Ovarian Cancer: Diagnosis and Treatment

Debate between Steve Brine and Marcus Jones

Tuesday 30th October 2018 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is a pleasure to see you in the Chair, Mr Bone. I, too, congratulate my hon. Friend the Member for North East Derbyshire (Lee Rowley) on securing the debate. As vice-chair of the all-party parliamentary group on ovarian cancer, the subject means a great deal to him. We also heard more about why it means a lot to him. I place on record my thanks to the all-party group and to the excellent ovarian charities. Target Ovarian Cancer is the biggest, but others work tirelessly in that space, such as Ovacome.

Watching my hon. Friend brought back memories of sitting in that exact chair as one of the vice-chairs of the all-party parliamentary group on ovarian cancer almost exactly seven years ago, in October 2011. I was talking about ovarian cancer, which has also had an impact on my family, although sadly not with the outcome that my hon. Friend currently has. I described it as a “silent national scandal”, which was then trending—quite something in 2011. I was also present for the 2014 debate that he remembers, which was the last time the subject was specifically debated in the House. It was a pleasure to hear him today; he reminded me of me—but I put on record the warning that this is where I have ended up.

I was pleased to meet with the hon. Member for Washington and Sunderland West (Mrs Hodgson) and Target Ovarian Cancer a couple of weeks ago to discuss the all-party group’s report, as the hon. Lady said. As she knows, I take the all-party groups very seriously. I have the report here—this is my coffee table copy in the Department of Health and Social Care, and anybody who knows my office knows that what is on the coffee table is what counts. It is an excellent report with many important recommendations and I will return to it a lot in my remarks. I have already committed to responding fully to it and the hon. Lady knows that I will do that.

I am responding to my third cancer debate in the House in less than two weeks, which demonstrates that improving cancer diagnosis and treatment is a priority for right hon. and hon. Members, as it is for me as the Minister with responsibility for cancer, the Government, the Prime Minister and the Opposition. In this job, I am fortunate to see first hand the superb work being done by our NHS staff and by our many partners and charities across the cancer community in implementing the 96 recommendations in the cancer strategy for England.

We are three years into that work and cancer survival rates have never been higher, as has been said. About 7,000 people are alive today who would not have been had mortality rates stayed the same as before Cancer Research UK and Harpal, who led the work, published the strategy. As I make clear every time I respond to a cancer debate, however, I know that we must do more and that people want us to do more, because we still lose 12,000 women a year to breast cancer and far too many women to ovarian cancer. We must do better. Despite the huge strides that I have mentioned, and the best-ever survival rates, ovarian cancer survival rates in the UK are among the lowest in Europe with fewer than half of all women diagnosed surviving five years or more, so there is much that we need to do.

[Mr Marcus Jones (Nuneaton) (Con)]

The Minister has mentioned the success rates in dealing with cases of ovarian cancer in our country compared with some of our European partners. Can he set out what we can learn from them in improving outcomes for women in this country?

[Steve Brine]

I will certainly cover that. Put bluntly, as I will come on to in a second, and as almost all hon. Members have mentioned, it is about early detection. That has an impact because, as the former chair of the all-party parliamentary group on cancer, my hon. Friend the Member for Basildon and Billericay (Mr Baron), has said many times, early diagnosis is cancer’s “magic key”. We have that magic key in some cancers in this country. We do very well in breast cancer, where the early-stage survival rates are well over the 75% target that the Prime Minister set out at the party conference earlier this month, but it is true that we do not yet have the magic key in enough cancers. I will come on to what we need to do.

I was pleased when the Prime Minister announced the ambitious package of measures for cancer care and treatment earlier this month, which will be at the heart of our long-term plan for the NHS. It will be backed up by the new funding that was announced in the summer and confirmed in yesterday’s Budget. We will overhaul screening programmes, provide new investment in state-of-the-art technology to boost our research and innovation capability and, critically, transform how we diagnose cancers earlier. As I have said, our ambition is to diagnose 75% of all cancers at an early stage, which will result in an estimated 55,000 more people surviving cancer for five years in England each year from 2028.

All hon. Members have mentioned early diagnosis, and many have mentioned some stats—or the same stats. The important one for me is that a quarter of women with ovarian cancer are diagnosed through an emergency presentation. When I first became an MP, I remember going to meetings with the all-party parliamentary group on ovarian cancer and the all-party parliamentary group on cancer, where I was shown the stats for my constituency of the number of people who presented in the emergency department with cancer. That really frightened and shocked me—it still does—and along with my personal history, it was one of the reasons I wanted to get involved in health and cancer when I joined the House.

Of that quarter of women with ovarian cancer who are diagnosed through an emergency presentation, just 45% survive for a year or more. That is no surprise—if someone is diagnosed in an emergency department, they have exhibited more outward symptoms, so they are at a later stage and their survival rate is lower. The survival rate is more than 80% when women are diagnosed following a GP referral, so it is crystal clear where improvements are urgently required. That is why early diagnosis is a key strategic priority in the cancer strategy. As has been said, it allows for more options for treatment and, crucially, the earlier a cancer is diagnosed, the more likely it is that doctors will be able to provide successful treatment or operate on the “bunch of grapes”—that is a good analogy, which I have heard before.

My hon. Friend the Member for North East Derbyshire talked about the multidisciplinary diagnostic centres. NHS England and the Department are testing new innovative ways of diagnosing cancer earlier. As regular attendees of cancer debates will know, I never tire of praising the accelerate, co-ordinate, evaluate—ACE—centres, which are the multidisciplinary diagnostic centres for patients with vague or non-specific symptoms. As the hon. Member for Washington and Sunderland West said, they are being piloted across 10 sites in the country. They offer patients a range of tests on the same day—a point that has been made by several hon. Members—with rapid access to results.

The centres are magnificent. I visited the ACE centre at the Churchill Hospital in Oxford earlier this year. I met the practitioners who work there, the commissioning group and the GPs who are involved in it. GPs are tremendously, and rightly, excited about the centres. They will make a huge step-change improvement in early diagnosis, particularly for cancers such as ovarian cancer, where symptoms can be vague and can appear less serious at first. The plan is for that innovation to address the delay that the hon. Member for Washington and Sunderland West and other hon. Members spoke about, so instead of a GP having to refer for one test and wait for the results, then refer for the next test and wait for an appointment, the ACE centres will allow for a snappy, quicker turnaround. They could be a game-changer and could unearth the magic key when it comes to ovarian cancer.

The APPG’s report says that we should roll out ACE centres nationwide, so I am delighted, as I know the hon. Member for Washington and Sunderland West is, that the Prime Minister recently committed to doing just that, as part of our long-term plan. I do not get excited easily, Mr Bone, as you well know, but I am excited about the ACE centres and they are potentially transformative.

I turn now to early diagnosis in primary care. Other support measures are necessary to ensure that more cancers are caught in primary care. The NICE guidelines for suspected cancer referral recommend safety netting for those people who are at higher risk of cancer but who do not meet the referral criteria. Both Cancer Research UK and Macmillan have produced additional advice and support for GPs to implement those guidelines, including the safety netting that I have just mentioned, over the last few years.

I was blown away to meet Macmillan GPs at Britain Against Cancer earlier this year. They are an excellent innovation and have an awful lot to give, but they are few in number. I am very interested in them and I talk to Macmillan about the potential use of Macmillan GPs in helping to transfer specialist knowledge of cancer to wider general practitioners. I always say of GPs that they are not dissimilar to MPs when we hold our surgeries, in that almost everyone who comes to our surgeries is more of an expert on the subject that they have come about than we are, because we are general practitioners. So GPs get a hard rap, but they are general practitioners and that is the area of the profession that they have chosen to go into.

We need to support GPs better through diagnosing cancer, from our targeted lung cancer screening in the lorries in car parks in the north-west—we trialled that approach in Manchester and it has been very successful—to the ACE centres that I have mentioned. That is all aimed at supporting the NHS, especially GPs, to identify cancer earlier.

The shadow Minister asked about the review of the referral pathway. As she knows, the implementation of the faster diagnosis standard requires trusts to review and speed up diagnosis pathways for suspected cancers. NHS England and NHS Improvement are working closely together to emphasise the key principles for improvement that we need in this area, which include ensuring that the most value is derived from each appointment. The standard is being measured for a year from April 2019 to April 2020, when it comes into place. That will ensure that patients are told that they have a cancer diagnosis or an all-clear within a maximum of 28 days of being urgently referred by their GP for suspected cancer. As I always say, 28 days is not a target; it is a maximum. When someone has a cancer worry, 28 minutes can seem like a lifetime, and such things always seem to come on a Friday night, when the weekend lies ahead. Twenty-eight days is our new target, but it is certainly not what we aim for; we aim to do better than that.

We heard from several Members—including the hon. Member for Strangford (Jim Shannon) and the shadow Minister—about Be Clear on Cancer. That campaign is one of the great successes of public policy in recent years. The APPG’s report also recommends, as the hon. Lady said, running a Be Clear on Cancer campaign to raise awareness of ovarian cancer symptoms. However, she is experienced and smart enough in this area to know that Be Clear on Cancer cannot focus specifically on a cancer type, such as breast cancer; it is about clusters. That is where we have found it to be most successful.

Public Health England, for which I have ministerial responsibility, takes a number of factors into account when deciding which campaigns to develop; of course, there is healthy competition in this space and unfortunately there is always more demand than supply. One of the main criteria in deciding which campaigns to run with is the scope to save lives through early diagnosis; that measure is what I will judge that work against.

Campaigns can be effective only if the cancer has a clear early sign or symptom that the general public can act upon if it should emerge. Being honest, even blunt, that is part of the challenge here, as has already been said and for the reasons that have already been given. So the regional Be Clear on Cancer pilot for ovarian cancer took place in the north-west of England in February and March 2014—a while ago now—with this simple key message:

“Feeling bloated, most days, for three weeks or more could be a sign of ovarian cancer. Tell your doctor.”

PHE is currently undertaking new data analysis and research to determine Be Clear on Cancer campaigns for next year, which is 2019-20. At this time, no decisions have been made, and I will take the bid from today’s debate very strongly. The outcomes from the regional pilot—and a pilot that focused on a range of abdominal symptoms such as diarrhoea, bloating and discomfort, which can be indicative of a number of cancers, including ovarian cancer—will of course be taken strongly into consideration, and that is where I think we will head with this work.

However, let me clear that PHE and NHS England have had a very clear steer from me that I want to run the campaign on lower abdominal symptoms as soon as practicably possible. We have to make sure that the operational capability is in place across the NHS, because the worst thing that we could do is create a demand without being able to meet it. That is a rather boring, practical reality, but it is a reality. I reiterated this point to the APPG recently when we met and I will of course keep Members updated; I know they follow these matters very closely.

The hon. Member for Strangford also asked about genetic testing and its role in identifying the increased risk of ovarian cancer. One area where England is very much at the cutting edge of cancer diagnosis is in the creation of the new national genomic testing network, which will be delivered through seven new genomic laboratory hubs, as we call them. They will give patients access to state-of-the-art tests that can diagnose their disease or help to inform their treatment. So the genomic lab hubs will do three things: provide consistent and equitable access to genomic tests, which is very important, as it will ensure there is a level playing field; operate to common national standards, specifications and protocols; and deliver the single national genomic testing directory, which will cover the use of all the genomic technology, from the single gene to the whole-genome sequencing for cancer and for rare and inherited disease.

The labs are in a period of transition, to embed fully the new infrastructure and the new national genomic test directory. I hope that this transition will ensure the safe roll-out of the service without disrupting clinical care. Patients will continue to receive the testing they need to inform their clinical care, and the new national test directory will also include the BRCA testing for women with ovarian cancer in line with NICE guidance, which the hon. Gentleman rightly mentioned.

While I am talking about the hon. Gentleman, or “the hon. Member for Westminster Hall” as I like to call him, I note that he also touched on screening programmes, as did the Opposition spokesperson and my hon. Friend the Member for North East Derbyshire. The UK National Screening Committee is awaiting the updated results of the UK trial of ovarian screening, which is the UK collaborative trial of ovarian cancer screening, as it is known. The secretariat is in contact with the researchers and the committee will review the findings as soon as they are published.

The hon. Gentleman was absolutely right to talk about the workforce. On page eight of its report, the APPG outlines the importance of sonographers. There will be increased emphasis on diagnosing cancers earlier, but we will not be able to find the magic key without those people who do the searching, who are our NHS workforce. So we must ensure that we have the right workforce in the right place to deliver that frontline care and meet the Prime Minister’s ambition.

Last December, Health Education England published its first ever cancer workforce plan, committing to the expansion of capacity and skills. HEE will follow that plan up with a longer term strategy that will be aligned with the NHS long-term plan, which seems sensible to me, and that will look at workforce needs beyond 2021. We have to look at a very long landscape when it comes to the NHS workforce. I will not pre-empt that plan, but I can assure hon. Members that it will set out how we will ensure that a sustainable cancer workforce are in place to deliver on the ambitions that we have set out.

My hon. Friend the Member for North East Derbyshire talked about the cancer dashboard. The APPG report, which of course he was involved in drafting, also recommends including ovarian cancer data within the dashboard. The dashboard was first published in May 2016 as a tool to help the cancer alliances, the commissioners and the providers in the acute trusts to quickly and easily identify the priority areas for improvement, and to enable easy tracking of progress towards our national ambitions.

PHE is working with NHS England’s cancer programme team on the next phase of the dashboard development, and that will be informed by the needs of the key stakeholders and the cancer charities, with which I hold a regular roundtable; some of those charities’ staff are here in the Gallery today. It is no secret that hon. Members know that I am frustrated about the cancer dashboard. I am impatient about most things, as my private office will sadly attest, and I am incredibly impatient about the dashboard being limited to the top four cancers. I want to see it expanded and I intend to see it expanded: NHSE and PHE have a very clear direction from me that I will be watching their work and I expect to see it producing what I and other Members in this House want.

The hon. Member for Washington and Sunderland West spoke about surgery and the mixed picture around the country. I do not want to short-change her by not giving her the detailed answer I want to provide to her good point, so I will look into it and write to her and the other Members who have been in the debate today. We obviously must diagnose early, as that gives us better and less radical treatment options, but for some surgery is a sad reality. We must ensure that the NHS is good at not only sharing best practice but implementing it, and that is as true in surgery as anywhere else.

I pay tribute to the hard work and professionalism of our dedicated cancer workforce, and to the Members who care so passionately about the subject and have brought it to the House today. Ultimately, it is our workforce who will determine the success of the cancer strategy and the long-term plan for the NHS. We can only set the direction and the ambition and ensure that the resources are in place, and I believe that I am doing that, as Minister for cancer.

I am excited by the huge potential for the next 10 years of cancer diagnosis, treatment and support. We have fully established the 19 cancer alliances. We have backed them with the funding they need to transform services, and will go on doing that, to ensure that the NHS long-term plan can be delivered on the ground through the alliances, with cancer at its heart. The plan can turbo-charge all that we have achieved through the cancer strategy. I have said before, and I will say again, that I want the alliances to be much more open and accountable and much more approachable, especially by Members of Parliament in England, who should be able to call them to account much more than they do. I suspect that many Members here have the chief executive of their local trust on speed dial; I hazard a guess that they do not have the leader of their cancer alliance there also, and that should change.

It was interesting to get the Scottish perspective from my hon. Friend the Member for Berwickshire, Roxburgh and Selkirk (John Lamont). We would like to see the ambition in England matched across the whole United Kingdom and we absolutely stand ready, as always, to work with Scottish Members and the Scottish Government. If there is anything we can do to help share that ambition, we will do it.

NHS England, Public Health England and I, with the tireless support of our cancer community—team cancer as I always call it—are committed to making a reality the ambitions that the Prime Minister has set out. That will ensure, as I said in this place not two weeks ago, that we continue to make huge leaps forward over the next 10 years to a future where cancer has no future.

Lymphoedema Services

Debate between Steve Brine and Marcus Jones

Tuesday 27th March 2018 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

I congratulate the new hon. Member for Gower (Tonia Antoniazzi)—I knew the last one—on securing her first debate in Westminster Hall, as she said, which is on a very important issue.

Lymphoedema Awareness Week took place earlier this month, so today’s debate is timely. We heard much from the hon. Lady on the impact of the condition, which she set out very well, although Members should watch themselves looking at people’s legs and feet in supermarkets. I am sure therein lies a problem for me in Winchester, but I take her point. She set out very well the difference that high-quality care and support can make. We can all agree that we want that for people affected by lymphoedema. I hope the debate will encourage service providers across England to consider the improvements that they might make.

It is estimated that between 75,000 and 220,000 people in England are affected by lymphoedema. The condition is caused by abnormal accumulation of lymph fluid in body tissue, which can be the result of a congenital defect, of damage to the lymphatic system or of removal of lymph nodes by surgery, radiation, infection or injury. Obviously, cancer plays a role in that, which I will come to. Regardless of the cause, it is important that the NHS responds appropriately in diagnosing and managing the condition, and that it provides appropriate support and advice to those affected. A lot has changed since we had the last debate.

[Mr Marcus Jones (Nuneaton) (Con)]

Will the Minister say more about consistency of services for lymphoedema across the country, and acknowledge the role of our hospices? In my constituency, the Mary Ann Evans Hospice, of which I am a patron, has a lymphoedema care service, which is very valuable to local people.

[Steve Brine]

In my response I will touch on services across England. My hon. Friend is right to mention the hospice movement. Many people working in hospices become experts in this field by virtue of their day-to-day work. I am very happy to endorse what he said, and I thank everyone working in the hospice movement who is helping patients affected by lymphoedema.

In Scotland, Wales and Northern Ireland, certain national lymphoedema initiatives have been developed—we have heard about the initiatives in Wales. Health is a devolved matter, and devolution is important. The devolution settlement from the last Government stands, and allows the four nations of our United Kingdom to develop the services that they believe meet the needs of their resident populations and the respective size of them. In England, responsibility for determining the overall strategic national approach to improving clinical outcomes for healthcare services lies with NHS England, and the provision of lymphoedema care is the responsibility of local NHS commissioners.

Although lymphoedema has no cure, interventions such as decongestive lymphatic therapy, skincare, exercise advice and weight management can ease symptoms and improve quality of life for those affected. The hon. Lady was absolutely right to raise the issue of weight management—there is a lot of discussion in this place about the obesity challenge that we face. This condition is a not-often-talked-about consequence of the obesity challenge, and I am grateful she raised it. People with lymphoedema can usually be treated through routine access to primary or secondary care services with access to dedicated lymphoedema clinics. I have experience in my family of attending such clinics.

To support clinicians in the diagnosis, treatment and support of patients with lymphoedema, an international consensus document on the condition was produced in 2006, which is endorsed by the British Lymphology Society and the Lymphoedema Support Network. Additionally, the Royal College of General Practitioners offers an e-learning course on lymphoedema—the hon. Lady said that that was one of her concerns. That often supplements GPs’ existing understanding of the condition, which is covered in the GP curriculum, and I am pleased to say that it is identified as a key area of knowledge that we expect of them in their qualifying exams.

We heard from the hon. Lady about calls for a national lymphoedema service in England. Hon. Members may be aware that, in 2015, the British Lymphology Society submitted a proposal for a nationally commissioned specialised lymphoedema service to the Prescribed Specialised Services Advisory Group—we like our titles and acronyms in health—which is an expert committee appointed by the Department to consider these very matters.

Four factors should be considered when determining which prescribed specialised services should be directly commissioned by NHS England, the first of which is the number of individuals needing the service. The second factor is the cost of providing the service—after all, it is a publicly funded health service. The third consideration is the number of persons able to provide the service—the workforce—and the fourth is the cost to clinical commissioning groups in England for providing the service.

Taking account of those four factors, the advisory group concluded that lymphoedema services were not suitable for national commissioning. As the patient population was high in England, there were numerous providers and the burden to commissioners was low. However, we keep that under constant review, which links to my next point about Wales. We recognise that there can be opportunities to learn from our partners in the devolved Administrations while taking high-quality clinical advice from our advisers, such as I just mentioned.

We are aware of the recent evaluation of the lymphoedema service in Wales, which was published in the British Journal of Nursing, and we agree that the results appear to be very positive in addressing the challenges faced in Wales. We also note the caution applied to some of the figures but, as I say, we keep it under constant review, and the hon. Lady’s debate is helpful in that regard.

In my experience as a Health Minister, NHS commissioners are always keen to hear about services that have demonstrated savings and improved care in other parts of the country and the United Kingdom. For example, the Healthy London Partnership, a collaboration including London’s NHS, councils and Public Health England, for which I have responsibility, has drawn on the work of the Welsh lymphoedema service for its own service. We watch that closely. NHS England is also aware of the evaluation of the Welsh service and—the hon. Lady asked about this—is in touch with the national clinical lead for lymphoedema in Wales, who is one of her constituents. That relationship is ongoing and bearing fruit.

The hon. Lady mentioned cancer, for which I am the Minister responsible. Lymphoedema resulting from cancer treatment, which, sadly, has touched my life, is common. About one in five people have lymphoedema of the arm after breast cancer treatment that affects the lymph nodes, which are so difficult. Much of the lymphoedema service improvement in England has developed as a result of national initiatives to improve cancer services and, sadly, the high number of breast cancer incidents. There is growing recognition of the need to support cancer survivors after they fall off the cliff edge when their treatment ends. Lymphoedema services are a key part of that, and I have seen them when out and about doing my job.

Over the years, the Government have driven forward the cancer survivorship agenda, which I am passionate about and committed to, first through the national cancer survivorship initiative, and then through the living with and beyond cancer programme, for which I am responsible. Central to that work has been embedding in mainstream NHS commissioning a recovery package, which is a combination of interventions that, when delivered together, can greatly improve outcomes and the co-ordination of care beyond the cancer pathway, which is what we are looking at, including through better and earlier identification of the consequences of treatment for conditions such as lymphoedema.

Members will be aware that our world-class cancer strategy for England, which has another two years left to run, was published in July 2015 by the independent cancer taskforce. It recommended that NHS England should accelerate the commissioning of services for cancer survivors, including the development of a minimum service specification to be commissioned locally for all patients, based on the recovery package I just mentioned. That specification was published in April 2016 and includes provision of lymphoedema care. It was followed by £200 million of funding to support the implementation of the recovery package and other areas of the strategy, which I am sure I will talk about again in debates in this place. Those services should be provided on the basis of need, not of whether someone has had cancer.

Finally, let me highlight the research that is being undertaken. We invest more than £1 billion a year in health research through the National Institute for Health Research. The NIHR is currently supporting three important lymphoedema studies: an analysis of genes and their functions in primary lymphoedema; an investigation of the pathophysiology of breast cancer-related lymphoedema of the arm, which I mentioned; and a feasibility trial of early decongestive lymphoedema treatment for women newly presenting with breast cancer-related upper limb lymphoedema, which is very important.

As well as thanking you, Mr Gray, for sitting through what I hope has been as interesting a debate for you as it has been for us, let me thank the hon. Lady again for using her first Westminster Hall debate to raise this important issue and highlight the many challenges that people with lymphoedema face. I am confident that, by continuing to build our expertise, increasing the research I listed and ensuring that our commissioners and clinicians have the training, tools and guidance to deliver high-quality lymphoedema care, we can ensure that patients receive the treatment and support they need and deserve. As ever, I am grateful to Members. We keep everything under constant review, because ultimately we have a publicly funded health service that is there for patients. As the Minister with responsibility for primary care, I have responsibility not only for cancer but for prevention, and I am interested in anything that can help us to reduce people’s suffering and the cost to that publicly funded health service.

Question put and agreed to.