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Integrated Strategic Needs Assessment Local Strategic Review of Cancer Corporate Research Joint Intelligence Third Floor Town Hall Blackburn BB1 7DY Integrated Strategic Needs Assessment (ISNA) the answer to Joint Strategic Needs Assessment (JSNA) Version 1.0 - 19th November 2012 Version 1.1 – 1st February 2013 Version 1.2 – 24th June 2013 Cancer 1. Defining the issue A Cancer is an uncontrolled growth of abnormal cells, which is malignant – i.e. liable to spread to surrounding tissues and other parts of the body1. Typically the cancer will take the form of a tumour, although some tumours are benign (i.e. not malignant), and some cancers, such as leukaemia, do not form a solid tumour. A more technical term which describes all cancers is malignant neoplasm. The ‘big four’ cancers - Lung, Bowel (or Colorectal), Breast (female), and Prostate – account for roughly half of new cases (54% in the UK in 2010 – see Figure 1), and almost half of cancer deaths (47% in England in 2008-10).* Every new case of cancer is logged with a regional Cancer Registry, such as the North West Cancer Intelligence Service (NWCIS). This means that we have reliable statistics not only on cancer mortality (i.e. death rates), but also on incidence (the Figure 1 –Cancer incidence (new rate at which new cases are diagnosed), and survival (the percentage of 2,† cases of cancer), UK 2010 people who are still alive one, five or more years after a cancer diagnosis). (Source: Cancer Research UK) Source: The King’s Fund (2011)3 Table 1 – Measures of cancer outcome 2. Why is this issue highlighted? Cancer mortality Each year in England, around 130,000 people die from cancer, which represents over a quarter of all deaths. The ‘Big Four’ cancers between them account for just under half of this number. Blackburn with Darwen has typically had between 300 and 350 cancer deaths each year; the latest (2011) figure was 298. Figure 2 - Proportion of deaths from Cancer, all ages, M & F, 2009-2011, Blackburn with Darwen and England Source: UKCIS and ONS * Source: IC Indicator Portal. Cancers other than the ‘Big Four’ are represented by the Rarer Cancers Foundation (www.rarercancers.org.uk/) and ‘Cancer52’ (www.cancer52.org.uk, named when they accounted for 52% of cancer deaths). † ‘All cancers’ usually omits non-melanoma skin cancers, which are inconsistently registered and seldom fatal. 1 Why is this issue highlighted? Nationally, just under a half of cancer deaths are in people aged under 75 (in Blackburn with Darwen in 2011, the proportion was exactly 50%). Cancer accounts for a higher proportion of deaths in this age-group than it does in older people. Incidence Between 1975-77 and 2008-10, the incidence rate of new cases of cancer in Great Britain rose by 22% in males and 42% in females, although much of this rise was before the late 1990s.4 Although the incidence rate now shows signs of stabilising, the number of new cases each year is predicted to continue to rise as the population grows and ages further. Research has predicted that although the rate will hardly change at all, the number of new cases in the UK will rise from 298,000 in 2007, to 374,000 in 2020, and 432,000 in 2030.5,6 Incidence and mortality compared Figure 3, adapted from the Cancer Research UK website, shows how the rising incidence in recent years contrasts with the falling mortality rate over the same period. Rates for Blackburn with Darwen, from 1993 onwards, have been superimposed for comparison. Figure 3 - Cancer incidence and mortality in Great Britain/UK (all persons, all ages), showing Blackburn with Darwen for comparison (1993 onwards) Source: Cancer Research UK and IC Indicator Portal Figure 4 illustrates the extent to which new cases outnumber cancer deaths in Blackburn with Darwen. Figure 4 - Cancer: New Cases and Deaths in Blackburn with Darwen in five years (2006-2010) Source: IC Indicator Portal 2 Why is this issue highlighted? Survival Mortality rates depend on both the rate of incidence of new cases of cancer, and on survival rates once cancer has been diagnosed. Interpreting survival The survival rate essentially tells us the proportion of patients who are still alive 1 or 5 years after diagnosis. However, it is usually adjusted to allow for the fact that some of these people would have died anyway, for reasons other than cancer. The adjusted version is known as the relative survival rate.7 Survival rates are chiefly a reflection of the quality of care provided once cancer has been diagnosed. However, they will also be influenced by how advanced the cancer was when diagnosed, and 1-year survival rates in particular are considered to be a good proxy for early detection.* Comparison with Europe The Public Accounts Committee in 2011 heard that 10,000 of the annual 130,000 cancer deaths in England could be avoided if survival rates matched the best in Europe.8 Just reaching the European average survival rate would save 5000 lives per year.9 Importance of early diagnosis The committee also learned that it was mainly on one-year survival rates that England compared poorly. Those who survived twelve months in England had as good a chance of reaching five years as anywhere else. The inference is that this country’s problem lies chiefly with late presentation and diagnosis. Too often, the cancer is at an advanced ‘stage’ before it is diagnosed. For instance, fewer than 10% of cases of colorectal cancer are diagnosed at the earliest stage (‘Stage A’).10 Table 2 gives a stark illustration of the difference this can make to survival prospects: Table 2 - Five year survival by stage for colorectal, breast, lung and prostate cancer Source: The King’s Fund (2011)3 Early diagnosis is a fundamental aspect of the Government’s cancer strategy.9 The National Awareness and Early Diagnosis Initiative (NAEDI) has been set up to tackle the inhibitions and barriers which can stand in the way of patients presenting early with symptoms and receiving a prompt diagnosis (see http://info.cancerresearchuk.org/spotcancerearly/naedi/).11 * A proxy is needed because of inadequate recording of the stage the cancer has reached when diagnosed (‘staging’ data). For cancers diagnosed in 2007, only the Eastern England cancer registry achieved an acceptable 70%, and our own NWCIS 8,18 was worst of all with only 15%. Since then, the registries have collectively committed to recording staging data for 70% of 11 all cancers diagnosed in 2012, and they expect to be well on the way to achieving that by September 2013. 3 Why is this issue highlighted? Living with cancer As Figure 3 and Figure 4 suggested, each year many more people develop cancer than die of it. As a result, the number of people alive who have ever had a cancer diagnosis (cancer survivors) has been increasing at about 3% per annum. It is estimated that there were about 2 million cancer survivors in the UK in 2009, and their number is expected to grow by approximately 1 million each decade from 2010 to 2040.12 Already almost two-thirds of cancer survivors are over the age of 659, and by 2040 it is estimated that almost a quarter of this age-group will be living with a cancer diagnosis.12 Approximately 49% of cancer survivors in this category have at least one other chronic condition too.13 Even for patients who are apparently ‘cured’ of their cancer, the accompanying fears and the strains upon mental health, finances and relationships can last for many years.14 Research by Macmillan has revealed the extent of isolation among cancer patients, with almost one in four reporting that they lack support from family and friends during their treatment and recovery.15 Traditional follow-up services, often consisting of little more than outpatient appointments, were established in an era when, it has been said, ‘if you lived, it was almost a bit of a bonus”.16 They are now widely regarded as inadequate for today’s cancer survivors. Cost of cancer Cost to society According to Programme Budgeting data17, the cost of NHS cancer care in England in 2011-12 stood at £5.5bn, or just under 6% of total NHS spending. This calculation, however, does not include the cost of screening, diagnostics and primary care activity (some of which is consumed by people who turn out not to have cancer).18 Neither does it attempt to reflect the cost to the wider economy, such as the lost productivity and earnings of patients and carers. Estimates of the total economic cost of cancer have been made by the Policy Exchange (a centre-right think tank) in 201019, and more recently by researchers at Oxford University.20 The Oxford study concluded that cancer was costing the UK economy over £15bn a year (Table 3), and argued that the cancers with the highest economic costs should be a priority for investment in research. Table 3- Estimated cost of cancer to the UK economy (Oxford University, 2012) However the cost is estimated, it is generally agreed to be on an upward trend. A report from BUPA predicts a 62% rise in the UK cost of cancer diagnosis and treatment from 2010/11 to 2020/21, across the NHS, private and voluntary sectors combined. This reflects not only the rising caseload, but the development of ever more expensive technologies and treatments.21 Cost to the individual Research by Macmillan has shown that over 80% of cancer patients are hit financially by their condition, suffering a net loss of £570 per month on average (described as equivalent to ‘a second mortgage’).22 This is made up of added expenditure incurred as a result of their condition (e.g. hospital travel and extra fuel bills), and/or loss of earnings through inability to work. 4 Why is this issue highlighted? Government policy Strategies and guidance The Labour government’s Cancer Reform Strategy of 200723 set out to address the challenge of cancer by improving outcomes across six areas: Prevention Improving patients’ experience Earlier diagnosis and treatment Reducing cancer inequalities Access to cost-effective treatments Delivering care in the most appropriate setting When the National Audit Office18 and Public Accounts Committee8 assessed progress against the Cancer Reform Strategy in 2010-11, they found that there were still significant weaknesses in early diagnosis and survival, wide and unexplained variations in performance and cost, and key gaps in the quality and availability of data. The Cancer Reform Strategy was superseded in January 2011 by Improving outcomes: a strategy for cancer9, setting out the Coalition government’s plans to save an additional 5000 lives per year by 2014/15. The major priorities laid out in the new strategy are broadly the same as before: Prevention and earlier diagnosis Better treatment Quality of life and patient experience Reducing inequalities The latest major cancer guidance from the Department of Health is Living with and beyond cancer: taking action to improve outcomes (March 2013)24. This document explains the new and growing importance of services for cancer survivors, and presents key messages for commissioners and providers based on the emerging evidence about this often overlooked aspect of cancer care and rehabilitation. Outcomes frameworks In the future, we can expect that the focus of attention will be upon those cancer indicators which feature in the Department of Health’s new NHS Outcomes Framework25 and Public Health Outcomes Framework26, and the CCG Outcomes Indicator Set27 against which clinical commissioning groups will be held to account: Table 4 - Cancer indicators included in Outcomes Frameworks NHS Outcomes Framework Indicator 1-yr survival for all cancer in adults 5-yr survival for all cancer in adults 1-yr survival for breast, lung and colorectal cancer combined 5-yr survival for breast, lung and colorectal cancer combined 5-yr survival for all cancers in children Under-75 mortality rate from cancer Rate of under-75 cancer mortality that is considered preventable % Cancer diagnosed at Stage 1 and 2 Cancer screening coverage - breast Cancer screening coverage - cervical Public Health Outcomes Framework CCG Outcomes Indicator Set 5 Why is this issue highlighted? 3. Who is at risk and why? Figure 5 – Major risk factors for cancer Causes 28% of all UK cancer deaths28 (down from approximately 50% 29) Causes c. 90% of lung cancer deaths in men and 80% in women28 Behind nearly 20% of new cases of cancer in UK30 Responsible for approx. 4% of new cases each year in UK, including cancers of mouth & throat, bowel and breast.30 Jointly responsible for approx. 18% of new cancer cases each year in UK.30 Overweight and obesity behind approx 17000 new cases of cancer p.a. in UK.30 In non-smokers, cancer mortality is 40% higher among obese than non-obese31, and 10% of cancer deaths are obesity-related.32 Controversial, but thought to account for 4.7% of new cases each year.30 Incidence and mortality generally higher in deprived groups (breast cancer an exception).33 Could save > 2600 deaths a year in England if all cancer patients had survival rates of most affluent quintile.34 Biggest single risk factor. Nearly ⅔ of cases diagnosed in UK are aged 65+35 Men are at significantly higher risk from nearly all the cancers that affect both sexes.36,37 BME risk generally lower than White, with some exceptions (e.g. Asian people 1.5 to 3 times more likely to get liver cancer)38 E.g. 10% of breast cancers in developed countries are due to genetic predisposition.39 6 Who is at risk and why? Modifiable risk factors The precipitating factors which we can (arguably) do something about are known as modifiable risk factors. As shown in Figure 5, examples include lifestyle factors such as smoking, drinking, diet and exercise. Several of the facts and figures in Figure 5 come from a major new study commissioned by Cancer Research UK, which explored fourteen modifiable factors and calculated the proportion of new cases of cancer attributable to each. Its findings are reported in a special 81-page supplement to the British Journal of Cancer30, as well as on the Cancer Research UK website itself40, and are summarised in Figure 6: Figure 6 - Number and % of cancer cases in the UK attributable to different modifiable risk factors (2010) The results are also available broken down by different types of cancer, as summarised in a large and colourful poster available from Cancer Research UK.41 Together the fourteen factors account for over 90% of cases of some cancers (e.g. cancer of the oral cavity, or the larynx). However, they do not help to explain any of the incidence of prostate cancer. Source: British Journal of Cancer30 Interpreting the findings Lifestyle factors are often strongly linked with each other, so that, for example, people in disadvantaged socio-economic groups are much more likely to smoke42, and people who smoke are also more likely to have a poor diet and exercise less.43 The researchers on the Cancer Research UK project have tried to disentangle these effects where possible, so that each percentage in Figure 6 represents the proportion of new cancer cases that could be averted by eliminating the risk factors one at a time. However, a given case of cancer could sometimes have been avoided in more than one way. Because of this overlap, the amounts in Figure 6 cannot simply be added up. The number of cases attributable to all 14 factors put together is approximately 134,000 (not 165,847), and the percentage is 42.7% (not 52.6%). Caveat It is important to appreciate that the ‘elimination’ of a risk factor is a hypothetical concept. Even if everybody gave up smoking tomorrow, the reduction in new cases of cancer would be gradual over many years. More than 50% of new cases of bowel cancer are attributed to lifestyle and environmental factors, but the authors themselves caution that only about half of this burden can realistically be prevented over the next 20 years. Deprivation The National Cancer Intelligence Network (NCIN) estimates that there could be as many as 14,000 fewer cases of cancer each year in England if everybody was as healthy as the least deprived.44 Overall, the most disadvantaged have: Higher cancer incidence and mortality Lower cancer awareness Lower screening uptake45 Lower 1- and 5-year survival A more recent study in London appears to confirm that the uptake of breast screening in particular is lower in deprived areas.45 When a map of age-standardised cancer mortality across England is shown alongside a map of deprivation, obvious similarities can be seen (Figure 7): 7 Who is at risk and why? Figure 7 - Cancer mortality 2007-09 and Index of Multiple Deprivation (IMD) 2010 Age-standardised mortality rate – all cancers, all persons, all ages, 2007-09, PCT level Index of Multiple Deprivation 2010, average score, PCT level Source : APHO National Cancer e-Atlas Source : ChiMat The relationship between deprivation and cancer mortality is believed to be largely attributable to lifestyle factors, particularly smoking, but later presentation and diagnosis in deprived groups could also be playing a part.44,46 A report from the North West Cancer Intelligence Service examines how inequalities in cancer outcomes are related to deprivation patterns within the region.47 Unmodifiable risk factors Unmodifiable risk factors are those which are essentially biological, such as age, gender and ethnicity. They can, however, be accompanied by behavioural factors and attitudes, which complicate the picture. Age and gender The influence of age and gender upon cancer incidence is graphically illustrated in Figure 8: Figure 8 - Incidence rates per 100,000 population for all cancers by age-group (UK, 2008-10) Source: Cancer Research UK48 Nationally, the numbers of cases and deaths in males and females are not very different, but given that women live longer, this means that men shoulder more than their ‘fair share’ of the cancer burden.46,49 After standardising for age, men have a 14% higher incidence rate and 37% higher mortality rate than women.49 It is widely assumed that men are later to seek advice for possible cancer symptoms than women, although the NCIN concedes that the research evidence for this is rather thin.46 Cancer mortality is higher in the 75+ age-group, which may be partly explained by older people being less likely to receive intensive cancer treatments. This is justifiable if they are too frail or otherwise ill to withstand them, but evidence suggests that such treatment decisions are too often based on chronological age alone.50 Ethnicity Research by the National Cancer Intelligence Network (NCIN) in 2009 found that most BME groups, including Asian males and females, had a lower risk of getting cancer than the White population.38 For Asian groups, this was also true of each of the ‘Big Four’ cancers individually. The only cancer posing a uniformly higher risk to Asian people than to the White population, across both sexes and all age-groups, was liver cancer. However, new research at Sheffield University has found a marked increase in the incidence of breast cancer among Asian women in Leicester, rising from 45% below the average for white women in 2001-04, to 8% above by 2005-09. It concludes that South Asian women should no longer be considered to be a low-risk group.51 Furthermore, the risk of poor cancer outcomes in BME communities is higher than it needs to be, due to a generally lower than average awareness of cancer, and lower uptake of screening programmes. The NCIN suggests that cultural factors and deprivation both play a part in this.46 8 Who is at risk and why? 4. Level of need in the population Caveat There are often small discrepancies between cancer rates taken from different sources, but currently the statistics are in an even greater than usual state of flux. This is due both to NHS reorganisation and to the fact that the 2011 Census showed that existing population estimates for 2002 thru 2010 were incorrect (too low in the case of Blackburn with Darwen). Revised population estimates, issued at the end of April 2013, have yet to find their way into any of the published cancer indicators, so all of them involve some degree of improvisation. With various conflicting versions in circulation, the rates quoted in this section, and at the back of the report (Figure 36 to Figure 38), should be interpreted as a useful, but imperfect, guide to the ‘big picture’. Quick overview Figure 9 - 'Tartan Rug' cancer summary (Blackburn with Darwen, all ages, v. 151 PCTs) One way of giving a NB – shading does not imply statistical significance Source: UKCIS quick overview of key cancer indicators is to draw a ‘tartan rug’, comparing the local area to its counterparts around the country.52,53 Figure 9 suggests, for instance, that Blackburn with Darwen’s high death rate from bowel cancer arises not so much from high incidence, as from relatively poor 1-year survival..* Cancer mortality Headline 3-year rates Figure 36 (in ‘Key Indicators’ at the back) summarises mortality rates for 2009-11 from the ‘Big Four’ cancers and from all cancers combined. The UK Cancer Information System (UKCIS) is understood to have used the original population estimates for 2009 and 2010, so in the case of Blackburn Figure 10 - Under-75 cancer mortality rate with Darwen these rates may be slightly too high. They show that Blackburn with Darwen has a significantly higher than average death for Blackburn with Darwen (2009-11), as depicted on 'Longer Lives' website rate for all cancers combined and for lung cancer, but that its mortality rate from prostate cancer is the lowest in the NW. A different version of the 2009-11 under-75 mortality rate for all cancers features in the Public Health Outcomes Framework, and in the new ‘Longer Lives’ website (http://longerlives.phe.org.uk and Figure 10). For Blackburn with Darwen, this rate is lower than the UKCIS estimate, and not significantly worse than England. However, it is probably slightly too low, because of the different way in which the 2009 and 2010 populations have been improvised. where 150th is worst Under-75 mortality for single years The premature cancer mortality rate in the NHS Outcomes Framework is calculated for single years, and published by the HSCIC.54 The 2011 rate for Blackburn with Darwen is 105.4 per 100,000, down from 125.5 in 2010. This apparent improvement may reflect a mixture of real progress, random variation, and the fact that the 2010 rate is slightly overstated (due to the use of a population estimate which is now known to be too low). * ‘Best’ and ‘worst’ incidence should not be taken too literally, as a rise in recorded incidence is sometimes to be encouraged. 9 Level of need in the population Under-75 mortality by CCG Under-75 (i.e. ‘premature’) mortality from all cancers is also available at the Clinical Commissioning Group level, as part of the CCG Outcomes Indicator Set. The 2011 rate for Blackburn with Darwen CCG is 123.3 per 100,00055, which is only fractionally above the England average (Figure 12). The CCG rate is based on the mortality of all patients registered with Blackburn with Darwen practices, regardless of where they live. There are additional, technical reasons why it is not valid to try to compare it with the NHS Outcomes Framework rate.* Blackburn with Darwen CCG England Figure 12 - Under-75 mortality from cancer, 2011, at CCG level (Blackburn with Darwen highlighted)56 Mortality trends (under-75 and over-75) The England cancer mortality rate for people aged 0-74 has declined steadily over the years for both males and females (Figure 11). Understandably, the Blackburn with Darwen rate shows more fluctuation, but it has tended to be higher than average, especially for males. Figure 11 - Directly standardised mortality rates per 100,000 from all cancers, under age 75, 1985-87 to 2009-11 Source UKCIS Above age 75, there has been a gradual downward trend in England, but no systematic improvement in Blackburn with Darwen (Figure 13). Figure 13 - Directly standardised mortality rates per 100,000 from all cancers, over age 75, 1985-87 to 2009-11 Source: UKCIS Under-75 mortality from cancer considered preventable The Public Health Outcomes Framework (PHOF) also contains an under-75 mortality rate from cancers considered preventable - i.e. those which are potentially avoidable through public health interventions. Again, the PHOF calculation has improvised the 2009 and 2010 populations in such a way that the Blackburn with Darwen rate may be slightly understated. * Figure 14 - Under-75 mortality rates from cancer considered preventable (Directly Standardised Rate, 2009-11) Source: Public Health Outcomes Framework The CCG rate is standardised to the England, rather than the Standard European, population. 10 Level of need in the population Blackburn with Darwen Cancer mortality and deprivation Blackburn with Darwen’s mortality rates for all cancers and for lung cancer are not only significantly higher than average overall, but particularly so in the most deprived parts of the borough. In Figure 15, the most deprived (‘bottom’) and least deprived (‘top’) local quintiles are compared with the other three: Figure 15 - Cancer mortality by deprivation within Blackburn with Darwen: directly age-standardised rate per 100,000 (all persons, all ages, 2005-09) Source: National Health Inequalities Gap Measurement Tool for England57 Figure 16a identifies which of Blackburn with Darwen’s 18 Middle Super Output Areas (MSOAs) have a cancer mortality rate significantly higher than the England average. The red-shaded area, consisting of Shadsworth with Whitebirk and part of Audley ward, has a rate at least 50% higher than average. Figure 16b alongside shows the Index of Multiple Deprivation 2010, overlaid with MSOA boundaries for comparison: Figure 16 – (a) Cancer mortality 2006-10 by MSOA, and (b) IMD 2010 by LSOA (overlaid with MSOAs) (a) Cancer mortality (persons) Source: DCLG 11 Level of need in the population Figure 17 - Incidence rates 2008-10 (persons, all ages, all cancers) Incidence As already seen from Figure 3 & Figure 9, the incidence rate for all cancers combined in Blackburn with Darwen tends to be somewhat higher than the national average. Figure 17 illustrates that although Blackburn with Darwen’s rate is above average for England, it is typical for the NW. Figure 37 (rear of document) confirms that the overall cancer incidence rate and the lung cancer incidence rate in Blackburn with Darwen are significantly higher than Source: UKCIS the England average, both for under75s and at all ages. The recorded incidence rates for bowel cancer and prostate cancer, however, are below average, although not significantly so. Incidence and mortality In order to understand the interplay between cancer mortality and incidence, it is recommended that they should be considered together. A flat mortality rate, for instance, might carry one interpretation if incidence is falling, and quite another if incidence is rising.52 Figure 18 shows that the relationship between mortality and incidence over time has been much the same in Blackburn with Darwen as in England generally. However, in the case of lung cancer, Blackburn with Darwen has failed to keep up with the improving national trend. Figure 18 – All-age mortality and incidence – Blackburn with Darwen and England, time trend Source: UKCIS 12 Level of need in the population Survival ‘Big Four’ cancers NCIN guidelines58 advise that only the ‘big four’ cancers generate sufficiently large numbers for robust analysis of survival at PCT level. Survival rates are dated according to the year(s) when the patients concerned were diagnosed with cancer, so they will appear to lag behind the corresponding mortality statistics. At present (June 2013), survival rates on the UKCIS site are delayed, so this lag is greater than usual. Local, regional and national survival rates are summarised in Figure 38 at the back of this document. The rates which are significantly worse than average in Blackburn with Darwen, and thus give greatest cause for concern, are 1-year survival from lung and bowel cancer, and 5-year survival from breast cancer. All cancers combined The final item in Figure 38 is a survival index for all cancers combined.* Developed by NCIN and ONS, it standardises for the mix of cancer types encountered as well as for age and sex.59 Blackburn with Darwen scores worse than the England average, but statistical significance is not provided. There are intentions to publish survival rates in the NHS Outcomes Framework for all cancer in adults, all cancer in children, and for breast, lung and colorectal cancer combined. It is not yet clear how or whether these rates will be standardised for the mix of cancer types. Breast cancer survival The most striking result from Figure 38 is Blackburn with Darwen’s 5-year survival rate from breast cancer for 2001-05, which at 76.9% is significantly lower than average, and one of the worst in the country. Meanwhile, five-year survival from breast cancer in East Lancashire in 2001-05 was 86.7%, which is higher than the national average (though not significantly), and one of the best in the North West. The contrast with Blackburn with Darwen is puzzling, because most patients use the same screening and hospital services.60 Figure 19 - Breast cancer survival - Blackburn with Darwen and East Lancashire compared 1-year 5-year 1985-1989 1986-1990 1987-1991 1988-1992 1989-1993 1990-1994 1991-1995 1992-1996 1993-1997 1994-1998 1995-1999 1996-2000 1997-2001 1998-2002 1999-2003 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 2005-2009 Relative Survival (%) Breast Cancer: 1- and 5-year survival rates in Blackburn with Darwen and East Lancashire 100 95 90 85 80 75 70 65 60 Source: UKCIS† It can be seen from Figure 19 that five-year survival in Blackburn with Darwen started to move in the wrong direction from about 1996-2000. The number of new cases of breast cancer in Blackburn with Darwen each year is barely a third of those diagnosed in East Lancashire, so the borough’s survival rate has a wider 95% confidence interval (Figure 19), and is bound to fluctuate more from year to year. Blackburn with Darwen’s 2009-11 breast cancer mortality rates have almost halved since their peak in 2001-03 (Figure 36), and 1-year survival rates have been improving since 2001-05 (Figure 19 and Figure 38). There is therefore reason to hope that 5-year survival rates for 2002-06 onwards will show an improvement when they eventually become available. * † The cancer survival index omits male breast cancer, non-melanoma skin cancer, and prostate cancer. One more year’s survival rates would normally be available by the time of writing (11/6/13), but these have been delayed. 13 Level of need in the population 5. Good practice Cancer Awareness Measure (CAM) The Cancer Awareness Measure (http://info.cancerresearchuk.org/spotcancerearly/naedi/AboutNAEDI /Researchevaluationandmonitoring/naedi_cam/ )is a validated set of questions developed as part of the National Awareness and Early Diagnosis Initiative (NAEDI). By adhering to these questions, we can be sure that local surveys of awareness levels will be directly comparable with results from CAM surveys elsewhere. The CAM questionnaire starts by asking respondents to name warning signs and symptoms of cancer, first as an open ‘recall’ question, then as a ‘recognition’ question based on a list. Risk factors are dealt with in the same way, first unprompted then prompted. Other questions ask about willingness to go to the doctor, awareness of screening programmes, and which are the most common cancers. Cancer survivorship With the growing numbers of people surviving a cancer diagnosis, increasing attention is being paid to the issues surrounding cancer as a long-term condition. Living with or beyond cancer has been the subject of recent supplements in the Times16, the HSJ13 and the British Journal of Cancer61, and has now given rise to a major government policy document: Living with and beyond cancer: taking action to improve outcomes.24 Figure 20 Macmillan logo for cancer survivorship The traditional approach An article in the Times supplement16 quotes research by Macmillan which found that nearly half of patients completing their hospital treatment received no support once it ended. 26% felt abandoned, and 28% did not know where to turn for help. Traditionally, the focus has been upon cancer as an acute illness, with the main emphasis on the acute phase of treatment. Ongoing care after completion of treatment has been conducted as a series of ‘follow-up’ appointments, primarily looking for signs of recurrence or spread.62 This approach is not geared up to meet the needs of the growing numbers of cancer survivors. Even those without active cancer have a health and wellbeing profile comparable to that of the population living with long-term conditions such as diabetes or arthritis. Over 15% struggle with routine daily or social activities, 25% are unable to work in their preferred occupation, and 29% report that their health has a negative impact on relationships.62 The new approach The Living with and beyond cancer guidance24 describes a ‘framework of survivorship’ consisting of the following five stages, and suggests appropriate actions for commissioners and providers at each step: Information and support from the point of diagnosis; Promoting recovery; Sustaining recovery; Managing the consequences of treatment; and Supporting people with active and advanced disease. It advocates that patients should be offered a ‘Recovery Package’, consisting of Structured holistic needs assessment and care planning; Treatment summaries (documenting care, prognosis, risk factors etc); Patient education and support events; and Advice about, and access to, physical activity and healthy weight management schemes. The holistic nature of this package should ensure that vocational rehabilitation and financial support and advice are available to all who need them. 14 Good practice 6. Current services / initiatives Cancer screening programmes Bowel cancer screening The national rollout of the Bowel Cancer Screening Programme began in July 2006 for people aged 60-69, and reached Blackburn with Darwen in 2008. The scheme has since been extended to 70-74 year-olds, which took effect in 2011 in Blackburn with Darwen. In 2012, average uptake in the North West was 56% (England average 58.2%). Blackburn with Darwen came 6th lowest out of 33 CCGs in the region, with 50% uptake. The best uptake in the NW was 65.5%, with only six CCGs achieving the 60% uptake required to be cost-effective.63 Over the first three years of the programme (2008-2011), there was a clear tendency for uptake to be higher in the less deprived parts of Blackburn with Darwen (Figure 21). The geographical pattern can also be seen in Figure 22, where the darkest colours represent the lowest uptake rates. Meanwhile, positivity (the percentage of tests with an abnormal outcome) is higher in the most deprived areas (Figure 23). In other words, those most in need of the test are least likely to take it up. Efforts to boost uptake are being coordinated across Lancashire by a dedicated health promotion specialist. Figure 21 - Uptake rates by deprivation quintile, 2008/092010/11, Blackburn with Darwen Source: NW Bowel Screening QA Reference Centre64 Figure 22 - Uptake rates 2009/10 by MSOA (darkest shading = lowest uptake) Source: NW Bowel Screening QA Reference Centre65 Figure 23 - Positivity rates by deprivation quintile, 2008/09-2010/11, Blackburn with Darwen 15 Source: NW Bowel Screening QA Reference Centre64 Current services / initiatives Cervical screening Cervical screening aims to detect and treat abnormalities before they develop into cancer. Women are invited for a smear test every three years between the ages of 25 and 49, and every five years between the ages of 50-64. There are separate coverage indicators for each of these age-groups, as well as the overall headline measure shown in Figure 24. Blackburn with Darwen has seen a steeper than average decline in coverage, and in 2011/12 it lay within the worst quintile of PCTs on all three measures. Figure 24 - Cervical cancer - percentage of women aged 25-64 screened within past five years Source: Cancer Commissioning Toolkit66 and HSCIC67 Figure 25 – Cervical screening coverage (% of women aged 25-64 screened in last 5 years), Blackburn with Darwen practices, five years to November 2011 In Figure 25, Blackburn with Darwen practices have been arranged in groups, so that Groups 1 and 2 consist of the practices with the youngest age profiles, highest deprivation and highest proportion of Asian patients. Groups 3, 4 and 5 serve successively more affluent populations which are mostly white, with a higher average age. Surname analysis using ‘Nam Pehchan’ Source: PCIU software appears to confirm the impression that screening coverage is lowest in practices with the highest proportion of South Asian patients. Coverage rates obtained from QOF have typically been higher than shown here (e.g. 80.6% for BwD in 2011/12), as QOF allows many more pretexts for excluding a woman from the denominator.68 Starting in 2011/12, QOF also publishes a version which does not exclude anybody, giving Blackburn with Darwen a rate of 73.7%. 14-day turnaround of cervical screening results is a former NHS ‘Vital Signs’ target. Performance on this measure in Blackburn with Darwen was transformed during the course of 2010-11: Figure 26 - 14-day turnaround of cervical screening results, BwD 16 Current services / initiatives Source: Open Exeter Breast cancer screening Breast cancer screening has received a mixed press lately. A study led by Sir Michael Marmot concluded in 2012 that screening did reduce breast cancer mortality, although it could lead to overdiagnosis.69 A new study from Oxford University, however, has failed to demonstrate that screening has any effect on breast cancer mortality at the population level.70 Screening remains NHS policy, but new guidelines are expected to be issued later in 2013 which will discuss the pros and cons for the first time.71 Figure 27 – Breast cancer - percentage of women aged 53-70 screened within past three years Women between 50 and 70 are Source: Cancer Commissioning Toolkit66 and HSCIC72 invited for regular breast screening every three years. Their first invitation could come at any time from their 50th to their 53rd birthday, so the headline coverage indicator 70% is the percentage of eligible women national aged 53 to 70 who have been standard screened within the last three years. Blackburn with Darwen struggles to remain above the 70% standard, and shows no improving trend. The Cancer Commissioning Toolkit also provides results for breast cancer screening uptake (the proportion of women invited in the past 12 months who attended within 6 months). Uptake in Blackburn with Darwen in 2011/12 was 68.3%, which is below the England average of 74.3% and slightly down on 2010/11. The numbers invited in a given year vary enormously from practice to practice; one possible reason may be the touring schedule of mobile screening units.66 Two Week Wait referrals The NHS Cancer Plan of 2000 introduced a maximum Two Week Wait (TWW) for an outpatient appointment for suspected cancer following urgent referral by a GP. The number of such referrals can be expressed as a rate per head of practice population, which reveals wide variation between practices and between PCTs.8,18 There is no right or wrong rate of TWW referrals73, and the Public Accounts Committe heard that some GPs would rather carry out their own diagnostic tests.8 As Sir Mike Richards put it, GPs should use the data to benchmark themselves, and say: "Oh gosh; I'm a low referrer”, or "I'm a high referrer".8 There was concern that low referrals combined with low use of diagnostic tests might mean that cases were being missed, and high referrals combined with high use of diagnostic tests might mean that money was being wasted. Referral rate74 The 2011 NHS Atlas of Variation75 drew attention to the Two Week Wait referral rate for 2010/11, and depicted Blackburn with Darwen as lying just within the lowest quintile of PCTs. This was based on a crude rate, and could have been partly a reflection of the borough’s young age profile. However, an age standardised version in the GP Practice Profiles within the Cancer Commissioning Toolkit also showed that referrals stood at only 86% of the England average.66 The profiles have since been updated with 2011/12 data, which shows that Blackburn with Darwen’s referral rate has now caught up with England, to stand at 100.2% of the national average. Conversion rate The proportion of Two Week Wait referrals which result in a diagnosis of cancer is known as the ‘conversion rate’.73 In 2012, the average conversion rate in Blackburn with Darwen was 10.6%, which is the same as the England average. The conversion rate for individual practices locally ranged from 0% to 29%, although both extremes tend to be seen in practices with relatively small numbers of Two Week Wait referrals.66 17 Current services / initiatives Emergency admissions for cancer Reducing emergency admissions for cancer across the board is an important plank of the Cancer Reform Strategy.23 Most such admissions arise from progression of the disease, or side-effects of treatment.66,75 The 2011 NHS Atlas of Variation expresses emergency admission activity in terms of the number of emergency cancer bed-days per new cancer registration, and encourages commissioners with a high rate to endeavour to drive it down. On this measure, Blackburn with Darwen already has one of the lowest rates in the country: Blackburn Figure 28 - Emergency cancer bed days per new cancer registration (2010-11, PCTs) with Darwen Source: NHS Atlas of Variation 2011 Emergency admissions as a route to diagnosis In 2010, the National Cancer Intelligence Network (NCIN) published an analysis in which they looked at all patients diagnosed with cancer in 2007, and attempted to trace the route by which that diagnosis had been reached (via screening, Two Week Wait, other GP referral, emergency admission, etc). For almost all cancers, they found that 1-year relative survival following diagnosis through the emergency admission route was significantly lower than average – often much lower. 76 The same exercise was repeated with 2008 data, down to practice level, and is now incorporated in the Cancer Commissioning Toolkit’s GP practice profiles. In Blackburn with Darwen, the emergency route accounted for 36.9% of presentations in 2008, compared with 23.7% nationally (counting only those that could be attributed to a practice). So although emergency cancer admissions in general are at a low level in Blackburn with Darwen, they are still too often the mechanism by which cancer is first discovered. Hospital care – the 2011/12 National Cancer Patient Experience Survey The 2011/12 National Cancer Patient Experience Survey received responses from 71,793 patients who had been treated across 160 hospital trusts.77 It asked 64 questions which track the patient’s journey from initial diagnosis and referral, to the ongoing care from hospital, GP and other staff after leaving hospital. Much of the emphasis is on how well informed the patient felt, how decisions were reached, and their confidence in those looking after them. There were 605 responses from patients of East Lancashire Hospitals NHS Trust, which is likely to be the most relevant to Blackburn with Darwen.78 East Lancashire Hospitals NHS Trust The results show that East Lancashire Hospitals NHS Trust generally ranks in the middle 60% of trusts for most questions, and often towards the better end of that band. It slips marginally into the bottom quintile on 13 questions, most of which are concerned with information-giving and understanding. The most strikingly positive result comes when patients are asked whether they were ‘definitely given enough care from health or social services’ after leaving hospital. With 76% of respondents agreeing, East Lancashire Hospitals NHS Trust sits firmly within the best quintile on this question, a result which is unlikely to have occurred by chance alone. Clinical Nurse Specialists The importance of the Clinical Nurse Specialist (CNS) was highlighted in the national report on the 2010 survey. In 2011/12, patients who had been allocated a CNS responsible for their care once again responded more positively to almost every other question than those who had not.77 At East Lancashire Hospitals NHS Trust, the percentage of patients given the name of a CNS had slipped from 91% in 2010 to 88% in 2011/12, which is still just above the national average (87%), but no longer in the top quintile. 18 Current services / initiatives Figure 29 - NCSI Vocational Rehabilitation Pilot - proposed four-level model Vocational Rehabilitation In 2010-11, the National Cancer Survivorship Initiative (NCSI) funded seven pilot projects to test the benefits of a four-level model of vocational rehabilitation in helping cancer patients return to or remain in work (Figure 29). With its existing experience of providing this type of support for people with long-term conditions, NHS Blackburn with Darwen was chosen as one of the flagship sites.79 Source: NCSI80 The Blackburn with Darwen pilot Staffed by two vocational rehabilitation specialists, the Blackburn with Darwen pilot forged links with major local employers as well as receiving individual referrals from health professionals and employers. Having anticipated that the main need would be for information and signposting (i.e. Levels 1-2 in Figure 29), they were initially surprised by the level of demand for intensive psychological support (Level 4). An article about the pilot projects in the HSJ supplement on Cancer Survivorship singled out the Blackburn with Darwen project for the most prominent coverage, and bore testimony to the fact that it had made a real difference to people’s lives.13 Unfortunately funding for the project ceased on 31st March 2011.79 Macmillan Pennine Lancashire Cancer Improvement Programme Blackburn with Darwen and East Lancashire CCGs have successfully bid for £211,255 in funding over 30 months to set up a sub-regional Cancer Improvement Programme, which will involve redesign of Community, Primary and Acute services for all those affected by cancer in the subregion. Further bids are expected to follow. 7. Gaps Cervical screening As already demonstrated (Figure 24), Blackburn with Darwen has a relatively poor and declining uptake of cervical screening. The cervical screening service across Pennine Lancashire, which covers Blackburn with Darwen, received a quality assurance visit from the North West Cervical Screening Quality Assurance Reference Centre (QARC) in November 2011, resulting in the following recommendations: Table 5 - Recommendations of North West Cervical Screening QARC Immediate (0-3 months) 1. 2. Short term (3-6 months) 1. Cervical screening coordinator post to be made permanent 2. Establishment of a sample taker register 1. GP practices to be asked to nominate leads for cervical screening 2. An annual report should be produced 3. Rolling programme of updating training to be established 4. Mentorship programme to be established to support all smear takers 19 Gaps 8. Value for money Programme Budgeting data Overall spend on Cancer ‘Programme Budgeting’ data from DH allows us to compare expenditure on 23 major ‘programmes’ of NHS activity. In Figure 30, Blackburn with Darwen’s expenditure on Cancer is compared with England and with a ‘cluster’ of 19 similar PCTs called ‘Centres with Industry’. Spending is expressed per head of Unified Weighted Population, an artificial headcount, scaled up or down to reflect local need. Figure 30 - Expenditure per head on Cancer after adjusting for need (Programme Budgeting data 2011/12) It can be seen that Blackburn with Darwen’s spend per head on cancer is lower than average. When all 151 PCTs are ranked on this basis, Blackburn with Darwen sits just within the lowest-spending quintile. Caveat Unified Weighted Population reflects the overall health need of the locality, but may not be the best denominator when focusing on one particular disease. The NCIN is particularly critical of its use for cancer.52 Care settings Figure 31 - Cancer Expenditure split by Care Setting (Blackburn with Darwen v. England, Programme Budgeting data 2011/12) A new feature of the Programme Budgeting data is that they are broken down into twelve ‘care settings’ (see Figure 31).* Compared with England, proportionally more of Blackburn with Darwen’s Cancer expenditure goes on Community Care, Prevention and Outpatient care, and proportionately less on Inpatient care (particularly nonelective). * NB – The term ‘Other secondary care’ has a technical meaning in Figure 31, relating to procedures which fall outside the usual charging structure. 20 Value for money Activity and spending in relation to QOF prevalence Given that the Unified Weighted Population is a reflection of overall health need, and not cancer in particular, a preferred alternative may be the number of patients on the QOF cancer register. Figure 32 breaks the 2010/11 figures for cancer admissions down into elective and emergency admissions, and also examines their cost, relative to the number of patients on the QOF cancer register. Overall cancer admissions activity in Blackburn with Darwen is similar to the regional average, but at a lower cost per patient. Figure 32 - Cancer admissions and associated cost (2010/11) relative to number of patients on QOF cancer register Source: NHS Comparators 21 Value for money 9. Involvement Cancer Awareness in Blackburn with Darwen - South Asian population A baseline face-to-face survey in Shear Brow and Bastwell wards in 2009, using the Cancer Awareness Measure (CAM)*, confirmed that cancer awareness was lower among South Asian residents than generally.81 Local community volunteers were then recruited and trained to raise awareness via leaflets, events and a DVD about cancer screening targeted at the South Asian population. A year later there was mixed progress on the recognition of risk factors, signs and symptoms, and the conclusion was that efforts to boost cancer awareness would need to be maintained.82 Asian women in the borough have been the focus of particular engagement initiatives in the past, notably the ‘Woman to Woman’ project, which sought to increase rates of breast and cervical screening. Plans are now being drawn up across Pennine Lancashire to identify new ways to increase uptake in specific target groups. Be Clear on Cancer Figure 33 - The 'Be Clear on Cancer' brand The ‘Be Clear on Cancer’ brand (http://info.cancerresearchuk.org/spotcancerearly/naedi/beclearoncancer/) was introduced by the Department of Health in 2011 in a bid to promote awareness and early diagnosis of cancer. Blackburn with Darwen has been fully involved from the start in piloting and then rolling out campaigns for bowel, lung, breast and other cancers, through a combination of advertising, community activity and outreach work. Dragon’s Apprentice The Dragon’s Apprentice initiative gives community and voluntary groups in Blackburn with Darwen the chance to bid for funding to deliver projects which support self-care, empower individuals and promote health & wellbeing. In 2013, the focus is on projects which deliver key messages around cancer – the signs and symptoms, screening programmes, and related lifestyle factors. A notable success was the ‘Dress to Kill Cancer’ fashion show at Darwen Aldridge Community Academy in May 2013, complete with health stalls and inspirational speakers, which attracted around 300 people. Boys at the school have now put together a business plan for a similar scale event aimed at men’s cancers. Figure 35 - Logo for the 'Dress to Kill Cancer' event at Darwen Aldridge Community Academy * Dragon’s Apprentice has also funded a large-scale event at Pleckgate High School organised by the Abu Hanifah Foundation; cancer awareness events and workshops at Ivy Street Community Centre; and Figure 34 - Logo for the Abu a themed concert at Bangor Street Hanifah Foundation event at by the Eastern Sangeet Society. Pleckgate High School There are plans for an awarenessraising project on testicular and prostate cancers aimed at the South Asian community in Darwen, and delivered via the local mosque. See p13 for explanation of ‘CAM’. 22 Involvement 10. Recommendations Key priorities The key priorities for cancer for Pennine Lancashire Cancer Steering Group, Blackburn with Darwen Clinical Commissioning Group and Blackburn with Darwen Health and Wellbeing Board should be: To reduce premature mortality from cancer in Blackburn with Darwen. To reduce inequalities in cancer mortality within Blackburn with Darwen, and between Blackburn with Darwen and England. Recommendations To achieve these priorities the following recommendations should be taken into account: 1. Overarching Recommendation 1.1. An overarching end-to-end pathway should be put in place, incorporating the prevention of cancer and raising awareness of the signs and symptoms of cancer, through to survivorship and end-of-life care, with clear outcomes and effective monitoring. 2. Risk Factors 2.1. All provider services across Blackburn with Darwen that work with individuals around lifestyle and generic risk factors should be engaged to ensure key lifestyle messages in relation to cancer and cancer awareness are given to the local population, making every contact count. 2.2. Stop smoking services, physical activity and alcohol services should be commissioned across the borough to ensure equal access for all individuals in a variety of settings, but targeting those most at risk of developing cancer. 2.3. Primary Care, including Healthy Living Pharmacies, the third sector and other partners such as Jobcentre Plus, should be engaged to ensure they are raising key lifestyle issues, giving consistent, agreed messages and signposting individuals to a range of services provided across the borough. 2.4. Cancer prevention programmes should be delivered in collaboration with other programmes which address health-related behaviours as well as wider determinants, including education and the environment where people live, work and socialise. This can be done in conjunction with external organisations as well as internal provider services, e.g. re:fresh, Healthy Living Centre. 3. Primary Care 3.1. The CCG should ensure that there is clear GP leadership across the borough, within each GP practice and in other primary care settings, with improved GP access for patients and improved access for GPs to diagnostics. 3.2. Initiatives should be put in place to encourage uptake of cancer screening programmes, including text messaging, letters and phone calls. 3.3. Each GP practice within the borough should have an action plan in place to identify areas on which to focus to improve outcomes for their patients, including the use of emerging tools, e.g. the local risk assessment tool.* * The risk assessment tool is a set of tables printed on a mousemat or desk easel, reminding doctors of the likelihood of a patient over 40 having bowel or lung cancer, given the symptom or combination of symptoms they present with. 23 Recommendations 4. NHS Population Cancer Screening: bowel; cervical; breast 4.1. The recommendations from the three-yearly North West Quality Assurance visit for each cancer screening programme should be fully implemented within the given timescales, with reporting subject to appropriate escalation. 4.2. Coverage of all three cancer screening programmes should be improved across the borough, with minimum national standards being met, increasing coverage for each screening programme by 5-20% dependent on the screening programme. There should be a focus on the population groups who are least likely to attend, including those with learning disabilities, from BME population groups or living in disadvantaged areas, young people (for cervical screening), and other protected groups. 4.3. A focused piece of work should be undertaken to look at reasons why individuals across the borough are not complying with the national screening programmes. In particular a key focus is required on initial invite and informed consent. This work needs to be fully evaluated and its findings should guide future planning on promotion of screening programmes. 5. Emergency Presentation 5.1. The proportion of emergency presentations should be reduced by raising awareness of the signs and symptoms of cancer within the general population and within targeted population groups, and by working with primary care. 5.2. Work should be undertaken within secondary care around individuals who present as an emergency admission and are diagnosed with cancer. 11. Where to find out more Screening – the website for all three NHS cancer screening programmes (Bowel, Breast and Cervical) is at http://www.cancerscreening.nhs.uk/ Awareness and early diagnosis – the National Awareness and Early Diagnosis Initiative (NAEDI), including the ‘Be Clear on Cancer’ campaign, can be found at http://info.cancerresearchuk.org/spotcancerearly/naedi/ Statistics – o The National Cancer Intelligence Network (NCIN) publishes a useful guide called ‘What cancer statistics are available, and where can I find them?’ The latest (June 2013) edition is available from http://www.ncin.org.uk/view?rid=664 o Cancer Research UK has a comprehensive collection of statistics at http://info.cancerresearchuk.org/cancerstats/ Survivorship o The National Cancer Survivorship site is at http://www.ncsi.org.uk/ o The National Cancer Survivorship survey examined a wide range of aspects of quality of life for cancer survivors. Reports are available summarising the numerical results83, and also the free text comments which patients were invited to give at the end of the questionnaire.84 o Macmillan’s pages on living with or beyond cancer are at http://www.macmillan.org.uk/GetInvolved/Campaigns/Weareaforceforchange/Survivorship/Li vingwithorbeyondcancer.aspx 24 Where to find out more 12. Key indicators Figure 36 – Mortality Spine Chart Footnotes Directly age-standardised mortality rate for relevant cancer type for persons (a, b & e)/females (c)/males (d). Source UKCIS. Last updated 11/6/13. NB – Rates obtained from different sources may differ more than usual due to phased introduction of revised population estimates (reflecting 2011 Census results). 25 Key indicators Figure 37 - Incidence Spine Chart Footnotes Directly age-standardised mortality rate for relevant cancer type for persons (a, b & e)/females (c)/males (d). Source UKCIS. Last updated 11/6/13. NB – 1. Scale marked ‘Higher/Lower’ rather than ‘Worse/Better’, as screening or early diagnosis campaigns may have the desired effect of raising recorded incidence 2. Rates obtained from different sources may differ more than usual due to phased introduction of revised population estimates (reflecting 2011 Census results). 26 Key indicators Figure 38 - Survival Spine Chart – all ages (except for indicator i, ages 15-99) Refers to year(s) when patients were diagnosed with cancer Footnotes a, c, e & g : b, d, f & h : i: One-year relative survival (all ages) for individual cancer type, pooled over five years. Source UKCIS Five-year relative survival (all ages) for individual cancer type, pooled over five years. Source UKCIS One-year survival index (age 15-99) for all cancers combined, measured over one year. Source ONS. Not available for region. UKCIS data extracted February 2012. 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