Health Inequalities in Breast Cancer in England: A Pragmatic Review to Inform National Institute for Care and Excellence (NICE) Recommendations

Abstract

Health inequalities refer to systematic, unfair and avoidable differences in health across the population and between different groups in society. We reviewed health inequalities related to breast cancer to inform National Institute for Health and Care Excellence (NICE) recommendations. This was a pragmatic, targeted review to identify examples of health inequalities related to breast cancer in England. The search focused on national cancer registries, screening programme datasets, patient experience surveys and reports from key organisations. The results were synthesised using 5 domains of interest, covering health status, risk factors, wider determinants, access to and quality and experience of care. These domains were subdivided across 4 dimensions of health inequalities, including deprivation, geography, protected characteristics, and inclusion health groups. It was found that although breast cancer is less common in more deprived groups, these groups have worse health outcomes and higher mortality rates compared to less deprived groups. Many disadvantaged groups are less likely to participate in breast cancer screening, leading to delayed diagnosis and more advanced cancers. Behavioural risk factors such as obesity, physical inactivity and alcohol consumption vary across groups and impact breast cancer risks and outcomes. While people from ethnic minority groups have lower breast cancer incidence, evidence suggests that the incidence of breast cancer in some groups is increasing. Ethnic minority groups are also often diagnosed at advanced stages due to presenting through non-screening routes. Low health literacy is an issue for many disadvantaged groups. This review demonstrates that late diagnosis and low screening uptake significantly contribute to health inequalities among different groups, including deprived and ethnic minority groups. There are many gaps in the evidence, and this review further highlights potential research areas for the broader health and care system from the perspective of health inequalities.

Keywords

health inequalities breast cancer breast cancer outcomes clinical guidelines pragmatic review

Introduction

Health inequalities are systematic, unfair, and avoidable differences in health across the population and between different groups within society. Health inequalities arise because of the conditions in which we are born, grow, live, work and age. These conditions influence our opportunities for good mental and physical health and wellbeing.¹

Breast cancer is the most common cancer in England. According to data from the National Health Service (NHS), there were 40 192 new cases of breast cancer registered in 2020, with 99% of diagnoses in women.² In England in 2020, 640 000 women lived with breast cancer. This is expected to increase to 1.3 million by 2040.³

Health inequalities lead to disparate outcomes, varied access to services, and poor experiences of care. This results in earlier deaths, lost years of healthy life, intergenerational effects from traumatic experiences, and significant economic costs for society.¹

The National Institute for Health and Care Excellence (NICE) in England provides national evidence-based guidance and advice, considering effectiveness and value for money. Reducing health inequalities is one of NICE’s core principles, and the national guidance supports strategies that improve population health as a whole while offering particular benefits to the most disadvantaged.

This pragmatic review identified health inequalities related to breast cancer and facilitated the development of breast cancer health inequalities briefing.⁴ The briefing aimed to assist the NICE internal team and the guideline development committee in creating breast cancer-related recommendations that reduce health inequalities and avoid making existing health inequalities worse.

Methodology

A pragmatic approach was adopted to literature searches for this review. An initial search sought to identify key data sources such as national cancer registries, screening program datasets, patient experience surveys and published reports by relevant key organisations. The identified evidence was synthesised using the King’s Fund framework to health inequalities using 5 domains of interest (health status, risk factors, wider determinants, access to and quality and experience of care) subdividing each by 4 dimensions of health inequalities (socioeconomic status and deprivation, geography, protected characteristics, and inclusion health groups) (see Table 1 for the definitions).¹

Table 1.

The King’s Fund Framework for Health Inequalities Adapted to Breast Cancer Briefing.

Inequalities Between Who?		Inequalities of What?
Socio-economic deprivation	E.g., Deprivation as measured using the index of multiple Deprivation	Health status	E.g., Life expectancy, breast cancer incidence and prevalence, breast cancer outcomes, breast cancer mortality
Geography	E.g., Southern vs Northern England	Behavioural risks to health	E.g., Obesity, smoking, alcohol consumption, physical activity, hormone therapies
Protected characteristics	E.g., Age, disability, ethnicity, sex, gender reassignment and sexual orientation	Wider determinants to health	E.g., Income and work, sick leave and financial support, access to healthy diets and physical activity, education and health literacy
Inclusion health groups	E.g., People experiencing homelessness, people in custodial environments and prisons, migrants, refugees	Access to care	E.g., Access to screening, diagnostic services and treatment services
		Quality and experience of care	E.g., Uptake of screening, experience of breast cancer related care, cancer outcomes

Source: The King’s Fund 2020.¹

The second stage of the search was developed iteratively to target the gaps in evidence for any of the 5 domains and 4 dimensions of health inequalities. This included targeted searches of bibliographic databases including MEDLINE and Embase to locate evidence for any areas with limited data. Searches were limited to the English language and the geographical area of England. However, this was expanded to the UK in cases of limited data.

Due to resource and anticipated data limitations, this review was pragmatic and aimed to educate on the breadth of existing inequalities and provide only examples. It was not a comprehensive systematic review. Therefore, there were no formal data selection criteria. Generally, one reviewer screened data sources for any relevant information with routinely available data sources, such as national cancer registry datasets and key published reports on inequalities by charities, nongovernmental bodies and governmental reviews given priority. Where data were lacking, e.g., the inclusion health groups, the reviewer considered data from grey literature and small‐scale studies. In most cases, summary data reported from the source was used. Some national datasets had to be manipulated to obtain the required data. This was undertaken by one reviewer.

There was a risk of subjectivity in conducting this review due to, for example, the targeted follow-up searches addressing specific gaps and being less comprehensive, resource constraints, and decisions on what to include. Limitations of the review and data sources were documented, and key decisions were recorded in the quality review matrix for each domain and dimension of health inequalities, following the King’s Fund framework (see Table 1). Three quality reviewers used this to ensure that an efficient and transparent process was undertaken in the data selection, and interpretation of the findings. The quality assurance was also provided by an external topic expert with an interest in health inequalities and breast cancer, an external reference group with representation from various national groups that was specifically set up for breast cancer, and the NICE breast cancer guideline development committee.

The remainder of this brief report summarises key examples of health inequalities related to breast cancer for the 4 dimensions of health inequalities, including deprivation, geography, protected characteristics and inclusion health groups (see Table 1 for the definitions). Some categories of protected characteristics were not covered, like marriage and civil partnership, pregnancy, maternity, and religion, due to the lack of health inequalities data in these groups. Similarly, the review did not cover all risk factors for breast cancer because there was insufficient literature on certain factors like reproductive behaviour and late age at first birth in relation to health inequalities in England.

Deprivation

The least-deprived groups tend to have a higher incidence of breast cancer.⁵ This may be due to factors such as higher rates of alcohol consumption, increased use of menopausal hormone therapy, and oral contraceptives.^6,7 Although the incidence of breast cancer is lower in more deprived groups, these groups experience worse health outcomes, including a higher mortality rate.

People from deprived groups are less likely to participate in breast cancer screening and are also less likely to be urgently referred for assessment of breast symptoms.^2,8 This can contribute to a delay in diagnosis and a more advanced stage of breast cancer at the time of diagnosis. More advanced stages of breast cancer may require more intensive combination treatment, including tumour resection, radiotherapy, and chemotherapy. Therefore, delayed diagnosis could be considered a significant factor contributing to many inequalities in care and outcomes for people from deprived groups.

There is also a higher prevalence of factors that contribute to poor health in people from more deprived groups, including unhealthy diets, physical inactivity and obesity.^9,10 The increased likelihood of having comorbidities could also contribute to worse outcomes in deprived groups.⁴

Geography

There is geographical variation in the incidence of breast cancer.⁵ Several factors can influence these differences. For example, breast cancer is more common among people from white ethnic family backgrounds and is less common among people living in deprived groups.^5,11 The risk also increases with age.¹² This means that affluent regions, such as south-east England, where these groups are more prevalent, have a higher incidence of breast cancer.

In areas with higher levels of deprivation and ethnic diversity, fewer people participate in breast cancer screening, and more people have urgent referrals for symptom assessment.^2,13 There is also greater use of more intensive combination treatment, including tumour resection, radiotherapy, and chemotherapy.² These factors contribute to geographical variation in outcomes, with some areas having higher mortality rates.¹⁴

Additionally, behavioural risk factors like obesity, physical inactivity, smoking and alcohol consumption vary across regions and impact breast cancer risks and outcomes.^10,15,16 Variations in the availability of certain treatments for breast cancer, including bisphosphonate therapy, hormone therapies and reconstructive surgery, and support services, such as psychological support also exist across different regions.¹⁷

Protected Characteristics

Age

Age is the most important risk factor for breast cancer. The risk of breast cancer increases with age, and the outcomes, including survival rates, also vary according to age.^12,18 Outcomes are best for those within the National Health Service Breast Screening Programme (NHSBSP) age range of 50 to 71, while younger people (aged 15 to 39) and older people (aged 71 and over) experience worse outcomes. However, the incidence in younger age groups is low, with 80% of diagnoses occurring in women over the age of 50.

People aged 71 and over who are experiencing a rising incidence of breast cancer have poorer outcomes and experience significant inequalities. This age group is not eligible for screening unless they self-refer or are referred by their GP.¹⁹ As a result, they are often diagnosed with more advanced stage disease.¹⁷ Additionally, core breast cancer data, including HER2 status, grade and cancer stage, are less frequently recorded for people aged 71 and over.²⁰ This can result in fewer people receiving appropriate treatment and contribute to worse outcomes.

Comorbidities and frailty are more prevalent in older age groups and are sometimes used as a reason for offering less effective active treatments.²¹ However, there is evidence of ageist attitudes irrespective of comorbidities and frailty. For example, older women are less likely to have discussions about breast reconstruction and experience many other barriers that make it challenging to participate in breast cancer care, such as mobility issues or caring responsibilities.^20,21

Ethnicity

People from ethnic minority groups have lower breast cancer incidence due to lower prevalence of known risk factors such as less alcohol consumption, lower rates of menopausal hormone therapy and hormonal contraceptive use.^11,22,23 However, there is evidence that the incidence of breast cancer in some ethnic minority groups is increasing due to changes in risk factor profiles as these communities change over time. For example, increased alcohol consumption, obesity, and greater use of menopausal hormone therapy and contraceptives, alongside decreased parity and lower rates of breastfeeding, are contributing to this trend.²⁴

Additionally, ethnic minority groups are on average younger than white groups and, therefore, more likely to seek healthcare through non-screening routes.^25,26 There is evidence that presenting through non-screening routes increases the risk of advanced-stage breast cancer.²⁷ It is important to note that even though ethnic minority groups have a younger demographic profile, there is no evidence of an increased risk of breast cancer at younger ages in, e.g., black Caribbean and black African groups.⁸ Furthermore, these groups often experience longer times to treatment initiation.²

Overall, ethnic minority groups have lower screening uptake and are more likely to present with advanced and high-grade cancer, yet their mortality rate is lower.^26,28-30 The reason for this is unclear. Evidence also suggests that people from ethnic minority groups may have additional barriers to receiving healthcare, including different language needs and cultural expectations.³¹ Some ethnic minority groups report emotional barriers, including fear, embarrassment and anticipated shame which may also contribute to a lower level of screening uptake.³² Additionally, there is a lack of representative support groups, and they generally report poorer care experiences.^33,34

Disability

In people with disabilities, behavioural risk factors for breast cancer, such as physical inactivity and obesity, are more prevalent.^35,36 Fewer people with disabilities participate in breast cancer screening due to barriers such as not receiving screening invitation (due to not being registered with their general practitioner) and lack of accessible screening equipment and screening locations.^37-39 As a result, many experience delayed diagnosis, present with advanced-stage breast cancers and have poorer outcomes.^40,41

Gender Reassignment and Sexual Orientation

Certain breast cancer risk factors are more common in people who identify as LGBTQ, such as alcohol consumption and physical inactivity.^42,43 Some trans people may also be at increased risk due to hormone treatment.⁴⁴ Screening uptake in cis lesbian women and bisexual cis women is similar to cis women in general.^42,45 However, the current NHSBSP fails to identify some eligible LGBTQ people because the system only invites those who are registered as female with their GPs.⁴⁵ Additionally, LGBTQ groups lack representative support groups, and people may feel intimidated by heterosexually-oriented cancer support groups, contributing to their poorer care experience.⁴⁶

Inclusion Health Groups

Many inclusion health groups are at higher risk of breast cancer because behavioural risk factors are more prevalent in these groups, and many also come from deprived communities.⁴⁷ Currently, breast screening services lack a systematic way to identify eligible people from these groups.^48,49 Many face challenges in registering with a GP and may not receive invitations for breast cancer screening.⁴⁷ Additionally, migrants may avoid seeking care due to NHS charges and concerns about their medical information being shared with immigration enforcement and potential deportation.⁵⁰ Financial challenges can also prevent people from accessing breast cancer screening and care.⁵¹ These barriers can lead to extremely delayed care-seeking and result in advanced breast cancer diagnoses through emergency routes, resulting in worse outcomes.

Health Literacy

Low levels of health literacy are a significant overarching theme affecting various groups, including those from deprived and ethnic minority family backgrounds, disabled individuals, older people, and many inclusion health groups.⁵² People with low health literacy may have limited awareness of breast health and be less likely to recognise symptoms of breast cancer.⁵³ This can lead to delays in seeking medical care and lower screening uptake, resulting in late-stage presentation and poorer health outcomes within these groups.

Discussion

When developing national guidelines and recommendations, decision makers should consider the potential underlying drivers of breast cancer inequalities. Late-stage diagnosis is a key issue for many groups, including deprived groups and people from ethnic minority family backgrounds. Therefore, it is a priority to identify optimal ways to enhance early breast cancer detection, including understanding factors that increase screening uptake among many of these groups and designing effective interventions to improve access to diagnostic and treatment services for these disadvantaged populations.

Policymakers and practitioners should also be aware that while some groups have a lower incidence of breast cancer, their outcomes are worse when they do get it. They should consider the demographic differences and lifestyle changes affecting breast cancer risk, as well as low health literacy and varying access to diagnostic and treatment services among different populations. It is also essential to co-design services with people in high burden groups to ensure that they are relevant, accessible and effective for these populations. It is important to be realistic about the underlying problems faced by these groups.

The review also identified significant gaps in the evidence base. There is a lack of data for many inclusion health groups, gender identity and inequalities between LGBTQ groups and disabled people. The reported data was often incomplete, poorly reported and inconsistently grouped. There is also a need for more data on the interaction between different inequality dimensions. For example, while deprivation is a major driver of health inequalities, there is not enough data to conclude how other inequalities, such as differences between people of different ethnic family backgrounds or geographic variations, overlap with deprivation.

It has to be noted that this was a pragmatic, targeted review of the literature rather than a comprehensive systematic review covering all inequalities in breast cancer care. As such, it is partly subjective and based on the evidence available and retrieved by the lead authors. Also, this review aimed to inform the NICE recommendations in England from a health inequalities perspective. It primarily focused on health inequalities research in the UK. However, the identified health inequalities can highlight issues that may also be present elsewhere. Moreover, the UK has a diverse population, and insights into different demographic groups can be particularly useful for other countries with similar demographics. Most importantly, bringing attention to the breadth of health inequality issues can raise awareness and encourage other countries to address health inequality issues.

Conclusion

This pragmatic review highlights the need for continued advocacy with partners across the system to tackle the causes of breast cancer inequalities, such as low screening uptake, late diagnosis, and low health literacy across many disadvantaged groups.

Footnotes

Authors Note

This original research and manuscript have not been submitted or accepted for publication in another journal.

Author Contributions

Eric Slade: Writing - original draft; methodology; writing - review and editing; supervision; formal analysis; validation. Kirsty Luckham: Writing - review and editing; methodology; formal analysis. Andrea Heath: Writing - review and editing; methodology; formal analysis. Lesley Owen: Methodology, validation; writing - review and editing; supervision.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Eric Slade, Kirsty Luckham, Andrea Heath and Lesley Owen are employees of NICE, which is funded by the Department of Health and Social Care to develop national guidelines. No authors received specific funding from NICE, the Department of Health and Social Care or the NHS to write this summary. All 4 authors confirm that they meet all 4 authorship criteria in the ICMJE uniform requirements. Eric Slade is the guarantor for this article. The views expressed in this publication are those of the authors and not necessarily those of NICE.

ORCID iDs

Eric Slade

Andrea Heath

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