The C-word, culture and class: why the breast cancer screening fails South Asian women

By: Maryam Sayeed

As a British Pakistani doctor, my family member knew who to call, the questions to ask and which referral to push for. Yet, even with that abundance of knowledge, the cancer diagnosis still felt like stepping into the unknown, into freefall. Too much knowledge can be mentally overwhelming but most ethnic minority women in the UK may not have this privilege to begin with. If one doesn't know the ins-and-outs of the system, doesn’t speak the language with fluency or has grown up to stay mute about the cancer as though a cursed death sentence, how are they expected to navigate the stream of letters, appointments and medical jargon that make up breast cancer screening? 

Recent figures suggest a drop in uptake of breast cancer screenings, with London specifically recording just a 62.8% uptake in 2024, falling short of the 70% benchmark set by the NHS. The government frames the problem as a matter of personal responsibility and awareness, blaming misconceptions about screening rather than the design of the system itself. Yet, I believe this narrative glosses over the embedded, systematic issues and fundamentally, the cultural barriers that limit the scalability of uptake. A one-size-fits-all approach of cancer screening lets down ethnic minority women, spiralling into lower uptake rates, negative attitudes towards screening and a later, more severe stage of diagnosis. South Asian communities, in particular, often present earlier signs for breast cancer and die younger with more aggressive symptoms. 

The infrastructure of screenings looks fair on paper. Women from ages 50-53 are invited for a mammogram, then recalled every 3 years until the age of 71. In theory, this should catch cancers early. Yet in practice, the invitation model is riddled with blind spots. Take the cost of living crisis for example, thousands are moving out of London while others move in, creating a relentless population churn. In the midst of this chaos, little room is left for the health service system to regularly track and update their eligible patient list. Letters drift to old addresses or pile up in crowded flats where no one has time or confidence to decode them. 

Meanwhile, the government is investing £70 million into a digitalised transformation of mammogram screenings, using AI to capture more precise and quick images for diagnosis. Of course, any improvement to screening is important but this misses the point. One can only benefit from this upgrade if they make it through the door in the first place. Whilst modernising the process of it, it’s clear policy makers have skipped a couple steps in the pathway, ignoring the initial invitation of screening that still exists as a maze of GP lists and posted letters that work best for already well-informed patients rather than for everyone. At the end of the day, this flaw doesn't fall evenly- it lands hardest on women who are pushed to the edges of the system, it lands on ethnic minorities.

Underneath the headline figure, the inequalities are stark. Studies highlight that British South Asian screening is lower than the national average. Qualitative research offers clues: many Bangladeshi Muslims speak Sylheti which is rarely used in written form, making translated letters or leaflets in standard Bengali do little. Layered onto this are powerful taboos. Cancer involving intimate body parts- breast, bowel or cervical- are shrouded in embarrassment and shame. Silence feeds ‘cancer fatalism’- the idea that cancer is predetermined, terminal and once you have it, that's the end of the story. So it’s no wonder that so many women feel quietly vulnerable and closed off, dreading a letter they can’t understand or might just ignore. 

This is precisely where policy should intervene. Yet the system reflects the biases it rests on. Many genetic research studies that examine risk profiles and the normal ages for onset or screening intervals have historically under-represented ethnic minorities, traditionally having participants from white European backgrounds who are familiar with the healthcare system. Ultimately, this evidence is embedded into healthcare policy, treating minority communities as outliers rather than central participants. Nonetheless, emerging studies are now increasingly suggesting that lowering the minimum age of 50 to 45 for invitation screening can double the chances of detecting breast cancer for women of both Pakistani and Bangladeshi heritage in our communities. Yet, policy has been painfully slow to adapt.  

In light of this research, London’s 62.8% screening rate is a predictable outcome of the healthcare system that exists today. It's far from a glitch or a mere shortfall. It's the output of a framework engineered for women from a stable and English-speaking background, leaving ethnic minorities to navigate illness in the dark, accompanied only by cultural stigma and cancer fatalist ideas looming over them. When these women are diagnosed later and die younger, the question isn’t about why they fail to attend their appointments or a lack of awareness. It’s why health policy continues to pretend that universal rules, built around a skewed imagined average patient, can ever fix deep inequalities. 

Image: Dr Deepak Chhabra