INFORMATION TO SUPPORT THE DEVELOPMENT OF THE LINCOLNSHIRE CANCER STRATEGY
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1 INFORMATION TO SUPPORT THE DEVELOPMENT OF THE LINCOLNSHIRE CANCER STRATEGY Refreshed March 2013 Ann Ellis, Health Improvement Principal, NHS Lincolnshire Andrew Smith, Information Analyst, NHS Lincolnshire 1
2 CONTENTS Page No. Chapter 1 Introduction Context What is this chapter telling us? 11 Chapter 2 Profile of Cancer within Lincolnshire Prevalence Premature Mortality First Presentation of Cancer What is this chapter telling us? 15 Chapter 3 Profile of Breast Cancer Incidence First Presentation of Breast Cancer in Females Premature Mortality of Breast Cancer Breast Cancer Stage at Diagnosis Breast Cancer Referral Rates Breast Cancer Conversion and Detection Rates Breast Cancer Survival What is this chapter telling us? 29 Chapter 4 Profile of Colorectal Cancer Incidence of Colorectal Cancer across Cancer Networks Incidence of Colorectal Cancer Premature Mortality Colorectal Cancer Colorectal Cancer Stage at Diagnosis Colorectal Cancer Referral Rates Colorectal Cancer Conversion and Detection Rates Colorectal Cancer Survival What is this chapter telling us? 49 Chapter 5 Profile of Lung Cancer Incidence of Lung Cancer Premature Mortality of Lung Cancer (under age of 75) Lung Cancer Referral Rates Lung Cancer Conversion and Detection Rates Lung Cancer Survival What is this chapter telling us? 69 2
3 Chapter 6 Profile of Prostrate Cancer Incidence of Prostrate Cancer First Presentation of Prostrate Cancer Premature Mortality for Prostrate Cancer Urology Cancer Referral Rates Urology Cancer Conversion and Detection Rates Urology Cancer Survival What is this chapter telling us? 81 3
4 Chapter 1 Introduction This document has been produced to assist the development of focused work across Lincolnshire, the Clinical Commissioning Groups (CCG s) and their localities. 1.1 Context Cancer affects around one in three people at some point in their lives. It is largely a disease of life style. According to the Cancer Reform Strategy (2007), over half of all cancers can be prevented by changes in lifestyle. Smoking, obesity, excessive alcohol consumption and too much exposure to the sun are examples of this. 84% of lung cancer deaths are attributable to smoking. Cancer is also a disease of ageing. Lincolnshire has an ageing population therefore it is to be expected to see a large number of cancers diagnosed each year. Cancer incidence is generally positively correlated with deprivation the exceptions being breast, ovary, melanoma and kidney cancers. Cancer screening remains an important way to detect early and in some cases such as cervical screening prevent cancers. The three key areas are recognised nationally: Prevention Awareness and early presentation Prompt diagnosis In Lincolnshire the Early Presentation of Cancer Programme (EPOC) is the vehicle for these three areas to be driven forward. The information contained in this document shows the picture of where we are today so that we can understand the here and now and enable Lincolnshire to move forward to meet the challenges of tomorrow. Definitions First presentation The definition of first presentation is the first identified presentation of cancer whilst the patient is registered with NHS Lincolnshire as an inpatient at hospital. Incidence The incidence is the number of new cases of disease that develop in a population during a specified time period. 4
5 Prevalence Prevalence is the total number of cases of disease in a population at one point in time, taken as a proportion of the total number of persons in that population. Indices of Multiple Deprivation (IMD) Areas of multiple deprivation are identified at the smallest area level and based on a methodology developed by the Social Disadvantage Research Centre at the University of Oxford; separate indices have been constructed for England, Northern Ireland, Scotland and Wales. Though not directly comparable, each index is based on the concept that distinct dimensions of deprivation such as income, employment, education and health can be identified and measured separately. These dimensions, sometimes referred to as 'domains' are then aggregated to provide an overall measure of multiple deprivation and each individual area is allocated a deprivation rank and score. The indices are used to help target policies and funding, and reinforce a common goal to improve the quality of life in disadvantaged communities. 1.1(i) Lincolnshire Cancer Mortality by Age and Deprivation Quintiles Source: Public Heath Mortality File Deprivation quintiles: IMD2010 5
6 When looking at the proportion of cancer deaths for these two age groups during (under and over 75 years) by deprivation quintiles, which ever quintile is analysed there is hardly any difference in both age groups for cancer mortality. The average deprived quintile has the highest proportion for both age groups The next few maps/charts depict: First presentation of cancer as a proxy measure for incidence also expressed as a number broken down to ward level within individual Clinical Commissioning Group (CCG) Age sex population break down (Skegness and Coast included as an example) All age all cancer mortality in number of deaths Multiple Indices of Deprivation. 6
7 1.1(ii) First Presentation of all Cancers in Lincolnshire April 2008 to March
8 1.1(iii) Age and Sex population breakdown of Skegness & Coast (Locality) compared to NHS Lincolnshire as at 1 st January 2012 as an example 8
9 1.1(iv) Mortality From all Cancer in Lincolnshire April 2009 to March
10 1.1(v) Index of Multiple Deprivation 2012 Overall Score 10
11 1.2 What is this chapter telling us? Cancer is largely a disease of life style. According to the cancer reform strategy (2007.) over half of all cancers can be prevented by changes in lifestyle. Smoking, obesity, excessive alcohol consumption and too much exposure to the sun are examples of this. 84% of lung cancer deaths are attributable to smoking. The first presentation map shows us that the incidence of all cancers is high across most of Lincolnshire. Looking at the Clinical Commissioning Groups (CCG s), incidence is high across most of them. Cancer is also a disease of ageing. Lincolnshire has an ageing population therefore it is to be expected to see a large number of cancers diagnosed each year. For Example Skegness has a higher proportion of its population between 60 and 80 years of age than Lincolnshire overall. The map of cancer mortality across Lincolnshire clearly shows us that Skegness and coast, Boston and East Lindsey have high numbers of deaths per ward during the period of April 2009 to March Mortality from all cancers is high across most of the CCG s with the exception of South West Lincolnshire The IMD map shows us areas of deprivation. The deprived and very deprived areas all have higher numbers of cancer deaths. For example Boston, and Skegness and coast (Lincolnshire East CCG). 11
12 Chapter 2 Profile of Cancer within Lincolnshire This chapter looks at the profile of cancer within Lincolnshire. 2.1 Prevalence Definition The definition of prevalence is: The number of people alive who have had a diagnosis of cancer at some point. Figure 2.1(i) Patients on GP Cancer Register Source: Information Centre, QOF 12
13 Practices within NHS Lincolnshire can produce a register of all cancer patients (See Previous Page) defined as a register of living patients with a diagnosis of cancer excluding non-melanotic skin cancer from 1 April It shows that the percentage of registered patients diagnosed with Cancer at a Consortium level is higher compared to the percentage for England. Figure 2.1(ii) Prevalence of Cancer Percentage Change Source: Information Centre, QOF The above depicts prevalence for individual CCG. NHS Lincolnshire overall prevalence has increased year on year. 2.2 Premature Mortality (Under 75 Year Olds) Figure 2.2(i) Directly Aged Standardised Rates (per 100,000) Source: The above depicts premature deaths (deaths under the age of seventy five) from the above cancer types comparing Lincolnshire and England by directly standardised rates (DSR). In Lincolnshire Colorectal (10.54), Malignant Melanoma (2.49) Oesophageal (6.66) and Prostate (9.06) are above the national average. There will need to be further work progressed around malignant melanoma and Oesophageal cancer. 13
14 2.2(ii) Premature Mortality Rates Source: This is a graph of what has been previously discussed in figure 2.2 (ii). 2.3 First Presentation of Cancer Source: Secondary User Service The above depicts first presentation of cancer as a proxy measure for incidence over time. The incidence is increasing in Lincolnshire East, Lincolnshire West and South Lincolnshire CCG s 14
15 2.4 What is this chapter telling us? The number of patients on GP cancer registers is higher than the national average. Prevalence of all cancers across Lincolnshire is rising year on year. This may well fit in with the fact that Lincolnshire has an older population structure than England. First presentation (incidence) is increasing across all of the CCG s with the exception of South West Lincolnshire In Lincolnshire Colorectal (10.54), Malignant Melanoma (2.49) Prostate (9.06) and Oesophageal (6.66) cancer premature mortality are above the national average. All cancer type s premature mortality rates are comparable to the national average. Comparing premature mortality in this report ( ) to last years ( ) there is no great change. The only real change is a reduction in Oesophageal Cancer (7.11 per to 6.66 per 100,000 in ). 15
16 CHAPTER 3 Profile of Breast Cancer 3.1 Incidence Three year average incidence rates have been calculated to lessen the effect of random variation. ( ) Figure 3.1(i) Source Trent Cancer Registry 16
17 There is no statistically significant difference in breast cancer incidence rates between the cancer networks and the national average. The highest rate is in Lincolnshire with per 100,000 female population. Both Sheffield and Leicestershire County and Rutland PCT s are statistically significantly higher than the England average of per 100,000 female population with around 150 per 100,000 female. The following two figures show the incidence of Breast Cancer utilising funnel plots Figure 3.1(ii) Female Breast Cancer Incidence by PCT Source Trent Cancer Registry The above shows the incidence of female breast cancer for Lincolnshire against the national average depicting in PCTs across the North Trent and East Midlands region. The incidence of breast cancer in Lincolnshire is above the average and above the rates of most of its peers. It is three standard deviations above the norm. 17
18 Figure 3.1(iii) Female Breast Cancer Incidence by Cancer Networks Source Trent Cancer Registry The above depicts female breast cancer incidence across the cancer networks in North Trent and East Midlands. East Midlands is above the average, two standard deviations above 18
19 3.2 First Presentation of Breast Cancer in Females First Presentation (incidence) represents the first identified presentation of Breast Cancer, whilst the patient is registered with NHS Lincolnshire as an inpatient at hospital. Figure 3.2(i) NHS Lincolnshire First Presentation of Breast Cancer Source: Secondary User Service The above depicts first presentation of breast cancer (incidence) at NHS Lincolnshire level by age groups. It clearly shows that across all years the incidence is higher in patients aged 75 and over. 19
20 Figure 3.2(ii) CCG First Presentation of Breast Cancer 2009/ /12 Source: Secondary User Service Source: Secondary User Service The above depicts first presentation of female breast cancer in the under 75 age group as a proxy measure for incidence per CCG. Lincolnshire South West CCG has the highest crude rate per 100,000 of patients under the age of 75. Within the CCG Skegness & Coast, Lincoln City South, East Lindsey and Welland are above the Lincolnshire average. 20
21 3.3 Premature Mortality Breast Cancer Figure 3.3(i) NHS Lincolnshire Directly Aged Standardised Rates (per 100,000) Source: 21
22 The previous figure depicts premature mortality from breast cancer across our family of PCT s. Lincolnshire at per 100,000 compares well with the other PCTs and being below the national average of Figure 3.3(ii) CCG Directly Aged Standardised Rates (per 100,000) Source: Public Heath Mortality File The above depicts breast cancer premature mortality rates i.e. deaths under 75 years of age per CCG. Lincolnshire East and Lincolnshire West CCG have the highest 22
23 premature mortality rate. Across the CCGs Lincoln City North, North of Lincoln City Boston and East Lindsey are above the Lincolnshire average. 3.4 Breast Cancer Stage at Diagnosis The following tables and charts show information on stage at diagnosis for new cases of breast cancer between 2009 and 2010 broken down by Cancer Network and PCT. Results for East Staffordshire were unavailable. Figure 3.4(i) Stage of Diagnosis for New Cases of Breast Cancer Source: Trent Cancer Registry 23
24 Source: Trent Cancer Registry According to this information, most cases of breast cancer in Lincolnshire are detected in stages one and two of the disease which is comparable to the rest of the cancer networks and to the East Midlands as a whole. 24
25 3.5 Breast Cancer Referral Rates The chart shows age standardised referral rates for April 2010 to March 2011 by PCT. The referrals are TWW (two week wait with suspected breast cancer) urgent referrals only, resulting in either a cancer diagnosis or no cancer diagnosis. Figure 3.5(i) Referral Rates by PCT Source: Trent Cancer Registry Referral rates for Lincolnshire are approximately 750 per 100,000 female population. 3.6 Breast Cancer Conversion and Detection Rates Definitions The chart shows the proportion of TWW referrals that have a diagnosis of cancer (Conversion Rate) and the proportion of cancers that are referred through the TWW route (Detection Rate). Conversion Rate: the proportion of TWW referrals that resulted in a diagnosis of breast cancer ranges from 7% in Nottingham City and Nottinghamshire County PCT to 15% in Rotherham and Derby City PCTs. 25
26 Detection Rate: the proportion of breast cancers referred through the TWW route is also lowest in Nottinghamshire County PCT at 52%, whilst three quarters of breast cancers diagnosed in Doncaster PCT were referred through the TWW routes. Figure 3.6(i) Conversion and Detection Rates by PCT Source: Trent Cancer Registry Looking at Lincolnshire approximately 58% of breast cancers are diagnosed via the TWW the remaining are diagnosed via other routes. 3.7 Breast Cancer Survival Definition of survival Survival is the proportion of people surviving after a given interval (such as one or five years). Relative survival is the definition most used that adjusts for other non cancer related causes of death. The following depicts information on one and five-year relative survival rates for women with breast cancer diagnosed in , and (one year survival only) by PCT and cancer network. Age-standardised relative survival (ASRS) results are presented here as estimates could be calculated for all areas. 26
27 For one-year relative survival, breast cancer survival rates have improved across all cancer networks over the time period analysed. Figure 3.7(i) Trends in one year relative survival for females aged years diagnosed with breast cancer. RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent cancer Registry One year relative survival rate for breast cancer has increased in Lincolnshire over time. Lincolnshire compares favourably with other PCT s in the cancer networks and in the East Midlands and England. 27
28 Figure 3.7(ii) Trends in five year relative survival for females aged years diagnosed with breast cancer RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry Five year relative survival rate for breast cancer has not greatly increased in Lincolnshire over time. Lincolnshire compares favourably with other PCTs in the cancer networks but lags a little behind East Midlands. 28
29 3.8 What is this chapter telling us?. There is no statistically significant difference in breast cancer incidence rates between the cancer networks or when compared to the national average. However Lincolnshire PCT is statistically higher than the national average of 141 per 100,000 female population with around 153 per 100,000 female. This is an increase from the previous period 150 per 100,000 females. Lincolnshire South West CCG has the highest crude incidence rate per 100,000 of patients under the age of 75. Within the CCG s Skegness & Coast and Lincoln City South and east Lindsey are above the Lincolnshire average. For breast cancer premature mortality across our family of PCTs, Lincolnshire compares well with its peer s. This report shows a slight decrease from per 100,000 female population in to per 100,000 per female population in Lincolnshire East CCG has the highest premature mortality rate for Breast cancer. Across the CCGs Lincoln City North, North of Lincoln City and East Lindsey are above the Lincolnshire average. Most cases of breast cancer in Lincolnshire are detected in stage one and two of the disease which is comparable to the rest of the cancer network. One year relative survival rate for breast cancer has increased in Lincolnshire over time. Lincolnshire compares favourably with other PCT s in the cancer networks and with the East Midlands. Five year relative survival rate for breast cancer has not greatly increased in Lincolnshire over time. Lincolnshire compares favourably with other PCTs in the cancer networks but lags a little behind East Midlands. 29
30 Chapter 4 Profile of Colorectal Cancer 4.1 Incidence of colorectal cancer across cancer networks Three-year average incidence rates have been calculated for to lessen the effect of random variation. There are no statistically significant differences in the rates of colorectal cancer incidence across the cancer networks and when compared to the England average. Lincolnshire compares well with its peers and the national average standing at 48.4 per 100,000. Figure 4.1(i) Source Trent cancer Registry 30
31 The following two figures show the incidence of Colorectal Cancer utilising funnel plots Figure 4.1(ii) Colorectal Cancer Incidence by PCT Source Trent cancer Registry The above shows the incidence of colorectal cancer for Lincolnshire against the national average depicting other PCT s in the North Trent and East Midlands region as well for comparison. Lincolnshire compares well to its peers. Figure 4.1(iii)Colorectal Cancer Incidence by Cancer Network Source Trent cancer Registry 31
32 The previous figure depicts the incidence of colorectal cancer across the North Trent and East Midlands Cancer Network. East Midlands is just above the average and compares well to its peers. 4.2 Incidence of Colorectal Cancer As stated earlier first presentation represents the first identified presentation of Colorectal Cancer. It is being used in this document as a proxy measure for incidence. 4.2(i) NHS Lincolnshire First Presentation of Colorectal Cancer Male and Female Source: Secondary User Service The above clearly depicts that across all years there was a higher incidence of patients aged 75 and over. 32
33 4.2(ii) NHS Lincolnshire First Presentation of Colorectal Cancer Male Source: Secondary User Service The previous figure clearly depicts that across all years there was a higher incidence in male patients aged 75 and over. 4.2(iii) NHS Lincolnshire First Presentation of Colorectal Cancer Female Source: Secondary User Service The above clearly depicts that across all years there was a higher incidence in female patients aged 75 and over. 33
34 4.2(iv) CCG First Presentation of Colorectal Cancer 2009/10 to 2011/12 Male and Female Source: Secondary User Service Source: Secondary User Service 34
35 The previous figure depicts first presentation of colorectal cancer in males and females across all CCG s and within the localities. Lincolnshire West and East CCG s are above the Lincolnshire average. Within localities, Skegness and coast have the highest incidence of 280 per 100,000 population, followed by North of Lincoln and Boston. 4.2(v) CCG First Presentation of Colorectal Cancer 2009/10 to 2011/12 Male Source: Secondary User Service Source: Secondary User Service The above depicts first presentation of colorectal cancer in males across all CCG s. Again Lincolnshire West and East CCG s are higher than the Lincolnshire average 35
36 Within the CCG s, Skegness and coast followed by Lincoln North are well above the Lincolnshire average followed by Boston and East Lindsey. 4.2(vi) CCG First Presentation of Colorectal Cancer 2009/10 to 2011/12 Female Source: Secondary User Service Source: Secondary User Service The above depicts first presentation of colorectal cancer in females across all CCG s. Only South West Lincolnshire CCG is below the Lincolnshire average. Within the localities Skegness and coast is the highest at 255 per 100,000 followed by South Holland, Boston and North of Lincoln. 36
37 4.3 Premature Mortality Colorectal Cancer Figure 4.3(i) NHS Lincolnshire Directly Standardised Rates (per 100,000) Males and Females Source: Lincolnshire is slightly higher than most of its peers at per
38 Figure 4.3(ii) NHS Lincolnshire Directly Standardised Premature Mortality Rates for Colorectal Cancer (per 100,000) Males Source: At per male premature mortality rates for colorectal cancer in Lincolnshire are slightly higher than the national average and to most of its peers. 38
39 Figure 4.3(iii) NHS Lincolnshire Directly Standardised Premature Mortality Rates for Colorectal Cancer (per 100,000) Females Source: Female Colorectal cancers Lincolnshire compares favourably to the national average and to most of its peers. 39
40 Figure 4.3(iv) CCG Colorectal Cancer Premature Mortality Directly Aged Standardised Rates (per 100,000) Males and Females Source: Public Heath Mortality File Source: Public Heath Mortality File Lincolnshire West CCG has the highest premature death rate at per 100,000 population. Within the CCG s Gainsborough (20.00) is double the Lincolnshire average. 40
41 Figure 4.3(v) CCG Colorectal Cancer Premature Mortality Directly Aged Standardised Rates (per 100,000) Males Source: Public Heath Mortality File Source: Public Heath Mortality File Lincolnshire West CCG has the highest premature death rate at 15 per 100,000. Across the CCG s Gainsborough at 30 per 100,000 is once more double the Lincolnshire average. 41
42 Figure 4.3(vi) CCG Colorectal Cancer Premature Mortality Directly Aged Standardised Rates (per 100,000) Females Source: Public Heath Mortality File Source: Public Heath Mortality File Lincolnshire West has the highest premature death rate at just over 9 per 100,000. Within the CCG s, Lincoln City south 11 per 100,000 and South of Lincoln 11.5 per 100,000 are the highest. 42
43 4.4 Colorectal Cancer Stage at Diagnosis The following tables and charts show information on stage at diagnosis for new cases of colorectal cancer between 2007 and 2009 broken down by cancer network and PCT. The majority of staging data is taken from pathology reports. Around two thirds of colorectal cancer cases have stage data available. Of all stage cases, North Trent have a higher proportion of stage I disease than in East Midlands and nationally, 21% compared to 15% and 16%, respectively. Stage II and III disease are most common with around a third of cases diagnosed with either stage. Stage IV disease is most common in Derby City at almost a quarter of staged cases Figure 4.4(i) Stage of Diagnosis for New Cases of Colorectal Cancer
44 Source: Trent Cancer Registry Across the networks many cases of lower colorectal cancer are diagnosed at a later stage with the bulk being in stages two and three. Lincolnshire is no exception. 44
45 4.5 Colorectal Cancer Referral Rates The chart shows age-standardised referral rates for April 2010 to March 2011 by PCT. The referrals are TWW (two week wait with suspected lower GI cancer) urgent referrals only, resulting in either a cancer diagnosis or no cancer diagnosis. Figure 4.5(i) Referral Rates by PCT Source: Trent Cancer Registry Referral rates vary from 150 per 100,000 person population in Leicester City PCT to 253 per 100,000 person population in Lincolnshire PCT. Both Leicester City and Leicestershire County & Rutland PCTs (165 per 100,000 person population) have statistically significantly lower referrals rates than all other PCTs in the region. 4.6 Colorectal Cancer Conversion and Detection Rates The chart shows the proportion of TWW referrals that have a diagnosis of cancer (Conversion Rate) and the proportion of cancers that are referred through the TWW route (Detection Rate). Conversion Rate: The proportion of TWW referrals that resulted in a lower GI cancer ranges from 4% in Leicester City PCT to 9% in Nottingham City PCT. Detection Rate: The proportion of cancers referred through TWW range from 37% in Northamptonshire PCT to 67% for Lincolnshire 45
46 PCT. Figure 4.6(i) Conversion and Detection Rates by PCT Source: Trent Cancer Registry Conversation rates are low across all the PCTs. Lincolnshire is no exception. 4.7 Colorectal Cancer Survival The following depicts one and five-year relative survival rates for patients with colorectal cancer diagnosed in , and (one year survival only) by PCT and cancer network. Age-standardised relative survival (ASRS) results are presented here as estimates could be calculated for all areas. One-year relative survival has generally improved across most areas over the time period analysed. At PCT level, Lincolnshire, Doncaster, Nottingham City and Leicester City residents have survival rates that are statistically significantly lower than the national average. Five-year relative survival has remained fairly stable over the time period analysed. At cancer network level, all cancer networks in the region have ASRS rates that fall below the national average of 52.0% (falling outside of the 2SD funnel). 46
47 RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry Lincolnshire has not greatly improved over the time period analysed. It is worse than the East Midlands and the National average. 47
48 Figure 4.7(ii) Trends in five year relative survival for all persons aged years diagnosed with colorectal cancer *Data for East Staffordshire is unavailable due to missing date of diagnosis in a substantial number of records RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry Lincolnshire s five year relative survival rate is better than most across the cancer networks and East Midlands for colorectal cancer. 48
49 4.8 What does this chapter tell us? Colorectal cancer is strongly associated with age. There are no statistically significant differences in the rates of colorectal cancer incidence across the cancer networks and when compared to the England average. Lincolnshire compares well with its peers and the national average standing at 48.4 per 100,000. The incidence of colorectal cancer is highest in the over 75 year age group in both male and female. Skegness & Coast CCG have an older population profile and a higher incidence of colorectal cancer. Incidence of colorectal cancer in males and females across Lincolnshire West and East CCG s are above the Lincolnshire average. Within the localities Skegness and coast have the highest incidence followed by North of Lincoln. Premature mortality rates Lincolnshire (10.45 per ) is slightly higher than the national average and to most of its peers at per However this has fallen from per 100,000 in Lincolnshire West CCG has the highest premature death rate at per 100,000 population.within the CCG s Gainsborough (20.00) is double the Lincolnshire average. Premature mortality rates for colorectal cancer are higher in males (14.05 per 100,000) than in females (7.18 per 100,000). Skegness and coast consortium is a deprived area and has the highest incidence of colorectal cancer but it has the lowest premature mortality rates. Across our family of PCTs, Lincolnshire is slightly above the national average and to most of its peers for colorectal cancer premature mortality Across the networks many cases of colorectal cancer are diagnosed at a later stage with the bulk being in stages two and three. Lincolnshire is no exception. Lincolnshire is doing better than most across the cancer networks and East Midlands for five year survival rates in colorectal cancer. 49
50 Chapter 5 Profile of Lung Cancer 5.1 Incidence of Lung Cancer Figure 5.1(i) Incidence of Lung Cancer across the Cancer Networks Source: Trent Cancer Registry 50
51 Three-year average incidence rates for have been calculated to lessen the effect of random variation. Lincolnshire s rates (45.7) are lower than the East Midlands (48.0) and national the average (48.1). The following two figures show the incidence of Lung Cancer utilising funnel plots Figure 5.1(ii) Lung Cancer Incidence by PCT The above shows the incidence of lung cancer for Lincolnshire against the national average depicting other PCT s in the North Trent and East Midlands region as well for comparison. The incidence of lung cancer in Lincolnshire is low compared to most PCT s. 51
52 Figure 5.1(iii) Lung Cancer Incidence by Cancer Network The above depicts lung cancer incidence across the cancer networks in North Trent and East Midlands. East Midlands is the same as the national average. Figure 5.1(iv) NHS Lincolnshire First Presentation of Lung Cancer Male and Female Source: Secondary User Service 52
53 As stated earlier first presentation of cancer is being used as a proxy measure of incidence in Lincolnshire. The above depicts incidence within NHS Lincolnshire and above clearly shows that there is a higher incidence in the over 75 age group. The incidence in under 75 year olds remains fairly constant. Figure 5.1(v) NHS Lincolnshire First Presentation of Lung Cancer Males Source: Secondary User Service The above depicts incidence within NHS Lincolnshire. It shows that there is a higher incidence in males over 75 years of age. The incidence in the under 75 year old males has declined slightly. Figure 5.1(vi) NHS Lincolnshire First Presentation of Lung Cancer Females Source: Secondary User Service 53
54 The previous figure depicts incidence within NHS Lincolnshire. The above clearly shows that there is a higher incidence in females over 75 years of age. The incidence in the under 75 year old females has remained fairly static. Figure 5.1(vii) CCG First Presentation of Lung Cancer 2009/10 to 2011/12 Males and Females Source: Secondary User Service 54
55 The previous two tables above figure depict first presentation (incidence) under the age of 75 years old with lung cancer for each of the CCG. Lincolnshire West has the highest incidence for all lung cancers. Within the CCG s, Skegness & Coast has the highest incidence. It is almost double the Lincolnshire rate. Figure 5.1(viii) CCG First Presentation of Lung Cancer 2009/10 to 2011/12 Males Source: Secondary User Service The previous two figures depict first presentation (incidence) for males under the age of 75 years old with lung cancer for each of the CCG s. Lincolnshire West CCG has the highest incidence of male lung cancer. Within the CCG s, Skegness & Coast has the 55
56 highest incidence of 300 per 100,000 population. It is almost double the Lincolnshire rate. Figure 5.1(ix) CCG First Presentation of Lung Cancer 2009/10 to 2011/12 Females Source: Secondary User Service The two previous figures depict first presentation (incidence) for females under the age of 75 years old with lung cancer for each of the CCG. Lincolnshire West CCG and Lincolnshire East have the highest rates. Within the CCG s Skegness & Coast have a high incidence, it is almost double the Lincolnshire rate. 56
57 5.2 Premature Mortality for Lung Cancer Males and Female (under the age of 75) Figure 5.2(i) NHS Lincolnshire Directly Standardised Rates (per 100,000) for Lung cancer premature mortality Males and Females Source: Lincolnshire PCT at per 100,000 compares favourably to its family of PCTs and to the national average of per 100,000 for lung cancer premature mortality. 57
58 Figure 5.2(ii) NHS Lincolnshire Directly Standardised Rates (per 100,000) for Lung cancer premature mortality Males Source: Lincolnshire PCT at per 100,000 compares favourably to its family of PCTs for premature mortality male lung cancer and to the national average of per 100,
59 Figure 5.2(iii) NHS Lincolnshire Directly Standardised Rates (per 100,000) for Lung cancer premature mortality Females Source: Lincolnshire PCT at per 100,000 compares favourably to its family of PCTs for female premature mortality, lung cancer and to the national average of per 100,
60 Figure 5.2 (iv) CCG Directly Aged Standardised Rates (per 100,000) for premature mortality from Lung cancers Males and Females Source: Public Heath Mortality File The previous two figures depict all persons premature death from lung cancer, Lincolnshire East CCG has the highest rate. Within the CCG Skegness and Coast and Gainsborough have the highest premature mortality rate from lung cancer compared with the NHS Lincolnshire rate. 60
61 Figure 5.2(v) CCG Directly Aged Standardised Rates (per 100,000) for premature mortality Males Source: Public Heath Mortality File The above two figures depict male premature mortality for Lung cancer. Lincolnshire East CCG has the highest male premature mortality rate followed closely followed by South Lincolnshire CCG. Within the CCG, Skegness and Coast locality has the highest premature mortality rate (deaths under 75 years) from lung cancer in males compared with the NHS Lincolnshire rate. 61
62 Figure 5.2(vi) CCG Directly Aged Standardised Rates (per 100,000) for premature mortality Females Source: Public Heath Mortality File The previous two figures depict female premature death from lung cancer. Lincolnshire West has the highest female premature mortality rate. Within the CCG s the Gainsborough locality have the highest premature mortality rate (deaths under 75 years) from lung cancer in females compared with the NHS Lincolnshire rate, followed by Lincoln city south and Skegness and coast 62
63 Figure 5.2(vii) Stage at Diagnosis Non-Small Cell Lung Cancer (NSCLC) Lung cancer stage data was taken from The National Lung Cancer Audit (LUCADA) dataset. This was then matched to registry data to assign stage to cases diagnosed in Small cell lung cancer staging is not included here as it is recorded differently to other lung cancer types in the LUCADA dataset. As a result, all figures presented here relate to non-small cell lung cancer (NSCLC) only. The proportion of cases with stage data available has improved in North Trent when compared to stage recorded for cases diagnosed in , 62% vs. 57% (please see the Lung CIA report). The completeness of stage data in the East Midlands appears to have reduced slightly when compared to , 45% compared to 49%. The proportion of staged cases that are stage 1 to 4 is similar to previous years, with stage IV cases accounting for around half of all staged cases. Figure 5.2 (viii) Stage of diagnosis of non-small cell lung cancer (numbers) Source Trent Cancer Registry 63
64 Figure 5.2(ix) Stage of diagnosis of non-small cell lung cancer (percentages) Source Trent Cancer Registry As stated earlier like other areas Lincolnshire has a lot of staging data missing. Looking at the data that is present most lung cancers are diagnosed at stage 4. This is comparable to the other PCTs in the networks. 64
65 5.3 Lung Cancer Referral Rates The chart shows age standardised referral rates for April 2010 to March 2011 by PCT. The referrals are TWW (two week wait with suspected lung cancer) urgent referrals only, resulting in either a cancer diagnosis or no cancer diagnosis. Referral rates range from 28 per 100,000 person population in Bassetlaw PCT to 102 per 100,000 person population in Rotherham PCT. Figure 5.3(i) Referral Rates by PCT Approximately in Lincolnshire 58 per 100,000 people were referred during the time period analysed. 5.4 Lung Cancer Conversion and Detection Rates Definitions The detection Rate is the percentage of lower GI cancers that were referred through a TWW referral. The following chart shows the proportion of TWW referrals that have a diagnosis of cancer (Conversion Rate) and the proportion of cancers that are referred through the TWW route (Detection Rate). 65
66 Detection rate: the percentage of lower GI cancers that were referred through a TWW referral. Conversion Rate: the proportion of TWW referrals that resulted in a lung cancer diagnosis ranges from 17% in Rotherham PCT to 35% in Derby City, Lincolnshire and Sheffield PCTs. Figure 5.4(i) Conversion and Detection Rates by PCT Source: Trent Cancer Registry 5.5. Lung Cancer Survival The following depicts information on one and five-year relative survival rates for patients with lung cancer diagnosed in , and (one year survival only) by PCT and cancer network. Age-standardised relative survival (ASRS) results are also referred to for those areas where these estimates are available. One-year relative survival estimates have generally improved across all areas over the time period analysed. At cancer network level, one-year relative survival for diagnosed cases is statistically significantly lower than the national average of 28.0% (ASRS = 31.6%) 66
67 Figure 5.5(i) Trends in one year relative survival for all persons aged years diagnosed with lung cancer RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry Lincolnshire s one year relative survival rates for lung cancer have improved over time and compares well with their peers and the East Midlands. Five-year relative survival estimates over the page have generally improved over the period analysed. At cancer network level the relative survival rate for Mid Trent is statistically significantly below the national average, 6.1% vs. 7.0%. 67
68 Figure 5.5(ii) Trends in five year relative survival for all persons aged years diagnosed with lung cancer. RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry Lincolnshire has a very low five year relative survival rate compared with its peers East Midlands and the National average. 68
69 5.6 What is this chapter telling us? Lung cancer incidence is associated with age. Incidence of lung cancer is highest in the over 75 year age group. However in in the under 75 year age group Lung Cancer incidence is highest in Lincolnshire West CCG and within the localities the highest is in Skegness and coast As stated earlier first presentation of cancer is being used as a proxy measure of incidence in Lincolnshire. Incidence of lung cancer across Lincolnshire has fallen from 46 per 100,000 per population to Lincolnshire West has the highest incidence for all lung cancers. Within the CCG s, Skegness & Coast has the highest incidence. It is almost double the Lincolnshire rate. Lung cancer is strongly associated with deprivation. Skegness and coast is a deprived area featuring highly on the IMD score and has the highest incidence of lung cancer and premature mortality rates within the CCG localities with the exception of premature mortality for female lung cancer where it is Gainsborough. Lincolnshire PCT at per 100,000 compares favourably to its family of PCTs and to the national average of per for lung cancer premature mortality. It has fallen from per population. All person premature mortality rate from lung cancer in Lincolnshire East CCG is the highest. Within the CCG s Skegness and coast and Gainsborough locality are the highest. Many people with lung cancer present in the later stages of the disease process usually stages three and four leading to less favourable outcomes. Lincolnshire s one year lung cancer survival rates compares favourably to East Midlands and to the national figures. Unfortunately five year survival rates for Lincolnshire are poor. 69
70 Chapter 6 Profile of Prostate Cancer 6.1 Incidence of Prostate cancer Three-year average incidence rates have been calculated for to lessen the effect of random variation. There is wide variation in the incidence of prostate cancer across the region and when compared to the national average of per 100,000 male population. The incidence rate is also statistically significantly higher than the national average in Lincolnshire PCT at per 100,000 male populations. This has risen from when it was per 100,000 male population. Figure 6.1(i) Incidence of Prostate cancer
71 Figure 6.1(ii) Prostate cancer Incidence rates 2007 to 2009 The following two figures show the incidence of Prostate Cancer utilising funnel plots Figure 6.1(iii) Prostate cancer incidence by PCT At PCT level, Leicester City has the lowest rate of prostate cancer with 79.8 per 100,000 male population, whilst Northamptonshire has the highest rates at followed by Lincolnshire at per 100,000 male population. Source: Trent Cancer Registry The above shows the incidence of prostate cancer for Lincolnshire against the national average depicting other PCT s in the North Trent and East Midlands region as well for comparison. The incidence for prostate cancer in Lincolnshire is above the national average and above the rates of most of its peers. It is three standard deviations above the norm. 71
72 Figure 6.1(iii) Prostate Cancer Incidence by Cancer Networks Source: Trent Cancer Registry The above depicts prostate cancer incidence across the cancer networks in North Trent and East Midlands. North Trent and Derby- Burton are well below the average for prostate cancer. East Midlands compares well with its peers. 6.2 First Presentation of Prostate Cancer As stated earlier first presentation is being used as a proxy for incidence 72
73 Figure 6.2(i) NHS Lincolnshire First Presentation of Prostate Cancer Source Secondary User Service The previous figure clearly shows that there is a higher incidence of prostate cancer in men over the age of 75. In the under 75 year age group it has remained fairly static. 6.2(ii) CCG First Presentation of Prostate Cancer 2009/10 to 201/12 73
74 Sourced: Secondary User Service The previous depicts first presentation of prostate cancer in males under the age of seventy five across all the CCG s The incidence in all CCG s apart form South West Lincolnshire is higher than the Lincolnshire average. Within the CCG s the North of Lincoln locality and Skegness and coast feature highly. 6.3 Premature Mortality for Prostate Cancer The following depicts premature mortality (deaths under 75 years of age) from Prostate cancer across its family of PCTs. 74
75 Figure 6.3(i) Premature Mortality Directly Standardised Rates (per 100,000) Source: Lincolnshire s premature mortality rate of 9.06 per 100,000 for prostate cancer is above the national average of 8.32 per 100,000 and higher than most of its family of PCT s Figure 6.3(ii) CCG Directly Standardised Rates (Per 100,000) The following depicts prostate premature mortality rate (deaths under 75 years of age) by CCG 75
76 Source: Public Health Mortality Files South Lincolnshire CCG (12, per 100,000) has a higher rate than the NHS Lincolnshire average of 9 per 100,000. Within the CCG s Welland locality has the highest rate of approximately 15 per 100, 000 males. Staging Data Staging data not available for prostate cancer/urology cancers 76
77 6.4 Urology Cancer Referral Rates The following shows age standardised referral rates for April 2010 to March 2011 by PCT. The referrals are TWW (two week wait with suspected urological cancer) urgent referrals only, resulting in either a cancer diagnosis or no cancer diagnosis. There is wide variation in the referral rates for urological cancer, ranging from 113 per 100,000 person population for residents of Leicester City PCT to 253 per 100,000 person population in Nottinghamshire County PCT. Figure 6.4(i) Referral Rates by PCT Source: Trent Cancer Registry 6.5 Urology Cancer Conversion and Detection Rates The chart shows the proportion of TWW referrals that have a diagnosis of cancer (Conversion Rate) and the proportion of cancers that are referred through the TWW route (Detection Rate). Conversion rate: The proportion of TWW referrals that resulted in a urological cancer diagnosis ranges from 10% in Barnsley PCT to 26% in Bassetlaw PCT. Figure 6.5(i) Conversion and Detection Rates by PCT
78 Source: Trent Cancer Registry There is a just over 20% conversation rate in Lincolnshire 6.6 Urology Cancer Survival Prostate cancer one-year relative survival rates have improved across the time period analysed. For patients diagnosed in , at cancer network level, one-year relative survival is statistically significantly lower than the national average of 93.1% (ASRS = 94.4%) in Mid Trent, East Midlands At PCT level, several PCTs have survival rates statistically significantly lower than the national average; 78
79 Figure 6.6(i) Trends in one year relative survival for males aged years diagnosed with prostate cancer Data for East Staffordshire is unavailable due to missing date of diagnosis in a substantial number of records RSR Relative survival rate LCI 95% lower confidence interval UCI 95% Upper confidence interval Source: Trent Cancer Registry One year survival rates in Lincolnshire for Prostate cancer have risen over time. Lincolnshire has one of the better relative survival rates across the cancer networks and it is higher than East Midlands. 79
80 Trends in five year relative survival for males aged years diagnosed with prostate cancer (C61) Source Trent cancer Registry 80
81 6.7 What is this chapter telling us? Prostate cancer is associated with age. The incidence of prostate cancer in Lincolnshire is highest in the over 75 year male age group. South Lincolnshire (500 per 100,000) CCG has a higher than the Lincolnshire average (350 per 100,000) for incidence of prostate cancers in the under 75 age group. Within the CCG localities North of Lincoln has the highest at 500 per 100,000 Lincolnshire s premature mortality rate of 9.06 per 100,000 for prostate cancer is above the national average of 8.32 per 100,000 and higher than most of its family of PCT s. This has fallen from 9.27 per population South Lincolnshire CCG (12, per 100,000) has a higher rate than the NHS Lincolnshire average of 9 per 100,000. Within the CCG s Welland locality has the highest rate of approximately 15 per 100, 00 males. One year survival rates in Lincolnshire for Prostate cancer have risen over time. Lincolnshire has one of the best relative five year survival rates across the cancer networks and it is higher than East Midlands. 81
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