Ethnic and racialised inequalities in cancer services: evidence review

Executive Summary

Introduction

The Scottish Government’s ten-year Cancer Strategy (2023 to 2033) ^[1] includes a cross-cutting ambition to tackle health inequalities. It highlights that people from minority ethnic groups and/or those experiencing racism and discrimination are among those who experience health inequalities and inequities of access to cancer services. This review was undertaken to provide the Scottish Government (SG) with better knowledge of the evidence base relevant to cancer inequalities associated with ethnicity and race. Its purpose is to inform the next Cancer Action Plan and associated policy development and delivery to tackle such inequalities. The broad scope of the review was defined as cancer screening, diagnosis, incidence, treatment, care, experience and outcomes. The research questions developed for this review were:

1. What evidence exists about cancer healthcare inequalities and inequities experienced by people from minority ethnic groups, including in access to screening, diagnosis, incidence, treatment, care, experience and outcomes?

2. What evidence is there about the impact of structural, institutional and interpersonal drivers of racism on cancer healthcare inequalities?

3. What evidence is there about cancer interventions (policies or services) which have been effective in mitigating inequalities and inequities experienced by people from minority ethnic groups?

77 cancer-related publications were reviewed. They comprised primary research articles and evidence reviews from the UK and Scandinavia, together with some grey literature, published between 2010 and 2025. (Grey literature comprises publications that are not books or journal articles, such as reports by government or non-governmental organisations). There was limited evidence available from Scotland: most of the evidence reviewed was from England.

A rapid evidence review approach was adopted to synthesise literature and analyse the evidence narratively. Findings are situated within a framework that recognises three levels at which racism operates: structural, institutional and interpersonal. Evidence is interpreted in relation to the impact of racism on health, and findings are considered in the context of intersectionality, whereby people’s overlapping forms of disadvantage compound each other and intensify inequalities.

Findings

It is important to note that inequalities vary across and within minority ethnic groups, therefore the findings from this evidence review do not necessarily apply to every group or individual. While some of the inequalities described here could be relevant to people in any ethnic group, including people from the wider population, many are more likely to be experienced by people from minority ethnic groups.

Cancer Inequalities

There is quantitative evidence of inequalities experienced by people from minority ethnic groups in relation to cancer screening, diagnosis, treatment and patient experience. Evidence shows that cancer incidence and mortality rates are generally lower among people from minority ethnic groups, though some commentary suggests that these rates could increase in future, for example if their cancer risk factors converge with those in the wider population.

Barriers contributing to Cancer Healthcare Inequalities in Access to Cancer Screening, Diagnosis, Treatment, Care and Experience

People from minority ethnic groups experience a range of barriers to access to cancer care, reflecting inadequate attention within the healthcare system to the specific needs of people from minority ethnic groups. Taken individually or combined, these barriers can cause delayed access to healthcare services, prevent early diagnosis of cancer, and cause poor experience of cancer treatment. They contribute to low confidence and trust in the healthcare system in general, which could discourage future uptake of care.

Barriers include difficulties in navigating the healthcare system, and healthcare staff behaviours including dismissal of symptoms and rudeness. The healthcare system is insufficiently responsive to cancer care needs, such as those relating to skin colour and under-representation of minority groups in information materials. Communication barriers include inadequate translation and formal interpretation services. Cultural barriers include some attitudes and beliefs, including that cancer diagnosis is not curable (fatalism) or should not be mentioned (taboo), and stigma about cancer. Some people from minority ethnic groups have insufficient awareness, knowledge and understanding about cancer symptoms and cancer risk, reflecting inadequate provision by the healthcare system of accessible and culturally appropriate information. Healthcare staff have insufficient awareness about how cancer symptoms manifest among people from specific minority ethnic groups, and in some cases poor understanding about ethnic variations in cancer risk. There is under-representation of people from minority ethnic groups in research relevant to cancer treatment, partly because of the barriers described above.

The Impact of Structural, Institutional and Interpersonal Drivers of Racism on Cancer Healthcare Inequalities

The drivers of racism hinder people from accessing healthcare, including cancer services. Ethnic inequalities in healthcare are located in the healthcare system and in wider society, rather than in the ethnic groups and individuals experiencing them.

Structural drivers of racism reflect disadvantaged access to physical, economic and social resources, which align with evidence about the social determinants of health. The cancer-related evidence in this review shows how people from minority ethnic groups experience socioeconomic disadvantage, to which practical barriers such as employment, housing, immigration status and care-giving responsibilities contribute, thereby compounding their disadvantage.

Institutional racism is reflected in routine processes, procedures and actions within institutions that negatively shape the experiences of people from minority ethnic groups. Cancer-related examples include some of the barriers discussed above, such as under-representation of minority groups in information materials. Those examples reflect institutionally inadequate responses to people’s needs relating to their ethnicity, skin colour, culture, religion or language.

Interpersonal racism comprises everyday expressions of racism experienced by people from minority ethnic groups, ranging from slights and microaggressions, to verbal or physical abuse. Examples found on the cancer pathway include delayed diagnosis attributed to racism, experience of more positive behaviour by healthcare staff towards White patients and negative racial stereotyping.

Potential Enablers which could contribute to Mitigating Cancer Healthcare Inequalities in Access to Cancer Screening, Diagnosis, Treatment, Care and Experience

Evidence about the barriers experienced by people from minority ethnic groups can be drawn on to develop interventions which could enhance their confidence and trust in the healthcare system. Implementation would need to be adapted to different ethnic groups and to different local contexts. Examples include the development of guidance to navigate the healthcare system, and primary care targeting of people from minority ethnic groups to support them to access services. Healthcare staff need to be enabled to provide culturally competent healthcare through improved training and skills development. Culturally appropriate policies, services and communication could include: practical interventions to improve screening uptake; the development of cancer advocacy services; the facilitation of support networks; the provision of practical information via trusted messengers and appropriate communication channels; and improved translation and interpretation services. Community-based and co-designed interventions should inform improved design of and access to cancer services: examples include community-led workshops, cancer roadshows and local health champions recruited from the target ethnic groups. Appropriate representation in research would involve increasing the ethnic diversity of people in research databases and other relevant datasets.

Policy Implications

Overarching Issues

• Addressing structural racism: progress on planned actions to address the social and economic determinants of health would contribute to this.
• Addressing institutional and interpersonal racism: delivery of SG’s national anti-racism agenda would contribute to this.
• Delivery of ‘Cultural Humility’ training for health and social care staff: would enable them to take a more explicitly anti-racism approach in their work.
• Improved data quality: improving the recording of ethnicity (level, consistency and granularity) would inform targeted interventions to address inequalities.

Addressing the Cancer Strategy’s cross-cutting ambition to tackle health inequalities - to be considered in the context of the next Cancer Action Plan

• Addressing healthcare system factors which present barriers to access.
• Enabling healthcare staff to provide culturally competent care.
• Delivery of culturally appropriate policies and services.
• Development of effective health communication.
• Delivery of culturally appropriate awareness-raising and communication.
• Support and funding for community-based and co-designed interventions.
• Embedding intersectionality in policy design, service delivery and evaluation.