtained for the extra money paid. If NICE approves a drug, it has to be funded by NHS England.
NICE has shifted its whole appraisal process forward, enabling appraisal to take place before a drug gets its formal licence. Consequently, NICE can issue a positive recommendation within a few weeks of a drug being licensed.
NHS England spends £18 billion annually on medicines, of which chemotherapy accounts for £2.5 billion.
Benefits of the new system
Until 2016, the NICE decision process was a simple yes or no. However, in 2016, the CDF allowed NICE to have a third option. For a drug that has clear uncertainties as to its clinical and cost effectiveness—which can be resolved with data maturation or collection, plus the manufacturer is willing to put a plausible reimbursement package on the table so it is cost-effective—NICE can obtain funding from the CDF.
The CDF offers the ability to give immediate access to a drug NICE approves, whereas previously drugs had to go through all the stages of the appraisal process and were only funded by NHS England 90 days after final guidance was published. This change has allowed access to drugs 5–8 months earlier than was the case before 2016. In just over 4 years, of the 168 topics on which NICE issued guidance, 130 were funded, 19 were rejected, and the appraisals of 19 were terminated because the manufacturer did not submit evidence. Regarding decommissioning, of the 40 drugs taken on by the new process, only two were decommissioned.
Professor Clark felt that the revised process was working. Overall access to drugs has increased, the process is quicker, and NICE, NHS England, and industry are working well together. Professor Clark stated that the biggest bonus of this joint working is that patients get early access to cancer medicines.
Developing Rapid Diagnostic Clinics
Dr Luigi De Michele, Consultant, Rapid Access Diagnostic Clinic, Guy’s and St Thomas’ NHS Foundation Trust, presented the findings of a pilot project to develop a Rapid Diagnostic Clinic (RDC) to deliver a faster and earlier diagnosis and an improved patient journey. From April 2020, it is expected that all cancer alliances will have at least one RDC for patients with non-specific symptoms that may indicate cancer.2
From April 2020 … all cancer alliances will have at least one Rapid Diagnostic Clinic for patients with non‑specific symptoms that may indicate cancer.
Barriers to early diagnosis
Unfortunately, the symptoms of an early presentation of cancer are very vague most of the time. Patients without specific symptoms can spend months being referred to different clinics and undergoing a range of investigations. Consequently, 60% of patients have a late presentation of cancer. Some of these patients unfortunately receive a diagnosis of cancer in the emergency department, which is not good in terms of prognosis.
The role of the RDC
Patients are referred to the RDC when there is a suspicion of cancer but no clear specialist pathway, with the aim of trying to achieve an early diagnosis of cancer in people who will otherwise experience a difficult diagnostic journey.
Performance of the pilot
To date, the pilot has received almost 2000 referrals, with 95% from GPs and 5% from emergency departments or hospital consultants. Patients are usually seen within 2 weeks in a one‑stop diagnostic clinic that organises investigations and scans. Of these patients, 7–8% are found to have cancer, 35% have a benign but significant health issue requiring further care from other specialists, and the remainder can be discharged with health advice.
Among the first 1000 patients assessed at the RDC, 80 cases of cancer were detected. A range of cancers were diagnosed, but lung cancer, colorectal cancer, lymphoma, neuroendocrine cancer, and breast cancer were the most prevalent. The average time from referral to commencing treatment was 41.4 days, and 40% of these cancers were detected at stage 1 or 2.
Improving cancer screening programmes in England
Professor Anne Mackie, Director, Screening, Public Health England and Director, Screening Programmes, UK National Screening Committee, discussed the current status and future directions of screening for cancer in England. Screening programmes are a huge undertaking and things can go wrong. Before new techniques can be considered, screening programmes must be designed and run to deliver reliable results every time.
Goals of screening
Screening aims to divide people into those more likely to have a condition and those less likely to have it, and then to follow up those more likely to have it with further tests. However, a number of people will be told that they have a problem when they don’t, whereas others will be told they don’t have a problem when they do. Also, uptake of screening varies widely: often, the people most likely to have the disease are the people least likely to attend screening programmes. Programmes with high uptake are really special, but expensive and difficult to achieve.
… screening programmes must be designed and run to deliver reliable results every time.
How can screening improve?
The most important thing to improve screening programmes is to do them right every single time. Technology seems to be a major driver of change and improvement at present. The UK National Screening Committee recommended that the bowel screening programme should use a much more sensitive test for blood in the faeces and start from 50 years of age.3 However, Professor Mackie asserted that an expansion of colonoscopy was well beyond England’s ability at the moment and would be necessary to implement this test.
The future of screening
In October 2019, an independent review of adult screening programmes chaired by Professor Sir Mike Richards identified several ways in which screening programmes in the UK are failing to realise their full potential.4 The report makes 22 recommendations for improvements to adult screening services that aim to save lives while supporting implementation of the NHS Long Term Plan. However, when screening works, it’s amazing. Cervical screening has saved the lives of about 4500 women, and once HPV vaccination has been adopted by the whole of the screening cohort, cervical screening may not be necessary at all.
Regarding the future of screening, stratification of patients may improve their referral into treatment pathways, and innovations such as the use of artificial intelligence in breast cancer screening and genome sequencing have the potential to improve future screening programmes.
- NICE. Cancer drugs fund. www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance/cancer-drugs-fund (accessed
21 October 2019).
- NHS England, NHS Improvement. Rapid diagnostic centres. Vision and 2019/20 implementation specification. London: NHS England and NHS Improvement, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/07/rdc-vision-and-1920-implementation-specification.pdf
- UK National Screening Committee. The UK NSC recommendation on bowel cancer screening in adults. London: UK NSC, 2018. Available at: legacyscreening.phe.org.uk/bowelcancer
- NHS England. Report of the independent review of adult screening programmes in England. London: NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/02/report-of-the-independent-review-of-adult-screening-programme-in-england.pdf