Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales

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2 Project team Rebecca Thomas, Tamsin Long, Gareth Davies and Martin Holloway Reference group Ceri White, Helen Crowther, Joan Wilding, Karen Gully, Siôn Edwards, Richard Neal, Sean Young, John Lucy, Anne Thomas, Fiona Porter, Janet Warlow and Dyfed Wyn Huws Acknowledgements A special thanks to all the Welsh Cancer Intelligence and Surveillance Unit s (WCISU) staff, especially the registration team without whom the data used within this report would not be produced. Thanks to the following people for their help with this publication: Julie Howe, Ciarán Slyne, Lloyd Evans, Rhian Hughes, Tracy Price, Leon May, Tim Hughes and Linda Bailey Title: GP Cluster Lung Cancer Profile Cwm Taf University Health Board Date: Published on 17 September 2015 ISBN: Contact: Welsh Cancer Intelligence and Surveillance Unit 16 Cathedral Road Cardiff CF11 9LJ wcu.stats@wales.nhs.uk Website: Public Health Wales NHS Trust Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales NHS Trust to be stated. Copyright in the typographical arrangement, design and layout belongs to Public Health Wales NHS Trust. 2

3 Guide to using the GP cluster reports This is the first piece of work we have produced at GP cluster level, but the third product from Public Health Wales. The Public Health Wales Observatory (PHWO) published GP Cluster Profiles 2013 by health board in Wales in March This contains descriptive analysis of the GP registered population and also information on chronic disease for a number of conditions that have a high impact on services such as chronic obstructive pulmonary disease, asthma and diabetes ( It is supported by interactive spreadsheets ( The PHWO later went on to publish New General Practice Population Profiles in June 2015 on their NHS Wales intranet site ( down to GP practice level. In this report, we do not intend to duplicate the descriptive analysis produced by the PHWO but to show lung cancer incidence and survival by GP cluster in terms of sex, age, deprivation and stage of disease at diagnosis. All charts and tables contained within this report (excluding the smoking prevalence tables) are based on Welsh residents diagnosed with lung cancer during the period and registered with a Welsh GP. All incidence rates shown are per 100,000 population. To assign a quintile of area deprivation or an area deprivation half, the income domain of the Welsh Index of Multiple Deprivation 2014 (WIMD14) was used. During this project, an error was found within the income domain of the WIMD14 owing to the accidental exclusion of some tax credit data. This is the domain used by WCISU to assign a deprivation quintile or deprivation half. Welsh Government stated that the error caused just over 10 per cent of lower super output areas (LSOAs) to have moved between deciles, with only one LSOA moving by more than one decile ( It should be noted that GP clusters do not have physical boundaries since they are based on grouped practice lists rather than grouped residential areas and therefore are not comparable with information produced by geographical-based boundaries. Throughout this report, we have only compared clusters within Cwm Taf University Health Board. 3

4 Definitions Age groups The younger age group in this report refers to patients aged less than 75 years at diagnosis and the older age group refers to patients aged 75 years and older at diagnosis. Stage category Early stage cancers are defined as those cases diagnosed in stage one or stage two. Late stage cancers are defined as those cases diagnosed in stage three or stage four and unknown stage cancers do not have a defined stage. See for further details. Crude rates and age specific rates Crude rates are calculated by taking the total number of cases and dividing by the total population for that area and do not take into account how many old or young people are in the population. An age specific rate is calculated by taking the total number of cases in a particular age group (and area), and dividing by the total population in that age group (and area). Age standardised rates and EASR Age standardisation adjusts rates to take into account how many old or young people are in the population being looked at. When rates are age standardised, you know that differences in the rates over time or between geographical areas do not simply reflect variations or changes in the age structure of the populations. This is important when looking at cancer rates because cancer mainly affects older people. Throughout this report we use European Age Standardised Rates (EASR) using the 2013 European Standard Population (ESP) unless otherwise specified. Statistical significance (expressed in this report with 95% confidence intervals (CIs)) If a difference between rates or survival between populations is statistically significant, it means that the difference is unlikely to have occurred due to chance alone, and that we can be more confident that we are observing a true difference. In this report we use the conventional arbitrary cut-off of less than a 5% chance to mean statistically significant. Just because a difference is statistically significant, it doesn t necessarily mean that it is large or important - that can depend on our judgement and other factors. Relative Survival This is a way of comparing the survival of people who have a specific disease in our case, cancer - with the survival experienced by the general population, over a certain period of time. It is calculated by dividing the percentage of patients with the disease who are still alive at the end of the period of time (e.g. one or five years after diagnosis) by the percentage of people in the general population of the same sex and age who are alive at the end of the same time period. The relative survival rate shows whether the disease shortens life. We use relative survival in this report. 4

5 Contents Contents... 5 Summary... 7 Introduction Lung cancer incidence Key findings a) By sex b) By age c) By deprivation d) By deprivation and age Lung cancer incidence by stage at diagnosis Key findings a) By sex b) By age c) By deprivation Lung cancer survival Key findings a) By sex b) By age c) By deprivation d) By deprivation and age Lung cancer survival by stage Key findings a) By sex b) By age c) By deprivation References Appendix 1 Counts for lung cancer incidence Appendix 2 Number of cases and deaths for lung cancer survival

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7 Summary Lung cancer is one of the commonest cancers in Wales and shows the widest inequalities. The incidence in women in Wales is rapidly increasing and is amongst the highest in Europe. In men it continues to decline. The gap between the high incidence in the most deprived areas and the lower rates in the least deprived areas is widening. Survival from lung cancer is poor. Around 70 per cent of people die within a year of diagnosis in Wales. Our survival rates are almost the lowest in Europe 1. People diagnosed at age 75 years and older and living in the least deprived areas in Wales have better survival than in the most deprived. Survival worsens with increasing deprivation for the earliest stage at diagnosis only, in other stages the association is unclear 2. Regardless of area deprivation, there is geographic variation. Some key factors associated with worse survival include late stage at diagnosis and older age. Over 70 per cent survive a year if diagnosed in the earliest stage, but most cases around two-thirds are diagnosed at late stages or at death. We know from national lung cancer audits that a low proportion of lung cancer patients receive definitive treatment in Wales 3. Cwm Taf has one of the highest incidence rates of the health boards. This is in the context of Wales incidence being relatively high in Europe, although Cwm Taf has one of the narrowest deprivation gaps of all the health boards for men s incidence. The crude lung cancer incidence rate varies widely between Cwm Taf clusters the highest rate is over one-and-a-half times the lowest rate. Women aged 75 years and older show the widest variation in incidence. Although late stage presentation is the most common in all health boards except Powys, the proportion in Cwm Taf is over four percentage points higher than Wales. The proportion of unknown stage cases is statistically significantly lower than Wales. Stage distribution varies considerably across the clusters, although no differences reach statistical significance. Cwm Taf has the second highest health board survival rate, but, of course, we must recall that Wales has a low survival rate compared to most European countries. Overall, no trend can be seen by deprivation, however, when age is taken into account, the least deprived in the older age group have better survival. Survival is lower in the older age group across all Cwm Taf clusters. Cwm Taf is very similar to Wales for survival of late stage cancers. The implications of our report for Cwm Taf s clusters are clear. The international and within-wales comparisons we make suggest lower incidence, less inequality and better survival may be possible at cluster level. Although variations between clusters due to small numbers often prevent us from making firm statistical conclusions, further interpretation with expert local knowledge and by considering the Wales and international context can add to the understanding of our cluster level findings. Smoking prevalence in Wales has reduced but could be lower, especially in deprived areas and amongst women. Our report sheds some light on the variation in stage at diagnosis and in survival by stage in relation to age, sex and deprivation across clusters. Earlier diagnosis and rapid access to potentially curative treatments such as surgery and radiotherapy are crucial to improved survival. We hope that our report can contribute to cluster level reviews of lung cancer cases and addressing inequalities in incidence and Wales poor survival. 7

8 Introduction Lung cancer incidence Lung cancer is one of the four most common cancers in Wales and the most common cancer worldwide. It is the commonest cancer leading to death in the European Union. In Wales, each year it accounts for more deaths than breast and colorectal cancers combined. Most cases of lung cancer are non-small cell lung cancer. At an early stage it is potentially curable or survival can be improved with surgery and/or radiotherapy. However, at present, most people in Wales present with a late stage of disease or are diagnosed at death. The women s lung cancer incidence rate in Wales is the third highest of 40 European countries 4. The rate in men is higher than 11 of those 40 countries. Lung cancer incidence cannot be ignored anywhere in Wales. The annual number of cases and the incidence rate is increasing in women in Wales, especially amongst older women. Over ten years, annual numbers remained similar in men, but in women they increased by over a third. Overall, numbers increased by ten per cent. The annual number of cases in women is now slowly approaching that in men. In Wales in 2013 there were 1,343 new cases in men and 1,075 in women. Around two-thirds of cases occurred in ages 60 to 79 years, just over ten per cent were in under 60s, and a quarter occurred in ages 80+ years. Risk factors Smoking (including environmental tobacco smoke or passive smoking) causes most cases of lung cancer, so it is largely preventable through effective tobacco control and by addressing other modifiable risk factors. It may be responsible for over 90 per cent of cases in men and around 78 per cent in women 5. In the Welsh Health Survey , 21 per cent of adults aged 16 or older self-reported they smoked daily or occasionally. Further detail is found in table 2. By comparison, the Organisation for Economic Co-operation and Development (OECD) 7 reported that 14 per cent of adults smoked daily in Sweden in These smoking rates have implications for the future, but today s lung cancer incidence reflects smoking patterns in the 1970s, 80s and early 90s men s cigarette smoking peaked in the 1940s, but women s peaked in the late 1980s, when the gap between men and women was getting smaller. We estimate that in smokers and non-smokers in Wales, around 36 new cases of lung cancer are diagnosed each week as a result of tobacco smoke s effects, and nine per week due to other factors such as naturally-occurring radioactive radon gas, asbestos exposure and transport air pollution 4. Separately to the risk of mesothelioma from asbestos, asbestos-related lung cancer risk is also quite high, but only people from certain occupations were exposed, along with their spouses or partners at home smoking increases the lung cancer risk from asbestos considerably. The risk from radon is modest but 8

9 increases with increasing radon exposure in homes and workplaces its risk is much higher in smokers, and many people may be exposed to both. Due to its geology, many parts of Wales lie in identified radon affected areas. Risk from outdoor fine particulate air pollution is modest but increases with increasing pollution, mainly from transport many people may be exposed and trafficrelated particulate pollution is increasing. Silica dust is also related to lung cancer risk where long-term silica dust exposure has caused silicosis in the lungs, but not from silica dust exposure alone. Silicosis used to be common in Wales amongst coal miners and slate quarry workers. Deprivation and lung cancer incidence Lung cancer has the strongest link to deprivation of all the most common cancers, mainly due to the link with smoking and past industries. Over twice as many new cases of lung cancer are diagnosed annually in the most deprived fifth of areas in Wales compared to the least deprived fifth. The gradient of incidence rate also increases steeply moving from the least to the most deprived areas it is about two-and-a-half times higher in the most deprived fifth of areas compared to the least deprived fifth. This gap in incidence rate between the most deprived and least deprived areas has increased by over a quarter in ten years. Poor survival but potentially curable Survival from lung cancer is poor compared to most other common cancers. Around 70 per cent of all people with lung cancer in Wales die from the disease within a year. Relative lung cancer survival in Wales is almost the lowest in Europe 28 th out of 29 countries in the Eurocare study 1. One year lung cancer survival in Wales is consistently the lowest of all UK countries 2 for men and women the slight increases since 1999 are the smallest in the UK. Survival dramatically decreases with increasing age. Lung cancer stage at diagnosis is strongly related to one year survival. Lung cancer can potentially be cured or survival improved if it is diagnosed early, although many other factors play a part in addition to early diagnosis. Most people in Wales present with a late stage of disease or are diagnosed at death, but 17 per cent present in early stage (stage 1 and stage 2), when the disease is potentially curable by surgery and radiotherapy. These figures vary between health board populations. Overall, survival varies little by area deprivation, unlike the wide inequalities in incidence. However, there are large differences in survival for potentially treatable early stage lung cancer cases and late stage cases, where one year survival in Wales is 71 per cent for early stage cases, but is only 23 per cent for late stage cancer cases in Wales. 9

10 The importance of GP clusters The Programme for Government 8 set out action to support the delivery of effective and efficient public services to meet the needs of people in Wales. Increasingly this involves people in the design and delivery of services for services in their community. Together for Health 9 the five year vision for the NHS in Wales - tasked each NHS organisation to work with its community and partners to plan and develop services to improve quality and ensure sustainability. In the Plan for a Primary Care Service for Wales 10, planning care locally is highlighted as one of five priority areas for action. Health boards have developed arrangements for small groups of GP practices, called GP clusters, to work collaboratively to develop services in the community, serving registered GP populations of between 25,000 and 100,000 patients. Currently there are 64 such clusters in Wales and eight associated with Cwm Taf University Health Board. This approach is intended to engage all local services in a coordinated response to address need through a social model of health to promote physical, mental and social wellbeing. GP Cluster Profiles 2013 were published by the Public Health Wales Observatory 11 in 2013 and later followed by New General Practice Population Profiles in June 2015 on their intranet site 12. They formed part of the high quality health intelligence intended to inform local analysis and priority setting and to help to engage local communities in developing appropriate solutions. They have informed local needs assessments and action plans. In addition, the prevention and early detection of cancer has been identified as a National Clinical Priority Area for General Practice for 2014/15 and 2015/16 in recognition of the relatively poor cancer survival outcomes in Wales compared to the best in Europe. Detailed analysis is undertaken through individual case reviews to explore potential diagnosis and treatment delays and to identify opportunities for service improvement, including for lung cancer cases. This work is informed by learning from the International Cancer Benchmarking Partnership Project. Our GP Cluster Lung Cancer Profiles are also intended to inform this process. 10

11 Cwm Taf University Health Board consists of the following eight GP clusters: Table 1: Cwm Taf s GP clusters are made up of 46 practices in total, each with a varying burden of lung cancer GP Cluster No. GP practices Average annual list size i Average number of lung cancer cases per year Crude rate per 100,000 population South Taf Ely * North Taf Ely North Merthyr Tydfil North Cynon South Merthyr Tydfil South Cynon South Rhondda North Rhondda ** Total i Welsh patients only * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by crude rate The following map shows where the practices in each cluster lie: 11

12 The GP surgeries within each GP cluster in Cwm Taf Crown Copyright and database right Ordnance Survey NB. Please note that some GP practices overlap and that the boxes do not represent the borders of the clusters 12

13 Section 1 Lung cancer incidence 1 Lung cancer incidence Key findings The age standardised lung cancer incidence rate in Cwm Taf is statistically significantly higher than Wales as a whole and highest of the health boards for both genders it also has the highest smoking prevalence of all health boards There is wide variation in the crude lung cancer incidence rate between Cwm Taf clusters. The highest crude incidence rate for women in North Rhondda is almost double the lowest rate for women in South Taf Ely, which is statistically significantly different to women in Cwm Taf There is a general trend of lung cancer incidence in Cwm Taf clusters being higher in men than women, with some variation Cwm Taf s men and women have the highest incidence rates of all health boards in both age groups - statistically significantly high for men in the younger age group, and women in the older age group, compared to the respective age groups in Wales as a whole In women aged 75 years and older, the incidence rate in the North Cynon cluster is less than half that in both South and North Merthyr Tydfil, and is statistically significantly lower than the women s rate for Cwm Taf in that age group Even though cluster lung cancer incidence rates are much higher in older than younger age groups, generally more cases occur in under 75 year olds The lung cancer incidence rate increases sharply moving from the least to most deprived areas of Wales and within each health board, a pattern also seen in the majority of clusters Nevertheless, Cwm Taf has the second narrowest deprivation gap of all health boards in lung cancer incidence for men when comparing areas in the least deprived fifth and the most deprived fifth Lung cancer incidence has a similar deprivation gap in both the younger and older age group for Wales as a whole, however Cwm Taf has a considerably wider incidence deprivation gap in the younger age group compared to the older age group a similar pattern is evident across a few Cwm Taf clusters although confidence intervals are very wide for the majority of these clusters 13

14 Section 1 Lung cancer incidence a) By sex Figure 1: The age standardised lung cancer incidence rate in Cwm Taf is statistically significantly higher than Wales as a whole and highest of the health boards for both genders Men Women Wales (men 99.9, women 65.4) EASR per 100,000 population Cwm Taf Cardiff & Vale Abertawe Bro Morgannwg Aneurin Bevan Betsi Cadwaladr Hywel Dda Powys 120.9** * 73.4* 81.7** * 41.3* * statistically significantly lower than Wales ** statistically significantly higher than Wales Ordered by persons EASR NB. Please do not compare figure 1 showing EASRs to figure 2 showing crude rates Table 2: Just over one in five Welsh people smoke with only small differences between the health board populations. Cwm Taf has the highest smoking prevalence of all the health boards Health Board Smoking Prevalence (%) Source: Public Health Wales Observatory derived from Quality Outcomes Framework Data 2013/14 (QOF) ii 1 = lowest smoking prevalence, 7 = highest smoking prevalence Ordered by rank Rank out of 7 health boards ii Powys Hywel Dda Cardiff & Vale Betsi Cadwaladr Abertawe Bro Morgannwg Aneurin Bevan Cwm Taf Wales

15 Section 1 Lung cancer incidence Figure 2: The lowest cluster crude lung cancer incidence rate is seen in South Taf Ely where it is statistically significantly lower than Cwm Taf for both men and women Men Women Cwm Taf (men 98.7, women 79.8) North Rhondda South Rhondda South Cynon South Merthyr Tydfil North Cynon North Merthyr Tydfil North Taf Ely South Taf Ely Crude rate per 100,000 population * 53.2* * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by persons crude rate NB. Please do not compare figure 1 showing EASRs to figure 2 showing crude rates Table 3: Smoking prevalence is high in Cwm Taf clusters with the majority of the clusters in the bottom half of the smoking prevalence table GP Cluster Smoking Prevalence (%) Source: Public Health Wales Observatory derived from Quality Outcomes Framework Data 2013/14 (QOF) iii 1 = lowest smoking prevalence, 64 = highest smoking prevalence Ordered by rank Rank out of 64 GP clusters iii South Taf Ely North Taf Ely South Merthyr Tydfil North Cynon North Rhondda North Merthyr Tydfil South Rhondda South Cynon

16 Section 1 Lung cancer incidence The Cwm Taf University Health Board population has the highest incidence rate of lung cancer of all the health boards for both men and women, and statistically significantly higher rates than Wales as a whole. We should also still remember that Wales and the health boards have high rates compared to many European countries 13. There is considerable variation between Cwm Taf clusters with South Taf Ely being statistically significantly lower than Cwm Taf as a whole (table 1), and North Rhondda statistically significantly higher. Although contemporary smoking prevalence in the health boards and clusters do not show us historic trends, the prevalence is broadly consistent with the observed variation in lung cancer incidence. Significant variation in the age profiles of practice populations will also account for a large amount. South Taf Ely is the largest GP cluster in Cwm Taf in terms of patient list size and has the lowest rate of lung cancer over all eight GP clusters in Cwm Taf. As expected, there is a general trend of the lung cancer incidence in Cwm Taf clusters being higher in men than women. In South Cynon, the rate for men is over one-and-a-half times that of women (109.9 compared to 72.7 per 100,000 population respectively), whereas in South Rhondda, the rate is very similar (92.8 for men compared to 94.6 for women per 100,000 population). In South Taf Ely, the incidence rate for women is just over half that of the highest rate in North Rhondda (53.2 compared to 99.0 per 100,000 population respectively) and is statistically significantly low compared to the women in Cwm Taf as a whole. The men s incidence rate in South Taf Ely is also statistically significantly lower than Cwm Taf s men. It is ranked lowest of all the GP clusters in Cwm Taf for smoking prevalence. Generally, for the health boards in Wales, the rate for women is between 30 and 40 per 100,000 population lower than the rate for men. However, as we have previously reported 4, although women in Wales still have a lower rate of lung cancer than men the gap is narrowing as the rate in women is increasing while the rate in men is levelling off. 16

17 Section 1 Lung cancer incidence b) By age Table 4: Cwm Taf has the highest rates of lung cancer of all health boards for each gender and age group statistically significantly higher than the corresponding rates in Wales for men aged under 75 years and women aged 75 years and older No. Cases <75 years 75+ years Men Women Men Women Age specific rate per 100,000 (CIs) No. Cases Age specific rate per 100,000 (CIs) No. Cases Age specific rate per 100,000 (CIs) No. Cases * statistically significantly lower than Wales ** statistically significantly higher than Wales Age specific rate per 100,000 (CIs) Betsi Cadwaladr (53.3, 60.9) (43.9, 50.8) (528.5, 610.7) (254.2, 301.8) Hywel Dda (52.3, 62.5) (42.6, 51.9) (421.2, 518.5) * (193.9, 250.4) Abertawe Bro Morgannwg (49.3, 57.7) (40.2, 47.8) (481.1, 577.9) (294.5, 356.6) Cardiff & Vale * (38.6, 46.5) * (31.2, 38.3) (511.9, 628.6) (257.7, 324.5) Cwm Taf ** (57.4, 69.6) (42.6, 53.1) (556.6, 705.1) ** (354.7, 451.1) Aneurin Bevan (48.6, 56.5) (35.0, 41.7) (485.4, 579.4) ** (309.9, 372.1) Powys (38.8, 54.6) (28.2, 41.9) * (344.5, 493.8) * (130.8, 212.8) Wales (51.7, 55.2) (41.0, 44.0) (517.2, 556.7) (283.2, 307.3) Table 5: Cwm Taf cluster incidence rates vary widely in those aged 75 and older older women in North Cynon have a rate statistically significantly lower than the women in the older age group in Cwm Taf GP Cluster No. Cases <75 years 75+ years Men Women Men Women Age specific rate per 100,000 (CIs) No. Cases Age specific rate per 100,000 (CIs) No. Cases Age specific rate per 100,000 (CIs) No. Cases Age specific rate per 100,000 (CIs) North Cynon (43.3, 75.6) (44.6, 77.4) (491.2, 921.2) * (147.8, 349.8) South Cynon (49.9, 99.6) (32.4, 75.2) (461.9, ) (158.3, 485.7) North Rhondda (60.2, 99.0) (41.1, 75.0) (472.1, 878.8) (327.6, 601.1) South Rhondda (47.8, 79.2) (46.0, 77.6) (398.9, 773.6) (307.4, 568.0) South Taf Ely (36.3, 60.7) * (20.9, 40.2) (350.9, 686.9) (250.5, 490.3) North Taf Ely (42.2, 70.3) (29.5, 55.4) (432.4, 811.0) (322.0, 586.6) South Merthyr Tydfil (42.2, 81.8) (28.6, 63.2) (401.1, 914.8) (343.8, 718.3) North Merthyr Tydfil (37.3, 71.6) (27.9, 59.1) (432.7, 903.9) (351.5, 694.7) Cwm Taf (57.4, 69.6) (42.6, 53.1) (556.6, 705.1) (354.7, 451.1) * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Cwm Taf has the highest rates of lung cancer for each gender and age group. These are statistically significantly higher than the corresponding rates in Wales for men in the younger age group and for women in the older age group. The rates in South Taf Ely women in the younger age group and North Cynon women in the older age group are statistically significantly lower than the corresponding rates in Cwm Taf. For women in the older age group in South Merthyr Tydfil, the incidence rate is over twice the rate of older North Cynon women (506.0 compared to per 100,000 population) (table 5). 17

18 European Age Standardised Rate per 100,000 population Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Section 1 Lung cancer incidence c) By deprivation Figure 3: For men, Cwm Taf has the second narrowest deprivation gap in lung cancer incidence between areas in the least deprived fifth and the most deprived fifth of all health boards Least deprived fifth Next least deprived fifth Middle deprived fifth Next most deprived fifth Most deprived fifth 0 Betsi Cadwaladr Hywel Dda Abertawe Bro Morgannwg Cardiff & Vale Cwm Taf Aneurin Bevan Powys Wales NB. Please note here that deprivation fifths have been used as opposed to deprivation halves in figure 4. Please do not compare figure 3 showing EASRs to figure 4 showing crude rates 18

19 Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Crude rate per 100,000 population Section 1 Lung cancer incidence Figure 4: Lung cancer incidence is higher in the most deprived areas of almost all Cwm Taf s clusters, with varying deprivation gaps, and generally men have higher rates than women 140 Least deprived half Most deprived half North Cynon South Cynon North Rhondda South Rhondda South Taf Ely North Taf Ely South North Merthyr Merthyr Tydfil Tydfil Cwm Taf NB. Please note here that deprivation halves have been used as opposed to deprivation fifths in figure 3 due to the smaller number of cases. Please do not compare figure 3 showing EASRs to figure 4 showing crude rates There were no lung cancer cases for women in South Rhondda in the least deprived half Although the overall lung cancer incidence rates for men and women in Cwm Taf are broadly similar to Wales, the inequalities within Cwm Taf are wider than those in Wales for women. There is a steep gradient of increasing incidence for men and women moving from the least deprived fifth of small areas through to the most deprived fifth. For men these inequalities are the second narrowest in Cwm Taf compared to the other health boards. The inequalities are still wide, however. These inequalities are of great concern because most cases of lung cancer occur in the most deprived areas. The general pattern of inequalities is also apparent when the most deprived half of areas is compared to the least deprived half within each Cwm Taf cluster, although some variation may be due to the small numbers of cases in some clusters. 19

20 Section 1 Lung cancer incidence d) By deprivation and age Figure 5: Lung cancer incidence has a similar deprivation gap in both the younger and older age groups for Wales as a whole, however Cwm Taf has the largest difference in the younger age group with the most deprived half having over twice the incidence rate of the least deprived half Most deprived half Least deprived half < 75 years 75+ years Cwm Taf Betsi Cadwaladr Abertawe Bro Morgannwg Cardiff and Vale Aneurin Bevan Hywel Dda Powys Wales ** * 53.4* ** * * * statistically significantly lower than Wales ** statistically significantly higher than Wales Ordered by the age specific rate for the least deprived half and the 75+ age group 20

21 Section 1 Lung cancer incidence Figure 6: The lung cancer incidence rate by deprivation half shows much variation across the clusters for the older age group, mainly due to the small numbers involved shown by the wide confidence intervals Most deprived half Least deprived half < 75 years 75+ years North Taf Ely South Merthyr Tydfil South Taf Ely North Cynon North Rhondda North Merthyr Tydfil South Cynon South Rhondda Cwm Taf * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by the age specific rate for the least deprived half and the 75+ age group Although there were no statistically significant results when comparing Cwm Taf to Wales and the GP clusters to Cwm Taf, statistically significant differences can be seen comparing the least deprived half to the most deprived half for each age group where the confidence intervals do not overlap. The majority of the rates in health boards show statistically significant results between the deprivation halves, whereas no statistically significant results can be seen at GP cluster level due to smaller numbers and wide confidence intervals. 21

22 Section 2 Lung cancer incidence by stage at diagnosis 2 Lung cancer incidence by stage at diagnosis Key findings Most cases of lung cancer are diagnosed at a late stage Cwm Taf has a statistically significantly higher proportion of late stage lung cancer cases compared to Wales as a whole but a statistically significantly lower proportion of unknown stage cases The stage distribution varies considerably across Cwm Taf clusters all clusters have a higher proportion of late stage cases than early or unknown stage, although no proportions are statistically significantly different to Cwm Taf The proportion of unknown stage lung cancer is consistently higher in the older age group compared to the younger age group across the health boards and Cwm Taf clusters Cwm Taf shows fairly similar stage distribution for both deprivation halves There is no clear pattern in the stage distribution between the least and most deprived areas across Cwm Taf clusters 22

23 Section 2 Lung cancer incidence by stage at diagnosis a) By sex Figure 7: There is variation in the lung cancer stage at diagnosis distribution across Wales - Cwm Taf has a statistically significantly higher proportion of late stage cancers compared to Wales as a whole but a statistically significantly lower proportion of unknown stage lung cancers Early stage Late stage Unknown stage Wales early stage (17.0) Wales late stage (63.6) Wales unknown stage (19.4) Cardiff & Vale Cwm Taf Aneurin Bevan Betsi Cadwaladr Hywel Dda Abertawe Bro Morgannwg Powys 22.1** * ** 13.1* * 22.7** ** 16.3* * 34.2* 58.0** * statistically significantly lower than Wales ** statistically significantly higher than Wales Ordered by proportion of early stage lung cancers Figure 8: The stage at diagnosis distribution varies across Cwm Taf clusters but all clusters show a high proportion of late stage cancers Early stage Late stage Unknown stage Cwm Taf early stage (19.0) Cwm Taf late stage (67.9) Cwm Taf unknown stage (13.1) South Rhondda South Taf Ely North Rhondda South Cynon North Cynon North Taf Ely North Merthyr Tydfil South Merthyr Tydfil * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by proportion of early stage lung cancers 23

24 Section 2 Lung cancer incidence by stage at diagnosis Lung cancer diagnosed at stage one and stage two have been classified as early stage. Depending on several other factors, people presenting with early stage lung cancer may be potentially treatable with a curative intent and survival tends to be much higher than in late stage disease. Lung cancers diagnosed at stage three and stage four have been classified as late stage and treatment can be aimed at prolonging survival, maintaining quality of life and amelioration of symptoms. Patients who have no stage recorded or not enough staging information to determine an overall stage have been classified as unknown stage on the cancer registry. Unknown stage consists of: death certificate only cases (DCOs) where the lung cancer is only identified on a death certificate and there is no further information on staging available cross-border cases where people are treated outside Wales and no staging information is received with their cancer registration. This mainly affects Powys and to a lesser degree Betsi Cadwaladr (please note this has now been rectified and all staging information will be received for newly diagnosed cases) patients with a more clinically advanced stage of lung cancer (with or without other co-morbidities) tend not to have biopsies, resections or further diagnostic investigations, therefore no or limited staging information is available patients with incorrect or incomplete staging information recorded In common with the rest of the UK and elsewhere in Europe, the majority of lung cancer cases are diagnosed at a late stage of disease in Wales. Cwm Taf has the second largest proportion of late stage lung cancers compared to the other health boards. This proportion is statistically significantly higher compared to Wales. This may be due to the proportion of unknown stage cases being statistically significantly lower in Cwm Taf than Wales, and as mentioned above, the majority of the unknown stage cases are thought to be late stage. Considering the clusters within Cwm Taf, no cluster has a proportion of cancers in any stage which is statistically significantly different to Cwm Taf. 24

25 Powys Aneurin Bevan Cwm Taf Cardiff & Vale Abertawe Bro Morgannwg Hywel Dda Betsi Cadwaladr Section 2 Lung cancer incidence by stage at diagnosis b) By age Figure 9: The proportion of unknown stage lung cancer is consistently higher in the older age group compared to the younger age group across health boards, but the proportion of early stage disease varies less Early stage Late stage Unknown stage 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <75 years years <75 years years <75 years years <75 years years <75 years years <75 years years <75 years years

26 North Merthyr Tydfil South Merthyr Tydfil North Taf Ely South Taf Ely South Rhondda North Rhondda South Cynon North Cynon Section 2 Lung cancer incidence by stage at diagnosis Figure 10: The proportion of unknown stage lung cancer is consistently higher in the older age group compared to the younger age group across Cwm Taf clusters Early stage Late stage Unknown stage 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <75 years years <75 years years <75 years years <75 years years <75 years years <75 years years <75 years years <75 years *** *** *** 75+ years *** *** *** *** numbers have been suppressed due to the small number of cases The distribution of stage at diagnosis for lung cancer varies by age but for all health boards (except Powys) and GP clusters in Cwm Taf, the largest category by far is late stage for both age groups. The proportion of cases with an unknown stage is higher for people aged 75 years and older compared to people younger than 75 years in figure 9 and figure 10. For both age groups, Cwm Taf has the lowest proportion of unknown stage cancers of all the health boards. There is less variation between the age groups in the proportion diagnosed with early stage disease. 26

27 Powys Aneurin Bevan Cwm Taf Cardiff & Vale Abertawe Bro Morgannwg Hywel Dda Betsi Cadwaladr Section 2 Lung cancer incidence by stage at diagnosis c) By deprivation Figure 11: There is little variation in stage distribution between the least and most deprived areas of Cwm Taf, which shows very similar stage distribution for both deprivation halves Early stage Late stage Unknown stage 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived

28 North Merthyr Tydfil South Merthyr Tydfil North Taf Ely South Taf Ely South Rhondda North Rhondda South Cynon North Cynon Section 2 Lung cancer incidence by stage at diagnosis Figure 12: There is no clear pattern in the stage distribution of Cwm Taf s clusters this may be due to the small numbers involved Early stage Late stage Unknown stage 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived Least deprived Most deprived NB. All numbers have been suppressed due to the small number of cases Generally, there is little variation in stage distribution between the least and most deprived areas of Cwm Taf and several other health boards. However, there is no discernible pattern in the stage distribution for Cwm Taf s GP clusters, possibly due to the small numbers involved. 28

29 Section 3 Lung cancer survival 3 Lung cancer survival Key findings Cwm Taf has slightly better survival for men than Wales as a whole but slightly worse survival for women neither of these results are statistically significantly different to Wales Survival rates for women are better than for men across the health boards and, in general, across Cwm Taf clusters Cwm Taf has the second highest survival rate for both age groups compared to the health boards and Wales as a whole although not statistically significant Lung cancer survival is considerably lower in the older than the younger age group across all health boards the variation between health boards is slightly greater in the older age group Survival is also lower in the older age group compared to the younger age group across all Cwm Taf clusters, but with wide confidence intervals Differences in survival between men and women tend to be wider in the younger age group compared to the older age group for all health boards Overall, there is no clear trend in the lung cancer survival related to area deprivation at the health board and Cwm Taf cluster level Taking age into consideration, people diagnosed at age 75 years and older and living in the least deprived half in Wales have a statistically significantly higher survival of four percentage points compared to those in the most deprived half 29

30 Section 3 Lung cancer survival a) By sex Figure 13: One year relative survival from lung cancer is consistently higher in women than men, with little variation across the health boards Men Women Wales (men 28.2%, women 33.9%) Betsi Cadwaladr Cwm Taf Hywel Dda Abertawe Bro Morgannwg Cardiff & Vale Powys Aneurin Bevan 32.2** * statistically significantly lower than Wales ** statistically significantly higher than Wales Ordered by persons one year relative survival Figure 14: One year relative survival from lung cancer is generally higher in women than men, with some exceptions and variation between clusters Men Women Cwm Taf (men 30.2%, women 32.6%) North Cynon North Merthyr Tydfil South Cynon North Rhondda South Taf Ely South Merthyr Tydfil North Taf Ely South Rhondda * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by persons one year relative survival 30

31 Section 3 Lung cancer survival Survival from lung cancer is poor compared to most other common cancers. Overall, one year relative survival is 5.7 percentage points higher in women than in men in Wales. In general, for both sexes there is only small variation between the health boards. For men, Cwm Taf has the second highest survival rate of the health boards but for women it has the second lowest survival. Similarly, there is a general pattern of higher survival in women than men across Cwm Taf clusters, but confidence intervals are wide due to small numbers. Only in North Taf Ely do men have higher survival than women. 31

32 One year relative survival (%) Section 3 Lung cancer survival b) By age Figure 15: Survival is consistently lower in the older versus younger age groups for each health board <75 years 75+ years Wales <75 years (35.2%) Wales 75+ years (24.0%) Betsi Cadwaladr Hywel Dda Abertawe Bro Cardiff & Vale Cwm Taf Aneurin Morgannwg Bevan Powys * statistically significantly lower than Wales ** statistically significantly higher than Wales Table 6: Women have better survival rates than men in both age groups in all health boards the difference between the genders is consistently wider in the younger age group compared to the older age group Men one year survival % (CIs) <75 years 75+ years Women one year survival % (CIs) Absolute difference Men one year survival % (CIs) Women one year survival % (CIs) Absolute difference Health Board Betsi Cadwaladr 35.3 (31.9, 38.7) 40.3 (36.4, 44.1) (23.2, 30.8) 27.0 (22.7, 31.4) 0.0 Hywel Dda 29.6 (25.3, 34.0) 39.0 (33.9, 44.0) (16.7, 26.2) 27.7 (21.4, 34.3) 6.5 Abertawe Bro Morgannwg 29.6 (25.8, 33.6) 39.9 (35.4, 44.5) (16.2, 25.0) 25.4 (20.8, 30.2) 5.0 Cardiff & Vale 29.0 (24.6, 33.5) 41.8 (36.5, 47.1) (12.1, 20.9) 28.6 (22.7, 34.7) 12.3 Cwm Taf 33.6 (28.8, 38.4) 38.9 (33.2, 44.6) (18.3, 29.8) 24.0 (18.5, 30.0) 0.2 Aneurin Bevan 32.2 (28.5, 36.0) 35.8 (31.4, 40.3) (15.8, 24.1) 21.7 (17.6, 26.1) 2.0 Powys 29.8 (21.7, 38.3) 41.2 (30.5, 51.4) (12.8, 29.8) 22.2 (12.1, 34.2) 1.6 Wales 31.9 (30.3, 33.5) 39.3 (37.4, 41.2) (20.1, 23.7) 25.4 (23.4, 27.5)

33 One year relative survival (%) Section 3 Lung cancer survival Figure 16: Survival is higher in the younger age group as expected, with the largest absolute difference showing in North Rhondda 55 <75 years 75+ years Cwm Taf <75 years (35.9%) Cwm Taf 75+ years (24.2%) North Cynon South Cynon North Rhondda South Rhondda South Taf Ely North Taf Ely South Merthyr Tydfil North Merthyr Tydfil * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Survival is consistently lower in the older versus younger age groups for each health board. In Cwm Taf, all the measures are close to the Wales survival rates. Survival is over ten percentage points higher in the younger compared to the older age group in Cwm Taf. Around a third of the younger people survive one year after diagnosis, whereas only a quarter of the older people do so. As expected, survival in the younger age group is also consistently higher than in the older age group across all Cwm Taf clusters. For each age group, there is variation between the clusters around the corresponding Cwm Taf survival rate. Variation due to the small numbers involved in each cluster is likely to explain most of the observed differences within the age groups. The confidence intervals remain wide, with no results statistically significantly different to Cwm Taf. However, survival is statistically significantly higher in the younger age group compared to the older age group in North Rhondda and South Taf Ely, where the confidence intervals do not overlap. 33

34 Section 3 Lung cancer survival c) By deprivation Figure 17: One year relative survival from lung cancer shows no apparent trend with increasing area deprivation in any health board or in Wales as a whole Least deprived fifth Next least deprived fifth Middle deprived fifth Next most deprived fifth Most deprived fifth Betsi Cadwaladr Hywel Dda Abertawe Bro Morgannwg Cardiff & Vale Cwm Taf Aneurin Bevan Powys Wales NB. Please note here that deprivation fifths have been used 34

35 Section 3 Lung cancer survival Figure 18: One year relative survival from lung cancer shows no apparent trend with increasing area deprivation across Cwm Taf clusters Least deprived half Most deprived half Cwm Taf least deprived half (30.6%) Cwm Taf most deprived half (31.1%) North Cynon South Cynon South Taf Ely North Rhondda North Merthyr Tydfil South Merthyr Tydfil North Taf Ely South Rhondda * statistically significantly lower than Cwm Taf ** statistically significantly higher than Cwm Taf Ordered by one year relative survival of the most deprived half NB. Please note here that deprivation halves have been used as opposed to fifths due to the smaller number of cases South Cynon, South Merthyr Tydfil and North and South Rhondda have been suppressed for the least deprived half due to the small number of cases The lack of a relationship between one year relative survival of lung cancer with increasing area deprivation for Wales as a whole and in each health board also occurs at Cwm Taf cluster level. Half of the GP cluster survival rates for the least deprived half have been suppressed due to the small numbers involved. 35