Ethnic and racialised inequalities in cancer services: evidence review

1. Introduction

1.1 Policy Context

SG’s ten-year Cancer Strategy (2023 to 2033), published in 2023, set out a ten-year vision and strategic aim:

10-year vision:

That more cancers are prevented, and our compassionate and consistent cancer service provides excellent treatment and support throughout the cancer journey, and improves outcomes and survival for people with cancer.

Strategic aim:

To improve cancer survival and provide excellent, equitably accessible care, underpinned by seven outcomes:

a. Reduced relative population burden of disease.

b. Reduced later stage diagnosis.

c. Timely access to treatment.

d. More people receiving curative treatment.

e. Improved experience of services, across all areas of care.

f. Optimised quality of life for each individual.

g. Embedded research, innovation and data capture in all services.

The Strategy includes a cross-cutting ambition to tackle health inequalities. This ambition highlighted 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. The Strategy’s Equality Impact Assessment^[2] discussed some evidence about disparities in relation to the protected characteristic of Race under the UK Equality Act 2010^[3]. However, it was recognised that SG did not have a comprehensive understanding of the evidence base about cancer inequalities and inequities experienced by people from minority ethnic groups in Scotland. Therefore, a decision was made to undertake this evidence review to provide SG with better knowledge of this evidence base. The Strategy is underpinned by the current Cancer Action Plan (2023 to 2026). This evidence will inform the next Cancer Action Plan and associated policy development and delivery to tackle such inequalities.

1.2 Scope of Review

The broad scope of this review was defined as cancer screening, diagnosis, incidence, treatment, care, experience and outcomes. Evidence about clinical trials is also discussed because barriers and enablers relevant to other aspects of the scope are also relevant to this issue, which in turn is relevant to cancer treatment. In order to keep the review manageable, cancer prevention and cancer risk factors were deemed out of scope. For the same reason, detailed evidence about ethnic inequalities in the social determinants of health over the lifecourse was also treated as out of scope. However, it is acknowledged that there is extensive evidence about this issue, and it is referenced in Section 3.1, which examines levels of racism and intersectionality.

1.3 Research Questions

The research questions developed to guide this review were as follows:

1. What evidence is there 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?

1.4 Terminology

1.4.1 Health Inequalities

The terms health inequalities and health equity are often used interchangeably. This review uses the term health inequalities to cover both terms; and the following definition used by Public Health Scotland (PHS)^[4] drawing on McCartney et al (2019)^[5]:

“Health inequalities are differences in people’s health across the population and between specific population groups, that are systematic, avoidable, and unfair.”

The King's Fund ^[6] uses a similar definition. It states that, while health inequalities are ultimately about differences in people’s health status, the term also refers to the differences in the care that people receive. That would include access to, and quality and experience of, healthcare.

1.4.2 Race and Ethnicity

The King's Fund ^[7] defines the terms ‘ethnic minority’ or ‘ethnic minority groups’ as referring to people belonging to ethnic groups that are in the minority in the context of the population of England. The NHS – Race and Health Observatory (RHO) Rapid Evidence Review ^[8] on ethnic inequalities in healthcare noted that, in terms of collective terminology about race and ethnicity, no single term had been found to be acceptable to all their stakeholders.

Consistent with the general approach to terminology used in that RHO review, this review generally uses the collective term ‘minority ethnic’ and does not use acronyms such as ‘BME’ or ‘BAME’ (both meaning ‘Black and Minority Ethnic’). There are some uses of the term ‘racialised’, including in the title of this review, and ‘minoritised’. This language recognises that racism is “a systemic problem where systems and structures unequally advantage or disadvantage people and communities based on their perceived ‘race’” (p.8). The issue of systemic racism is discussed in Chapter 3. Other collective terms are used only when directly quoting specific publications. When referring to specific ethnic groups, this review uses the terminology used in the research reviewed. Some studies included participants from a wide range of ethnic groups and these are not set out in detail at each citation.