SCOTLAND IS THE TALE OF DEPRIVATION and cancer deaths going hand-in-hand. That is the story we are repeatedly told. What we don’t talk about nearly enough is what might sit between the two. Every now and then, the question is birthed from the ether: why?
Here are a few reasons we rarely get to discuss because, well, they’re not very nice.
The first starts at the very end of the cycle, which is where so many headlines chew the cud: access to treatment and, of course, its side effects. My background is surgery, and I have been taught many times by some of the UK’s top surgeons that detection and resection remain the bread and butter of surviving many cancers. Find it early, while it is still localised, and you have a much better chance of removing it and curing the patient.
Once you get further into radiotherapy and chemotherapy, things become more complicated. Both are hugely important treatments and, in the right circumstances, can be curative, but as disease advances we increasingly find ourselves trading quality and quantity of life for diminishing returns. In the UK we have gone hell for leather in maximising quantity because, unless being alive on therapy feels worse than death, our health economists and politicians alike will try to extract every last month from the Kaplan-Meier curve.
This matters because we are spending a galloping fortune too far down the line. The second-best cancer treatment is cure; the very best is no cancer at all. That is where diet, exercise, smoking cessation and screening come into their own. It is as much about personal attitude as funding.
We are profoundly ignorant about cancer, and I suspect that for as long as we fear death this is subconsciously a choice. People who can name you twenty models of Ford and tell you the last ten results of Hearts games won’t necessarily spend much detail discussing the handful of cancers which account for a huge proportion of deaths in Scotland. I know people with private pensions who smoke every day and would not dream of funding their own cancer screening while they plan their next cruise. People know they’re going to die and have absolutely no idea when that will be.
So before we get into the nitty-gritty of cancer within the NHS, I’d like to give you the best retirement plan money can buy and perhaps change your view of the world that will one day pass away.
Buy the best God-damn sandwich you can, every time.
More than once I have attended a cardiac arrest — we have quite a lot of them in A&E — and there, in the corner of the room, behind the chaos, alarms and relatives crying, the nurses broken by exhaustion, lies a lonely sandwich. Sometimes it’s a cheap one from the shop over the road that’s cheaper than Costa. Sometimes it’s a shockingly good Reuben, obese with pastrami. They all share a truth: the person who bought that sandwich was well enough to look forward to eating it, and then they just died.
You don’t know when you’ll buy your last sandwich and it may well outlive you. We simply don’t know, individually, when we will check out. That matters because it reminds us how important our life is up to that point and how we live it.
Do poorer, more deprived people look forward to the next day, or even the next year? If not, it is hard to argue that they should naturally be thinking in five-year survival terms. They may not be thinking that far ahead or even want to.
There is an obvious objection here. It is very easy for a comfortable professional to tell someone in a deprived community to stop smoking, lose weight, exercise more and think about their health in twenty years’ time. That person may be living in circumstances where tomorrow is the immediate problem. Personal responsibility matters, but so does the environment in which responsibility is exercised. If we want people to plan for the future, we probably need to build a society in which having a future feels sufficiently real to plan for.
So let’s talk a bit about the middle-class world of screening — or, to put it another way, the world in which planning to be alive five or ten years from now feels like a reasonable assumption.
As a man, there are a few runners and riders for killing me off. The first is the ketamine-sprinkled drunk driver, for which there is little defence. I have to accept that one day there is a chance I will die because of someone else’s catastrophic decision. Someone with a serious untreated mental-health crisis could kill me too, and that someone could easily be me. Of course, being British, we don’t exactly have a culture of systematic mental-health surveillance and early intervention, particularly in high-risk occupations. We largely let people roll until something breaks.
Then there are the cardiovascular risk factors. Workers of the world, for Heaven’s sake get your blood pressure checked and get the occasional ECG where it is clinically appropriate. Know your cholesterol. Know whether your blood sugar is heading in the wrong direction. While we’re at it, take a rubber to the blubber. We are guilty one and all, but carrying excess weight into your seventies plays absolute hell with joints, diabetes and cardiovascular disease.
Then get off the daily fags. An occasional cigar? Perhaps the angels can forgive you. A vape? It isn’t the same risk as smoking combustible tobacco. Twenty a day? Not so much. Most chronic lung disease is heavily smoking-driven, and if you’re grinding stone for a living, respiratory protection helps too.
It is, of course, about mindset. Where do you see yourself in five years’ time? Hopefully, not dead.
Once we’ve batted the big balls away, we can talk about screening. I honestly can’t see why people fret endlessly about cancer until they’ve made serious attempts to derisk themselves from it. It is a bit like fearing a car accident interrupting your daily session of motorway hopscotch.
Cancer screening is about picking up a lot of cancers cheaply and effectively while, crucially, not picking up things that are not cancer. You want true positives, not false positives. False positives are expensive, consume resources we might better spend elsewhere, and subject people to invasive tests that can harm them physically and psychologically.
The whole point is that when we find cancer, we want a real increase in survival or a meaningful improvement in outcomes. If I find a cancer two years earlier than expected, have I really helped that person live two years longer? Their measured survival from diagnosis may be two years longer, but not necessarily their actual lifespan. They may simply have known for two more years that they had cancer. That is lead-time bias, and it matters enormously when we assess screening.
The prostate is where this becomes particularly difficult. A PSA (prostate-specific antigen) blood test measures the level of a protein made by the prostate gland. Doctors use it to help screen for and monitor prostate cancer, as well as to check for non-cancerous prostate problems. But PSA levels can be raised for reasons other than cancer, may not be dramatically elevated in every clinically important cancer and tend to rise with age. It is not the wonderfully specific cancer detector we might like it to be. An elevated PSA can launch a man into repeat tests, MRI and biopsy; biopsies can miss cancer, and we can end up diagnosing and treating cancers that might never have harmed the patient.
That does not mean prostate cancer is unimportant. Quite the opposite. It is the most common cancer suffered by men in Scotland.
The Scotsman reported, “New statistics from Public Health Scotland show there were 37,657 new cancers registered in Scotland in 2024. For the second consecutive year, prostate cancer was the most common, with diagnoses increasing 6 per cent in a year and 50 per cent in a decade.”
This means that if we are going to screen millions of men, we should want a method that is much better at distinguishing cancers that matter from those that do not.
The UK has now made a difficult but defensible decision. As of the UK National Screening Committee’s March 2026 review, it does not recommend population screening for prostate cancer. It does, however, recommend targeted PSA screening every two years for men aged 45 to 61 with a pathogenic BRCA2 variant and a relevant family history. That is a much more nuanced position than simply saying “we don’t screen”. The remaining question is whether we can find something better for everyone else.
There are already options worth investigating. Why not be daring and run a properly funded UK trial?
Scotland, Northern Ireland and Wales have cancer outcomes that differ from England, with deprivation, lifestyle and late presentation among the factors. Give three comparable populations three different approaches: 4Kscore, Stockholm3 and a newer genomic risk model. Then add a fourth arm examining what happens when earlier detection is paired with a better pathway for treating clinically significant early prostate cancer.
Stockholm3 is particularly interesting because it combines protein biomarkers, genetic markers and clinical information. NICE has reported evidence suggesting it can improve detection of clinically significant disease and reduce some unnecessary biopsies compared with PSA-based pathways, while also noting that the evidence is still insufficient to establish its long-term clinical impact. That is precisely why a proper trial is needed.
And measure the right things. Not simply how many cancers we find. Measure clinically significant cancers, unnecessary MRI scans and biopsies, complications, treatment burden, quality of life and, ultimately, whether men live longer or better lives. If one strategy is spectacularly good, adopt it. If they are all rubbish, stop doing them. That is what evidence-based medicine is supposed to look like.
Scotland has a particular reason to try. Public Health Scotland’s latest data for 2020–2024 shows cancer mortality of 397.2 per 100,000 in the most deprived fifth of areas compared with 227.7 in the least deprived. PHS points to differences including cancer type, comorbidity and screening uptake.
If deprivation contributes to poor outcomes, Scotland should become a laboratory for improving them rather than simply a place where we measure the problem yet again.
As for waiting lists, the same argument goes for limited competitive training places for doctors and the lack of GP slots while much of what is seen is self-limiting and needn’t have been seen at all. We can debate rationing and misallocation, but these are the fruits of the red tree and they are as bitter as they are juicy. They are inevitable.
We can argue about whether resources are allocated intelligently and whether targets distort clinical priorities. We should. But we should stop pretending rationing can be abolished. You cannot simultaneously promise unlimited demand, unlimited access, unlimited staffing and unlimited money. Something has to give. The political question is where we put the rationing, how transparent it is and whether it produces the greatest possible benefit.
For those opposed to waiting lists, breadlines, ration books and whatnot, imagine where we’d all be in five years’ time without socialist targets. We’d be thriving, not surviving. Or perhaps we’d simply have found another mechanism for rationing something scarce. Either way, scarcity does not disappear because we dislike the waiting list. It merely moves somewhere else.
And so we come back to the sandwich.
For the record, I am treating myself to a luxury colonoscopy for my fiftieth birthday. This is not an argument that everyone should simply buy a colonoscopy; it is an acknowledgement that I would quite like to be around for the next few decades and am prepared to spend some money and inconvenience myself in pursuit of that objective.
Frankly, I want to live. I like being useful and productive. I like discovering the world I live in. I like posh sandwiches and I think five years ahead, though the Mounjaro means I eat less of them now.
Perhaps that is the real dividing line in our approach to health. It isn’t simply rich and poor, public and private or left and right. It is whether we believe that the person we will be five or ten years from now is sufficiently important to us that we are prepared to make sacrifices for him today.
That is an uncomfortable question for an individual. It is an even more uncomfortable question for a society.
Because if someone cannot imagine themselves being alive in five years, telling them to change their diet for their cancer risk in fifteen is not much of a public-health strategy.
So perhaps we should stop asking only why deprived people die more often from cancer. Perhaps we should ask a harder question: what kind of society makes it easier for some people to believe they have a future worth protecting?
And until we have answered that, buy the best sandwich your overtaxed income allows.
You don’t know when it will be your last.
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Photo of deluxe pastrami sandwich by annapustynnikova via Adobe Stock
