Download Lung Cancer Survival: Key Findings

Lung Cancer in Wales
Lung cancer survival and survival by stage
Key findings
1.
Why prioritise lung cancer?

Lung cancer is one of the four most common cancers in Wales and the
commonest cancer worldwide. There were 2,370 new cases diagnosed in
Wales during 2012, equivalent to around 45 cases each week, and accounting
for 13 per cent of all new cancer cases.

Lung cancer is the third most common cancer in men, and the second most
common cancer in women in Wales. The number of new cases in women is
approaching the number in men. We estimate that for 2012, Wales’ women
had the third highest incidence rate of 40 European countries.

Lung cancer can be prevented. Smoking accounts for around 36 cases per
week in Wales, mainly in smokers but also in non-smokers. Around 9 cases
per week can be linked to other factors such as radon, asbestos, particulate
air pollution and occupational exposure, and silicosis, again in smokers and in
non-smokers. The risk from radon and asbestos is greatly multiplied by the
addition of smoking. Effective population-level measures exist to control
tobacco and most of the other risk factors.

Each year in Wales, lung cancer is responsible for more deaths than bowel
and breast cancers combined.
2. Lung cancer survival in Wales and the rest of Europe
Lung cancer has a very low survival rate

Survival from lung cancer is poor compared to most other common cancers.

Around half of all people with lung cancer in Wales die from the disease
within six months of diagnosis, almost three-quarters within a year.

Lung cancer can be cured or survival improved if it is diagnosed early,
although many other factors play a part in addition to early diagnosis.
Survival in Wales is almost the lowest in Europe

Wales had the 28th lowest lung cancer one-year and five-year survival rates
in both men and women of 29 countries in the Eurocare study.

If the European average lung cancer survival in the Eurocare study applied in
Wales during 2012, an approximate estimate of
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over 120 more women might have survived at least a year
about 135 more men might have survived at least a year
Welsh Cancer and Intelligence and Surveillance Unit
Lung Cancer in Wales
Lung cancer survival and survival by stage
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
over 65 more women might survive at least five years
about 50 more men might survive at least five years
If the best lung cancer survival in Europe in the Eurocare study applied in
Wales during 2012, an approximate estimate of
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well over 155 more women might have survived at least a year
well over 185 more men might have survived at least a year
over 113 more women might survive at least five years
about 77 more men might survive at least five years
One-year lung cancer survival in Wales is consistently the lowest
of all UK countries for men and women – the slight increases since
1999 are the smallest in the UK, although there was a decrease
for men in Northern Ireland

During all periods between 1999 and 2009, one-year lung cancer survival
rates in Wales remained the lowest of all the UK countries for both men and
women, but the differences were small.

Although one-year survival increased by only a few percentage points across
the UK countries for women, the smallest absolute increase was in Wales.

One-year survival in men increased across the UK, except for a decrease in
Northern Ireland – of the increases, Wales had the smallest.

There was little improvement in five-year survival across UK countries
between 1999 and 2005 - it remains very low in all the countries, although
Northern Ireland has the highest for men and women, but with little
difference between the other countries.
3. Lung cancer survival trends in Wales
Almost a third of women in Wales survive at least one year, only a
quarter of men do so – a mere 6.5 per cent of all survive for five
years or more

Most people with lung cancer die within the first year after diagnosis or are
diagnosed at the time of death.

Only 28 per cent of people diagnosed with lung cancer in Wales during 2007
to 2011 survived at least a year.

Of people diagnosed between 2003 and 2007, a mere 6.5 per cent survived
for five years or more.

There was an increase in one-year survival in both sexes from 2000 to 2011,
but the size of the absolute increase in women was over one and a half times
that in men so that most recently almost a third of women survive at least
one year, but only a quarter of men do so.
Welsh Cancer and Intelligence and Surveillance Unit
Lung Cancer in Wales
Lung cancer survival and survival by stage

There was almost no increase in five-year survival from 2000 to 2007 in
either men or women, although the survival in women remained slightly
higher than men.
Survival dramatically decreases with increasing age
4.

There is a clear pattern of decreasing one-year and five-year survival with
increasing age.

One-year survival in the 45-54 year-old group is almost twice that in the 75+
age group, although most cases occur between ages 65 to 79.

There has been a gradual improvement in one-year survival in all age groups.

One-year survival is lower in men than women for all age groups - the
difference is largest in the 55-64 year-old age group (9.8 percentage points),
and smallest in the 75+ age group (2.6 percentage points) in 2007-2011.
How is area deprivation related to survival?
Overall, survival varies little by area deprivation, unlike the wide
inequalities in incidence, but the survival by stage at diagnosis
does vary by area deprivation
5.

The relationship of survival from lung cancer with deprivation is different to
that of incidence, with little or no gradient in overall one-year or five-year
survival as area deprivation increases.

However, survival does vary by area deprivation for different lung cancer
stages at diagnosis (see below).
Survival in different lung cancer types
One-year survival from non-small cell lung cancer is higher than
small cell lung cancer, but the difference is small

In men, small cell lung cancer one-year survival has been consistently lower
than non-small cell.

In women, small cell one-year lung cancer survival is now lower than nonsmall cell, but was previously higher than it.

Women’s one year survival from small cell lung cancer is higher than both
non-small cell and small cell in men.

There have been smaller improvements in one-year small cell survival
compared to non-small cell for men and women.

Five-year survival is poor in both types, but is worse for small cell than nonsmall cell in men and women.
Welsh Cancer and Intelligence and Surveillance Unit
Lung Cancer in Wales
Lung cancer survival and survival by stage

Whereas most recently, five-year survival for non-small cell lung cancer is
higher in women than men, the opposite is true for small cell lung cancer,
although in 1999-2003 small cell survival was higher in women.
6. Variation in lung cancer by stage at diagnosis
Lung cancer stage at diagnosis is strongly related to one-year
survival

One-year survival for stage 1 disease (78 per cent) is approximately fiveand-a-half times that from stage 4 disease (14 per cent).

One-year survival is modestly higher for women than men for all stages apart
from stage 2 where survival is more similar, but slightly higher in men.
For potentially treatable stage 1 disease one-year survival is 23
per cent higher in the least deprived areas compared to the most
deprived

For stage 1 disease although almost three-quarters survive at least one year
in the most deprived areas of Wales, there is a steep gradient with 91 per
cent surviving in the least deprived areas – that is 23 per cent or 17
percentage points higher. There is a ten percentage point variation for stages
2 and 3 also, but no clear gradient moving from most to least deprived areas.
7. Health board populations and lung cancer survival
The highest health board one-year survival rate is for the Betsi
Cadwaladr population - the only one statistically significantly
higher than Wales’ survival with no health board significantly
lower

There is a modest seven percentage point difference in survival between
health board residents with the highest (Betsi Cadwaladr) and lowest
(Aneurin Bevan) one-year lung cancer survival (2010-2012).

The highest survival in Betsi Cadwaladr (34.7 per cent) is the only one that is
statistically significantly higher than the 2010-2012 one-year survival for
Wales (30.9 per cent), and no health board is statistically significantly lower.

When each stage at diagnosis is considered separately wider differences in
one-year survival between health board area of residence are apparent.

Residents of Cwm Taf have the highest stage 1 one-year survival (86.2 per
cent) - over eight percentage points higher than stage 1 survival for Wales,
and almost 15 percentage points higher than the lowest (Cardiff and Vale).
8. Explaining variations and inequalities in survival
Welsh Cancer and Intelligence and Surveillance Unit
Lung Cancer in Wales
Lung cancer survival and survival by stage
Poor lung cancer survival in Wales appears to be due to a number
of factors that need to be better understood, mapped and
quantified. They possibly include:
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a low surgical resection rate of early stage patients
too many patients presenting as emergencies
variations in lung cancer staging practices
GPs and patients delaying referral
GP access to specialist advice
waiting times for x-rays
Our ageing population and higher prevalence of other illnesses may also
play a part. We will be examining some of these issues later in our series
of reports on lung cancer in Wales.

Presentation at an earlier stage is one predictor of improved survival – the
survival rates by stage for Wales show this with survival rapidly decreasing in
later stages.

As in most other countries, the majority of people diagnosed with lung cancer
in Wales present at a late stage – a major factor in the overall low survival
from lung cancer.

One explanation for the predominance of late presentation is the natural
history of the disease - it can move from stage 1 to 4 very quickly and
without treatment even stage 1 disease can be rapidly fatal. Symptoms tend
to be absent, non-specific, or have little relationship to disease stage.

The International Cancer Benchmarking Partnership (ICBP) 1 study showed
the proportion diagnosed at an early stage for non-small cell lung cancer was
slightly lower in the UK and Denmark compared to Australia, Canada, Norway
and Sweden. All had the majority of cases diagnosed at a later stage.
Similarly, within Wales the variation in stage at diagnosis between health
board populations is not very wide.

Reasons for Welsh patients presenting slightly later than elsewhere are not
entirely understood. The ICBP 2 study showed that in Wales and the rest of
the UK, people are more likely than people in Australia, Canada, Denmark,
Norway and Sweden to say that embarrassment and not wanting to waste
the doctor’s time would stop them going to the doctor with a possible cancer
symptom. Yet most people in the UK and Wales held positive views about
cancer, for example the benefits of early diagnosis and improved cancer
outcomes. However, negative beliefs about cancer, such as “cancer is a death
sentence”, were prevalent among people with lower levels of education or
living in deprived areas of Wales. There is evidence that negative beliefs may
be linked to delayed presentation.

Once patients present to primary care, other reasons for slightly later stage
at diagnosis in Wales may lie at the GP and hospital care boundary along with
access to diagnosis. The ICBP 3 study (about to be published) showed that
Welsh Cancer and Intelligence and Surveillance Unit
Lung Cancer in Wales
Lung cancer survival and survival by stage
GPs in Wales, compared with those in other UK countries and Canada,
Australia and Scandinavia, opted to investigate potential symptoms of lung
cancer at a later stage. They also reported longer waiting times for x-rays,
poorer access to specialist advice, and less ability to hasten tests if cancer is
suspected.

If stage at diagnosis was the only major factor affecting survival then areas
or countries with different stage distributions - and so different overall lung
cancer survival - should still expect survival for each stage to be similar. But
there is wide variation in survival by stage between Welsh health board
populations and between countries, as shown in the ICBP 1 study - UK
survival figures were among the lowest at all stages compared to the other
countries. Add to that stage distribution varies little between them but there
is wide variation in overall survival, then factors other than stage distribution
must play a part.

The point of access to the NHS at the time of diagnosis appears to be a
factor, over and above the stage at diagnosis. Around half the people
diagnosed with lung cancer present as an emergency and have worse
outcomes than other routes into the NHS in Wales. This proportion of
emergencies is higher than in England.

One of the major issues in relation to survival is timely access to potentially
curative treatment for people with early stage disease if they wish and are
suitable. This may include surgery, radiotherapy or chemotherapy, depending
on cancer type. UK countries have low surgical resection rates compared to
some other European countries. Wales has a significantly lower surgical
resection rate than either England or Scotland. It is not clear why this is, but
other existing illnesses (co-morbidity), general health, surgery not being
offered to older people, patient choice or access to and capacity of specialist
surgical services may all play a part, as well as differences in staging
practices.

An ICBP team is examining the effect of access to treatment on the
international variation in survival rates. We are participating in the ICBP 5
study to examine the contribution of co-morbidity
Welsh Cancer and Intelligence and Surveillance Unit