What do we know? Summary Around one in three of us will develop cancer at some time in our lives according to our lifetime risk estimation (Sasieni PD, et al 2011). The 'lifetime risk of cancer' is an estimation of the risk that a newborn child has of being diagnosed with cancer at some point during its life. It is based on current incidence and mortality rates, and therefore is calculated on the assumption that the current rates (at all ages) will remain constant during the life of the newborn child. An individual's risk of being diagnosed with cancer depends on many factors, including age, lifestyle and genetic factors. It is estimated that more than four in 10 cancer cases could be prevented by lifestyle changes, such as not smoking, cutting back on alcohol, maintaining a healthy body weight, and avoiding excessive sun exposure (Parkin et al 2010). Hence, cancer is largely preventable. According to data from the Lincolnshire Research Observatory (LRO), the incidence rates (new cases) of cancer are higher in Lincolnshire than the national average death rates are comparable. is a disease of ageing. In Lincolnshire, there is an ageing population, so it is to be expected that the number of new cases of cancer each year will increase substantially in the future. Facts and figures The following information is sourced from the LRO and Health and Social Care Information Centre, unless stated otherwise. The Directly Age Standardised Rate (DASR) for incidence (number of new cases) of cancer per 100,000 for all persons aged under 75 years between 2009-2011 shows the following: England: 309.40 per 100,000 Lincolnshire: 326.98 per 100,000 and with highest rate, Lincoln 342.12 per 100,000 lowest rate, South Holland 309.44 per 100,000 Thus, the rate for Lincoln is higher than both the national rate and the Lincolnshire average. 1 of 12 June 2014 (v3)
The Directly Age Standardised Rate (DASR) for incidence of cancer per 100,000 males aged under 75 years between 2009-2011 shows the following: England: 313.82 per 100,000 Lincolnshire: 333.58 per 100,000 and with highest rate, Lincoln 354.52 per 100,000 lowest rate, South Holland 321.36 per 100,000 Thus, the rate for Lincoln is higher than both the national rate and the Lincolnshire average. The Directly Age Standardised Rate (DASR) for incidence of cancer per 100,000 females aged under 75 years between 2009-2011 shows the following: England: 307.11 per 100,000 Lincolnshire: 320.28 per 100,000 and with highest rate, Lincoln 332.21 per 100,000 lowest rate, South Holland 298.32 per 100,000 Thus, the rate for Lincoln is higher than both the national rate and the Lincolnshire average. The Directly Age Standardised Rate (DASR) for deaths from cancer for all persons per 100,000 population under the age of 75 years between 2010-2012 shows the following: England: 123.36 per 100,000 Lincolnshire: 106.01 per 100,000 and with highest rate, Lincoln 124.43 per 100,000 lowest rate, South Kesteven 94.00 per 100,000 Thus, the rate for Lincoln is higher than both the national rate and the Lincolnshire average. 2 of 12 June 2014 (v3)
The Directly Age Standardised Rate (DASR) for deaths from cancer for males per 100,000 population under the age of 75 years between 2010-2012 shows the following: England: 131.05 per 100,000 Lincolnshire: 111.20 per 100,000 and with highest rate, East Lindsey 126.83 per 100,000 lowest rate, South Kesteven 99.84 per 100,000 Thus, the rate for East Lindsey is higher than the Lincolnshire average. The Directly Age Standardised Rate (DASR) for deaths from cancer for females per 100,000 population under the age of 75 years between 2010-2012 shows the following: England: 115.49 per 100,000 Lincolnshire: 101.03 per 100,000 and with highest rate, Lincoln 125.44 per 100,000 lowest rate, South Kesteven 89.27 per 100,000 Thus, the rate for Lincoln is higher than both the national rate and the Lincolnshire average. With regard to Directly Age Standardised Rate (DASR) mortality rates per 100,000 (under the age of 75) from cancer, the most recent figures, for 2010-2012, rank the four Lincolnshire CCGs as follows: Lincolnshire East 106.90 per 100,000 Lincolnshire West 103.80 per 100,000 South West Lincolnshire 91.50 per 100,000 South Lincolnshire 86.20 per 100,000 This data indicates that: There are more new cases of cancer, and more deaths from cancer, in men than in women. (This is probably due to lifestyle behaviours that many men exhibit, such as having higher smoking rates than women, a worse diet than women and consuming more alcohol than 3 of 12 June 2014 (v3)
women. It may also be due to the fact that many males present later on in the disease process than most women, resulting in poorer outcomes for them.) Incidence rates and death rates from cancer vary within the county. As the City of Lincoln is one of the most deprived areas in Lincolnshire, it is not surprising that it has a higher rate of new cases and deaths compared to the average for Lincolnshire. The Plan 2000 stated that: Obesity is a major risk factor for post-menopausal breast cancer; 3% of all cancers (mouth, throat and liver) are due to alcohol; Increasing physical activity can reduce the risk of colorectal cancer; and Exposure to the sun is the main cause of skin cancer. There has been a huge reduction in the number of people smoking since the Second World War, particularly amongst men. More recently, the prevalence of smoking in Great Britain has remained relatively unchanged, standing at 22% of men and 19% of women in 2012. In Lincolnshire, the prevalence of smoking in those above the age of 18 is 20.98% (2011-2012). Trends Trend data is available on the Lincolnshire Research Observatory (LRO) for both cancer incidence and premature mortalities for patients over 75 years of age. DASR incidence rates in Lincolnshire (for all persons under 75) are above the national average. However, incidence has fallen from 333.38 per 100,000 (DASR) in 2008-2010 to 326.98 in 2009-2011. DASR mortality rates for cancer (for all persons under 75) have consistently fallen since 2006-2008. The most recent figures (2010-2012) show the rate in Lincolnshire (106.01) to remain below the East Midlands average (106.88) and the England and Wales average (106.96). Though mortality rates for cancer have declined in Lincolnshire, the rates have also dropped for cardiovascular disease (CVD), so that the DASR for all persons under 75 in 2007-2009 was greater for cancer (111.17) than for CVD (69.80). Age-standardised mortality rates will fall, partly due to the fall in smoking rates, but also due to changes in the proportion of different cancers within the total number of cases. For example, a smaller proportion of all cancer cases will be lung cancer (which is nearly always fatal), and a higher proportion will be breast cancer (many women survive breast cancer). 4 of 12 June 2014 (v3)
Targets In 2000, the Department of Health (DoH) Public Service Agreement set out that, by 2010, the mortality rate from cancer in people aged under 75 should fall by 20% from the baseline rate set in 1995-1997. The baseline rate was 141.2 giving a target of 113.0. The Public Health Outcomes Framework and the NHS Outcomes Framework share the 'under-75 mortality rate from cancer' indicator, recognising the crucial contributions that both the NHS and the public health services can make to reducing 'preventable mortality'. This shared indicator will enable progress in improving cancer mortality rates to be assessed in a more structured manner. Performance This target was met with a DASR of 108.43 nationally in 2009-2011. At this time, the Lincolnshire average was 107.39. 5 of 12 June 2014 (v3)
What is this telling us? Summary Primary prevention of cancer through promoting a healthier lifestyle (particularly in relation to tobacco use, maintaining a healthy weight, undertaking physical activity, and drinking alcohol at sensible levels) remains an important part of cancer prevention. Earlier detection of cancer may be achieved through: Encouraging attendance for cancer screening; Promoting awareness of cancer signs and symptoms; and Encouraging people to attend their GPs earlier in the disease process, in order to improve their outcomes and survival rates. The Early Presentation of (EPOC) Programme will continue to focus on primary prevention and early diagnosis, raising awareness and improving cancer screening uptake, working with communities in Lincolnshire. services, although planned in a co-ordinated manner, will be revisited as part of the Lincolnshire Health and Care review. Local Views The Strategic Clinical Networks (SCNs) for the East Midlands bring together clinicians and commissioners with partners from social care, the voluntary sector, patients and carers, in order to improve services for particular conditions, and also to improve the quality of care and outcomes for patients. This enables views from Lincolnshire people to be fed into the decision-making process. Also, the Lincolnshire cancer strategy, 'Improving outcomes in cancer a strategy for Lincolnshire 2014-2019', which is currently in draft format, will include the views of local patient participation groups. National and local strategies On April 1 st 2013, as part of the NHS re-organisation, Strategic Clinical Networks (SCNs) were introduced and replaced the regional networks. The SCNs across the East Midlands bring together clinicians and commissioners with partners from social care, the voluntary sector, patients and carers to improve services for particular conditions, and to improve the quality of care and outcomes for patients. 6 of 12 June 2014 (v3)
They place particular focus on the following conditions and areas of healthcare: Cardiovascular Disease Maternity and Children's Services Mental Health, Dementia and Neurological Conditions The Plan was published in 2000, and has been updated at regular intervals. The current government published their cancer strategy, 'Improving Outcomes: A Strategy for ', in January 2011. This strategy builds on previous strategies by: Focussing on the prevention of cancer; Reducing delays in diagnosis and starting treatment; Improving cancer treatment by investing more in drug treatment and in radiotherapy; and Improving services for those who are terminally ill. The Patient Experience Survey 2013 (CPES) has been pivotal in highlighting variations reported by cancer patients, and in highlighting areas where trusts can make improvements. The third annual National Patient Experience Survey was published in August 2013, and reported the views of over 116,000 cancer patients in all 155 NHS trusts in England that provide treatment to cancer patients. (See website Quality Health) In September 2013, Macmillan Support published the ' Patient Experience Survey: Insight Report and League Table 2012-13', which identified the 10 most improved trusts between the 2011-12 and 2012-13 surveys. (See Patient Experience Survey) The Lincolnshire Clinical Commissioning Groups (CCGs) commission services to deliver world-class outcomes for patients, their families and carers, to ensure they can rely on safe and high-quality services to receive a 'good experience' of their cancer journey. 'Improving outcomes in cancer a strategy for Lincolnshire 2014-2019' is in draft format currently, but it is hoped that this document will go some way towards helping the CCGs to deliver their aim of ensuring the provision of a high-quality service. Current activity and services Nationally, it is recognised that late presentation of cancer is a key factor in the United Kingdom's relatively poor survival rates for some cancers. Diagnosing cancers earlier leads to better outcomes for individuals. 7 of 12 June 2014 (v3)
A piece of work by Lincolnshire's Public Health Directorate confirmed that this was an area for improvement in services. Consequently, a substantial programme of work is being undertaken, under the overall banner of the Early Presentation of (EPOC) programme, to address this issue. Development workers and volunteers work in areas of high incidence of, and high mortality rates from, cancer. The programme concentrates on the cancers of significance for the CCG areas, encouraging people to present earlier to their doctor if they think that they have a sign or symptom of cancer and are concerned about it. They also promote cancer screening programmes, and EPOC is currently working closely with CCGs to increase the uptake of cervical screening across Lincolnshire. The Area Team, Lincolnshire Public Health and EPOC are working with the Breast and Bowel Screening Services to reduce the amount of people who do not attend for their appointments, and to ensure that their services are accessed by people living in deprived communities. Smoking causes nearly one-fifth of all cancers in the UK (and over 80% of lung cancers). Lincolnshire County Council (through the Smokefree Lincolnshire Alliance) has made a commitment to tackling smoking with the development of a comprehensive five-year tobacco control strategy that works across the six internationally recognised strands, which are: Helping tobacco users to quit Reducing exposure to second-hand smoke Effective communications for tobacco control Stopping the promotion of tobacco Effective regulation of tobacco products Making tobacco less affordable In line with the six strands, they commission a countywide 'stop smoking' service, Phoenix, which is a free NHS service in Lincolnshire for anyone who would like to give up smoking. Additionally, the Smokefree Lincolnshire Alliance runs a range of public awareness and education programmes with the aim of encouraging smokers to quit, and discouraging young people from starting in the first place. Through the Alliance, co-ordinated local activity supports national campaigns such as 'No Smoking Day', for which the Alliance recently won an award for the 'Best Use of 2013 s Theme'. Future work could include the introduction of 'standardised packaging' for tobacco products. Helping smokers to quit, and decreasing the numbers of new smokers, will impact directly on the reduction of cancer rates in Lincolnshire. 8 of 12 June 2014 (v3)
In April 2011, the government established a Drugs Fund (CDF). This is now the responsibility of NHS England, and will continue in its current form until 2016. The CDF is valued at 200 million a year, and contains a list of drugs that will be routinely funded on the NHS. This fund will make no difference to overall survival rates, because very few cancers are curable with drugs, but, for those patients whose treatment is funded from this source, survival times should be prolonged by a couple of months on average. The National Institute for Health and Clinical Excellence (NICE) appraises the clinical effectiveness and cost effectiveness of a large number of cancer drugs each year to ensure that NHS resources are targeted to best effect. Key inequalities For most types of cancer, and particularly those where smoking or diet are risk factors, patients who live in deprived areas have higher rates of new diagnoses. Patients who live in deprived areas are also more likely to present late with symptoms, and thus have lower survival rates. All screening programmes, including those for cancer, tend to have higher uptake rates amongst higher socioeconomic groups. It is essential, therefore, that all services, particularly smoking cessation services and screening programmes, ensure that they are reaching deprived and disadvantaged communities. EPOC also targets areas of deprivation to extend the reach of early presentation and awareness messages into these communities. Key gaps in knowledge and services As a result of our system of cancer registration, there are few gaps in knowledge in comparison to those for other diseases. It is vital that we monitor value for money from the Drugs Fund. 'Improving outcomes in cancer a strategy for Lincolnshire 2014-2019' is in draft format currently, but it is hoped that this document will go some way towards helping the CCGs deliver their aim of ensuring the provision of a high-quality service and reducing gaps in knowledge. Risks of not doing something Not doing anything could lead to: More people presenting late to their doctor, leading to poorer outcomes for the patient; A further decline in people attending cancer screening programmes; and 9 of 12 June 2014 (v3)
An increase in premature mortality rates, and a decrease in survival rates. What is coming on the horizon? The Lincolnshire Sustainable Services Review (LSSR), now called Lincolnshire Health and Care (LHAC), will no doubt have recommendations about the future of cancer services in Lincolnshire. 'Improving outcomes in cancer a strategy for Lincolnshire 2014-2019' is in draft format currently, but it is hoped that this document will go some way towards helping the CCGs deliver their aim of ensuring the provision of a high-quality service. This document will support the development of the LHAC review of cancer services. Further work is to be carried out on the delivery of Lincolnshire s five-year tobacco control strategy, and updating actions as new initiatives arise. Further initiatives to reduce the proportion of the population who smoke are being considered. For example: The government has launched a review of the evidence base for the plain packaging of cigarettes. This follows a pilot scheme in Australia, which became the first country to legislate for standardised packaging in 2011. The European Union has also moved towards banning the sale of packs of 10 cigarettes and menthol cigarettes, although the latter is unlikely to be introduced before 2020. Obesity pathways for Lincolnshire will be improved by the development of a tier 3 weight-management service, and improving weight-management support for families, which should assist with cancer prevention. There will be further targeted local campaigns to raise awareness of cancer symptoms, and to encourage earlier presentation to the GP. This will be done in partnership with the Clinical Commissioning Groups (CCGs), and will focus on areas of deprivation and high premature mortality rate from cancer. The pink pants campaign (led by EPOC) is intended to increase cervical screening uptake rates, particularly in the younger age range (24-and-a-half to 49 years of age), and will continue this year, alongside the work with GP practices on their systems and processes within the surgery (led by Public Health Lincolnshire). 10 of 12 June 2014 (v3)
What should we be doing next? The focus should continue to be primary prevention, through the targeting of modifiable risk factors, and early diagnosis. Key areas include the following: Prevention and awareness messages Delivery on actions in the Lincolnshire Tobacco Control Strategy 2013 2018 Improving obesity pathways Delivery of key campaigns relevant to CCG areas Pursuing programmes to encourage timely diagnosis, with individuals presenting earlier Promotion of NHS health checks (identifying risk factors) Building on the changes brought about as a result of the Lincolnshire Health and care review 11 of 12 June 2014 (v3)
References 1. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010 (Parkin DM, Boyd L, Walker LC) British Journal of, 2011. 105 Suppl 2: S77-81 2. What is the lifetime risk of developing cancer? The effect of adjusting for multiple primaries (Sasieni PD, Shelton J, Ormiston-Smith N et al) British Journal of, 2011. 105(3) p460-5 3. Improving outcomes in cancer a strategy for Lincolnshire 2014-2019 (Greater East Midlands Support Unit) draft document 4. Improving Outcomes: A Strategy for January 2011 (Department of Health) 2011 5. Quality Health 6. Patient Experience Survey 12 of 12 June 2014 (v3)