Cancer in Scotland: Waiting times, incidence and mortality

That target was last achieved at the end of 2012.

Between October and December 2022, just 71.7% of people who began treatment for a newly-diagnosed cancer had done so within 62 days of that initial referral for tests or scans.

For the second quarter in a row, the 62-day target was missed by every single health board region and for every single cancer type.

READ MORE: What happened to Scotland 800 'missing' cancer cases? 

The figures - outlined in a report from Public Health Scotland on Tuesday - have been dubbed "unacceptable" by cancer charities, as well as "shameful" and "beyond disgraceful" by the SNP's political opponents.

Performance against the 62-day cancer waiting time standard was the worst on record by the end of 2022, with the 31-day standard also missed for the second quarter in a row (Image: Public Health Scotland)

Given that cancer is the number one cause of death in Scotland, and a disease that will affect nearly half of us in our lifetime, it is worth drilling down into the statistics to see what is really going on - and why.

One of the first things to consider is how people are referred in the first place. The 62-day rule applies to people whose symptoms were detected as a result of routine breast, cervical or bowel cancer screening; who were referred by their GP or dentist; or after presenting at A&E.

Individuals with an "urgent suspicion of cancer" should be prioritised for diagnostic scans and tests such as MRI, ultrasound and colonoscopies. Ideally, they should wait no longer than two weeks.

This is where most of the bottlenecks are occurring.

Partly, it is an issue of increased demand. As the PHS report notes, these urgent referrals "have continuously exceeded pre-Covid levels since [the second quarter of] 2021".

In the final quarter of 2022, there were 4,262 such referrals - an increase of 14.5% compared to the same period in 2019.

The figure excludes cases deemed "clinically complex" - where diagnosis or treatment is particularly difficult - as well as any patients who refused, or died before, treatment. In total, 92 cases fell into these categories.

Cancer referrals have steadily increased and now exceed pre-pandemic levels (Image: PHS)

The feedback from health boards also points to a range of obstacles slowing patients' progress from referral to diagnosis, and diagnosis to treatment.

NHS Dumfries and Galloway cited demand for its only CT scanner and "significant increases in MRI requests for patients with possible prostate cancer".

Several health boards reported staffing shortfalls due to vacancies or sickness absence, with NHS Greater Glasgow and Clyde describing "workforce challenges across all specialties".

Global shortages of a radioisotope used in bones scans was also responsible for "extended delays", particularly for prostate cancer patients.

Just 42% of patients who started treatment for prostate cancer in the final three months of 2022 had done so within 62 days of referral.

READ MORE: Why are Scotland's cancer deaths lower in 2022 than before the pandemic? 

Once a diagnosis and decision to treat has been made, half of patients in Scotland still begin cancer treatment within five days, and 94% within 31 days (the target is 95%).

In October to December 2022, a total of 6,757 people began cancer treatment - an increase of 5.8% versus the same period in 2019.

So demand is increasing - both from patients who have cancer which requires treatment, and from patients with suspected cancers who require investigation.

However, given that the latter has increased more rapidly over the past three years than the former, one question is whether we can - and should - be doing more to reduce unnecessary referrals?: those patients referred with an "urgent suspicion of cancer" who turn out not to have cancer at all.

Patients with an urgent suspicion of cancer should be prioritised among referrals for diagnostic tests and scans (Image: PA)

Many of these will be false positives thrown up by screening programmes where there is a careful balance to be struck between the benefits of catching disease early versus the risk of needless investigations on healthy people and overloading diagnostic pathways in such as way that too many genuinely sick people wait too long.

Between May 2020 and April 2022, for example, a total of 29,228 people who returned a stool sample for routine bowel cancer screening received a positive result - triggering an automatic referral for a colonoscopy.

Of these, 21,921 patients (75%) actually took up the offer of a colonoscopy, but only 1,132 actually turned out to have cancer.

This may seem like a poor 'hit rate' - but on the other hand, it has to be weighed against the fact that three in five of these cases (61%) were diagnosed at stages one or two, when the disease is most curable.

READ MORE: Are excess death rates in Scotland really soaring after the pandemic?

Ironically, given the concerns about the impact of the pandemic on cancer, average waiting times from referral for tests to start of cancer treatment were actually the fastest of the past three years (a median of 37 days) in April to September 2020, when screening was paused, compared to 49 days by the end of 2022.

The median waiting time between an urgent referral and start of cancer treatment was 37 days from April to September 2020, when routine screening was paused (Image: PHS)

Overall, the long-term legacy of the Covid years on cancer outcomes is not yet clear.

A separate report from PHS last week found that 35,379 new cancer cases were registered in Scotland in 2021.

Time lags in data collection mean that we will not know the incidence for 2022 until March 2024, but we do know that the cancer rate in 2021 (adjusted for the population's changing age and size) was 3.3% higher than it had been in 2019.

However, there was no sign that common cancers such as lung or breast had experienced a surge in later-stage diagnoses.

Separate figures also indicate that the cancer mortality rate in Scotland during 2022 was actually 4.9% lower than the five-year average.

There may be a range of possible explanations, from new survival-extending drugs to elderly people who would have gone on to develop cancer having died instead from Covid in 2020. 

Unless we can reverse the deterioration in cancer waiting times we see today, however, it may be impossible to avoid poorer outcomes in the years ahead.