Download Cancer - Blackburn with Darwen Council

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. Subsequent year’s survival data is delayed, and was still not available from UKCIS as of 11/6/13.
* NB – Survival from prostate cancer is heavily influenced by the uptake of screening. This is a contentious issue, and results should be interpreted with caution.
27
Key indicators
13.
References
1
Cancer Research UK. What cancer is. Available from http://www.cancerhelp.org.uk/about-cancer/what-iscancer/cells/what-cancer-is
2
Cancer Research UK. Incidence, survival and mortality. Available from http://www.cancerhelp.org.uk/aboutcancer/what-is-cancer/statistics/incidence-survival-and-mortality
3
The King’s Fund (June 2011). How to improve cancer survival. Available from
http://www.kingsfund.org.uk/publications/cancer_survival.html
4
Cancer Research UK (2011). Cancer incidence for all cancers combined. Available from
http://info.cancerresearchuk.org/cancerstats/incidence/all-cancers-combined/
5
Mistry, M et al (2011). Cancer Incidence in the United Kingdom: projections to the year 2030. British Journal
of Cancer (2011) 105, 1795-1803. Available from
http://www.nature.com/bjc/journal/v105/n11/full/bjc2011430a.html
6
Cancer Research UK (2011). Projections for all cancers combined. Available from
http://info.cancerresearchuk.org/cancerstats/incidence/projections/
7
NCHOD (2011). User Guide 2011. Available from
http://www.nchod.nhs.uk/NCHOD/HomeDb2R6.nsf/089de59e1cffbe8f65256cd100209bf0/bf63879867c072f
480256d0100621a24/$FILE/User%20Guide%202011%20(March).pdf
8
Public Accounts Committee (2011). Delivering the Cancer Reform Strategy. Available from
http://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubacc/667/66702.htm
9
DH (2011). Improving Outcomes: A strategy for cancer. Available from http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371
10
Cancer Research UK (2012). Spot Cancer Early. Available from http://www.cancerresearchuk.org/cancerinfo/spotcancerearly/
11
DH (2013). Improving Outcomes: A Strategy for Cancer. Second Annual Report 2012. Available from
https://www.gov.uk/government/publications/the-national-cancer-strategy-second-annual-report
12
Maddams J et al (2012). Projections of cancer prevalence in the United Kingdom, 2010-2040. British
Journal of Cancer (2012) 107, 1195-1202. Abstract available from
http://www.nature.com/bjc/journal/v107/n7/abs/bjc2012366a.html
13
HSJ (2011). Cancer Survivorship supplement, 14th April 2011.
14
Maddams J et al (2009). Cancer prevalence in the United Kingdom: estimates for 2008. British Journal of
Cancer (2009) 101, 541-547.
15
Macmillan (2013). A quarter of cancer patients face isolation each year. Available from
www.macmillan.org.uk/Aboutus/News/Latest_News/Aquarterofcancerpatientsfaceisolationeachyear.aspx
16
Times (2011). Living with Cancer supplement, 6th April 2011. Available from http://www.thetimes.co.uk
upon payment of £1.
17
DH (2011). Programme Budgeting estimated England level gross expenditure for all programmes and
subcategories for all years collected. Available from http://www.dh.gov.uk/prod_consum_dh/groups
/dh_digitalassets/@dh/@en/documents/digitalasset/dh_131856.xls
18
National Audit Office (2010). Delivering the Cancer Reform Strategy. Available from
http://www.nao.org.uk/publications/1011/cancer_reform_strategy.aspx
19
Policy Exchange (2010). The cost of cancer. Available from
http://www.policyexchange.org.uk/publications/publication.cgi?id=174
20
BBC (2012). Cost of cancer in the UK ‘over £15bn’ a year. Available from
http://www.bbc.co.uk/news/health-20222759
21
BUPA (2011). Cancer diagnosis and treatment: a 2021 projection. Available from
http://www.bupa.com/media/355766/cancer_diagnosis_and_treatment_-_a_2021_projection_-_final.pdf
28
References
22
Macmillan (2013). Cancer costs four in five patients on average £570 per month. Available from
www.macmillan.org.uk/Aboutus/News/Latest_News/Cancercostsfourinfivepatientsonaverage570amonth.aspx
23
DH (2007). Cancer Reform Strategy. Available from
http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_081006
24
DH (2013). Living with and beyond cancer: taking action to improve outcomes. Available from
www.gov.uk/government/publications/living-with-and-beyond-cancer-taking-action-to-improve-outcomes
25
DH (2011). NHS Outcomes Framework 2012-13. Available from
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131700
26
DH (2012). Healthy lives, healthy people – improving outcomes and supporting transparency. Available from
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358
27
NHS Commissioning Board (2012). CCG Outcomes Indicator Set – 2013/14 Technical Guidance. Available
from http://www.england.nhs.uk/wp-content/uploads/2012/12/ccg-ois-tech-guide.pdf
28
Cancer Research UK. Tobacco and cancer risk – statistics. Available from
http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/tobacco/
29
Guardian 24/1/11. Smoking warnings hit home as UK cancer rates drop. Available from
http://www.guardian.co.uk/society/2011/jan/24/smoking-message-hits-home-cancer-rates?INTCMP=SRCH
30
Parkin M et al (2011). The fraction of cancer attributable to lifestyle and environmental factors in the UK in
2010. British Journal of Cancer, Volume 105, Issue S2 (Si-S81). Available from
http://www.nature.com/bjc/journal/v105/n2s/index.html
31
Foresight (2007). Tackling Obesities: Future Choices – Modelling Future Trends in Obesity & Their Impact on
Health. Available from http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/14.pdf
32
DH (2011). Obesity general information. Available from
http://www.dh.gov.uk/en/Publichealth/Obesity/DH_078098
33
NCIN (2010). Reducing cancer inequality: evidence, progress and making it happen - a report by the
National Cancer Equality Initiative. Available from http://www.dh.gov.uk/prod_consum_dh/groups
/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_114354.pdf
34
NCIN (June 2011). Deprivation leads to over 2,600 cancer deaths a year. Available from
http://www.ncin.org.uk/view.aspx?rid=662
35
Cancer Research UK. What causes cancer? Available from http://info.cancerresearchuk.org
/cancerandresearch/learnaboutcancer/whatcausescancer/what-causes-cancer2#Age
36
Cancer Research UK. Cancer inequalities. Available from
http://info.cancerresearchuk.org/cancerstats/inequalities/
37
Cancer Research UK (2013). Excess cancer burden in men. Available from
http://publications.cancerresearchuk.org/downloads/Product/CS_REPORT_EXCESSBURDEN.pdf
38
National Cancer Intelligence Network and Cancer Research UK (2009). Cancer Incidence and Survival by Major
Ethnic Group, England 2002-2006. Available from http://info.cancerresearchuk.org/cancerstats/inequalities/
39
Health Development Agency (2004). The contribution of smoking, diet, screening and treatment to cancer
mortality in the under-75s. Available from
http://www.nice.org.uk/nicemedia/documents/cancer_under75s_briefing.pdf
40
Cancer Research UK (2011). The causes of cancer you can control. Available from
http://scienceblog.cancerresearchuk.org/2011/12/07/the-causes-of-cancer-you-can-control/#comment-5647
41
Cancer Research UK (2011). How many cancers can be prevented? Available from
http://scienceblog.cancerresearchuk.org/wp-content/uploads/2011/12/Attributable-risk-circles-poster.pdf
42
All Party Parliamentary Group on Cancer (2009). Report of the All Party Parliamentary Group on Cancer’s
Inquiry into Inequalities in Cancer. Available from http://www.macmillan.org.uk/documents/getinvolved
/campaigns/appg/britainagainstcancer2009/cancerinequalitiesreport.pdf
43
NICE (2010). Prevention of cardiovascular disease at population level. Available from
http://www.nice.org.uk/nicemedia/live/13024/49273/49273.pdf
29
References
44
NCIN (2010). How is the NCIN changing what we know about cancer? Available from
http://www.ncin.org.uk/view.aspx?rid=435
45
Public Health England (June 2013). Levels of socio-economic deprivation affect screening uptake for breast
cancer. Available from https://www.gov.uk/government/news/levels-of-socio-economic-deprivation-affectscreening-uptake-for-breast-cancer
46
NCIN (2010). Evidence to March 2010 on cancer inequalities in England. Available from
http://www.ncin.org.uk/equalities/docs/100614-NCIN-Inequalities.pdf
47
NWCIS (2010). Cancer in the North West: Inequalities by PCT of residence and socio-economic status.
Available from http://www.nwcis.nhs.uk/documents/publications/inequalities_oct2010.pdf
48
Cancer Research UK (2012). Cancer incidence by age – UK statistics. Available from
http://info.cancerresearchuk.org/cancerstats/incidence/age/
49
Cancer Research UK (Jan 2013). Excess cancer burden in men. Available from
http://publications.cancerresearchuk.org/downloads/Product/CS_REPORT_EXCESSBURDEN.pdf
50
DH (2012). The impact of patient age on clinical decision-making in oncology. Available from
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133095.pdf
51
University of Sheffield (June 2013). South Asian women should no longer be considered at low risk of breast
cancer. Available from http://www.sheffield.ac.uk/news/nr/breast-cancer-risk-1.280243
52
NCIN (2010) Cancer decision-making – turning data into intelligence. Available from
http://www.ncin.org.uk/view.aspx?rid=25
53
Anglia Cancer Network (2009). Moving forwards on cancer services in Anglia. Available from
www.angliacancernetwork.nhs.uk/documents/AngCN-S1_v1.pdf
54
HSCIC (March 2013). NHS Outcomes Framework – Indicator 1.4.vii (under 75 mortality rate from cancer).
Available from https://indicators.ic.nhs.uk/download/Outcomes%20Framework/Data
/NHSOF_1.4.vii_I00730_D_V3.xls
55
HSCIC (March 2013). CCG Outcomes Indicator Set – Indicator 1.9 (under 75 mortality rates from cancer).
Available from http://nww.indicators.ic.nhs.uk/download/Clinical%20Commissioning%20Group%20Indicators
/Data/CCG_1.9_I00756_D_V3.xls
56
NHS England (June 2013). CCG outcomes tools. Available from
http://www.england.nhs.uk/resources/resources-for-ccgs/ccg-out-tool/
57
National Health Inequalities Gap Measurement Tool for England. Available from
http://www.sepho.nhs.uk/gap/gap_national.html
58
NCIN (2009). Local Awareness & Early Diagnosis Baseline Assessments: A Guide for Cancer Networks & Primary
Care Trusts. Available from www.ncin.org.uk/publications/guidance_documents/naedi_baseline_guide.aspx
59
ONS (2011). Index of cancer survival for Primary Care Trusts in England – patients diagnosed 1996-2009
and followed up to 2010. Available from http://www.ons.gov.uk/ons/rel/cancer-unit/combined-cancersurvival-by-primary-care-trusts/patients-diagnosed-in-1996-2009--followed-up-to-2010/index-of-cancersurvival-by-pct-sb.html
60
Lowey (2011). Cancer in the North West: Inequalities by PCT of residence and socio-economic status. NHS
Blackburn with Darwen – briefing for Pennine Lancashire Cancer Locality Group.
61
British Journal of Cancer (2011). The National Cancer Survivorship Initiative: New and Emerging Evidence
on the Ongoing Needs of Cancer Survivors. Volume 105, Issue S1 (S1-S94), 3rd November 2011.Available from
http://www.nature.com/bjc/journal/v105/n1s/index.html
62
NHS Improvement (2010). National Cancer Survivorship Initiative – Vision. Available from
http://www.ncsi.org.uk/wp-content/uploads/NCSI-Vision-Document.pdf
63
North West Bowel Screening Quality Assurance Reference Centre (2012). QA Report No 12.
64
North West Bowel Screening Quality Assurance Reference Centre (Oct 2011). North West Bowel Cancer
Screening Programme Report – Report Number 8 (Blackburn with Darwen).
30
References
65
North West Bowel Screening Quality Assurance Reference Centre (April 2011). North West Bowel Cancer
Screening Programme Report – Report Number 5.
66
Cancer Commissioning Toolkit. Available from www.cancertoolkit.co.uk.
67
HSCIC (2012). Cervical Screening Programme – England 2011/12. Available from http://www.hscic.gov.uk
/article/2021/Website-Search?productid=8907&q=screening&sort=Relevance&size=10&page=1&area=both#top
68
North West London Cancer Network (2010). Assessing cervical screening coverage, using QOF and KC53
data as its indicators: Implications for service providers and commissioners. Available from
http://www.nwlcn.nhs.uk/Downloads/Patient-and-Public/QMAS%20and%20KC53.pdf
69
Cancer Research UK (2012). Breast screening review. Available from
http://www.cancerresearchuk.org/cancer-info/publicpolicy/ourpolicypositions
/symptom_Awareness/cancer_screening/breast-screening-review/breast-screening-review
70
Mukhtar, TK et al (2013). Breast cancer mortality trends in England and the assessment of the
effectiveness of mammography screening: population-based study. J R Soc Med 2013 106: 234. Available
from http://jrs.sagepub.com/content/106/6/234.full.pdf
71
Times (8th June 2013). Screening for breast cancer ‘has downside’.
72
HSCIC (2013). Breast Screening Programme – England 2011-12. Available from http://www.hscic.gov.uk
/article/2021/Website-Search?productid=11172&q=screening&sort=Relevance&size=10&page=1&area=both#top
73
YHPHO (2010). QIPP Resource Pack, September 2010 (Cancer). Available from
http://www.yhpho.org.uk/resource/item.aspx?RID=86827
74
NCIN (2011). Urgent GP referral rates for suspected cancer. Available from
http://www.ncin.org.uk/publications/data_briefings/gp_referral_rates.aspx
75
RightCare (2011). NHS Atlas of Variation in Healthcare 2011. Available from
http://www.rightcare.nhs.uk/index.php/atlas/atlas-of-variation-2011/
76
NCIN (2010). Routes to Diagnosis – NCIN Data Briefing. Available from
http://www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis.aspx
77
DH (2012). Cancer Patient Experience Survey 2011/12 – National Report. Available from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126880/Cancer-PatientExperience-Survey-National-Report-2011-12.pdf.pdf
78
NHS (2012). National Cancer Patient Experience Programme 2011/12 National Survey – East Lancashire
Hospitals NHS Trust. Available from http://www.quality-health.co.uk/images/stories/pdfs
/2012CancerReports/rxreastlancshospitals2011-12nationalcancerpatientexperiencesurveyreport.pdf
79
National Cancer Survivorship Initiative (2011). Vocational Rehabilitation Pilot Sites. Available from
http://www.ncsi.org.uk/what-we-are-doing/vocational-rehabilitation/vocational-rehabilitation-pilot-sites/
80
NCSI (2012). Thinking positively about work – delivering work support and vocational rehabilitation for
people with cancer. Available from http://www.ncsi.org.uk/wp-content/uploads/NCSI-VR-Evaluation-FinalReport-Full-Final-Version-July-2012.pdf
81
Lancashire and South Cumbria Cancer Network (2010). Network delivery of the Local Awareness and Early
Diagnosis agenda 2010. Available from http://info.cancerresearchuk.org/prod_consump/groups
/cr_common/@nre/@hea/documents/generalcontent/cr_054419.pdf
82
Alley, Neil (2010). Blackburn with Darwen Cancer Awareness Project. Presentation supplied by Lancashire
and South Cumbria Cancer Network.
83
NHS (2012). Quality of life for cancer survivors in England. Available from www.gov.uk/government
/uploads/system/uploads/attachment_data/file/127272/9284-TSO-2900701-PROMS.pdf.pdf
84
University of Southampton (2013). Quality of life of cancer survivors in England: Analysis of patients’ free
text comments – final report. Available from https://www.gov.uk/government/publications/cancer-survivorssurvey-quality-of-life-after-diagnosis-and-treatment
31
References