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Part of: Ill Health and Disability

Contains: Digestive Cancers - Bowel (Colorectal) Cancer and Upper Gastrointestinal (GI) Cancer , Lung Cancer, Breast Cancer, Cervical Cancer, Skin Cancer (Melanoma), Prostate Cancer

Related to:  Ageing Population, Socio-economic Inequality, Births and Fertility, Mental Health and Illness, [[Health Checks]], Major Causes of Mortality, Smoking, End of Life Care, Healthy Weight, Food Poverty

Key Facts

  • Cancer incidence is increasing in B&NES, from 732 new diagnoses in 1993 to 944 new cases in 2010/11. This rise is in line with regional and national levels.
  • There were 4,338 people in 2012/13 (financial year) registered with cancer in GP practises in Bath and North East Somerset, a rate of 2.2% of the registered population.
  • Cancer accounts for around a third of all deaths in the area and is the largest contributor of deaths in under 75s, although mortality rates are low compared to similar areas.
  • There is a relationship between cancer and Socio-economic Inequality.
  • Early indicators suggest that early death rates from cancer, while still below national rates, may not have fallen in line withreductions experienced elsewhere.

Cancer is a common condition where cells in a specific part of the body grow and reproduce uncontrollably. The cancerous cells can invade and destroy surrounding healthy tissue, including organs. There are over 200 different types of cancer, each with its own methods of diagnosis and treatment. In 2009, 320,467 new cases of cancer were diagnosed in the UK. More than one in three people will develop some form of cancer during their lifetime. 1

What does the data say?

National Cancer trends 2

A 2013 Cancer mortality trends report from Macmillan, looking at existing data back to 1992, makes the following statements about cancer trends and survival to 2020;

  • In 2010, 44% of people had been diagnosed with cancer in their lifetimes.
  • By 2020, it is estimated that 47% of people will get cancer in their lifetime, but 38% will not die from the disease. This has increased by more than a third over the past 20 years from 32% in 1992.
  • This increase is diagnosis in part due to overall longer life expectancy and the ageing population and may place a higher demand on cancer primary care and support agencies.
  • The increase in survival rates (death by other causes) is in part due to a greater focus on early diagnosis and improved treatment.

Local and regional cancer data

Cancer incidence is rising in England, the South West, and in Bath and North East Somerset, where since 1993, it has risen from a directly standardised rate of 318.59 per 100,000 (732 people) to a rate of 373.74 per 100,000 (933 people) in 2009. In 2010/11 there were 944 new cancer cases in the registered GP Population of Bath and North East Somerset. 3

There were 4,338 people in 2012/13 (financial year) registered with cancer in GP practises in Bath and North East Somerset.4

In line with this, the number of people registered with a GP as having cancer has been steadily increasing locally, regionally and nationally. In B&NES  it has increased from 1.5% in 2008/09 (financial year) to 2.2% in 2012/13.* 5

The prevalence of cancer in B&NES is slightly higher than that of  England which had a prevalence rate of 1.3% in 2008/09 (financial year) and 1.9% in 2012/13 (financial year).*

cancer_-_rate_in_bnes_and_england_gp_populations 

Figure 1: Cancer prevalence in B&NES and England GP registered populations (2008/09 – 2012/13 financial years) 6

*It is important to note that the above rates are based on the GP registered population of Bath and North East Somerset and so some of these people may not be residents of Bath North East Somerset. Nevertheless, the vast majority of people will be registered with a GP in their county of residence.

For more up to date prevalence figures for cancer recorded as part of the NHS Quality and Outcomes Framework (QOF), see the Ill Health and Disability section. 

The incidence of cancer by gender is characterised by gender-specific cancers as the most common cancers are breast for female and prostate for male, followed by bowel and then lung; with there being very similar rates for the latter two cancers. 7

The rate of emergency admissions of people with cancer of the GP population of Bath and North East Somerset is 551 per 100,000, which is lower than therate for England which is 583 per 100,000. 8

Cancer mortality

Cancer is the largest contributor of deaths in under 75s. 9 Cancer mortality is nevertheless decreasing in England, the South West, and in Bath and North East Somerset. In general, BANES has lower rates of mortality from cancer than comparator areas. In 1993 the Bath and North East Somerset age standardised rate was 197.25 per 100,000 (484 people), in 2010 it had decreased to 160.64 per 100,000 (464), however there is some variation between GP Practices. 10

Cancer mortality rates - line graph

Figure 2: Directly age standardised rate of cancer mortality in B&NES and comparator areas (1993-2010). 11

Cancer mortality in under 65’s is also decreasing in B&NES although less steeply than some of the comparators. In 1993 the rate was 78.14 per 100,000 (105) and in 2010 it had decreased to 60.29 per 100,000 (96) and is currently in line with national rates, but slightly higher than regional rates (~58 per 100,000). 12

Despite these improvements locally and nationally, cancer survival in England consistently lags behind other EU and developed countries. A number of studies have compared 5 year survival rates of various cancers and found that survival in England is consitently worse than other countries 13 As a result of this, one-year and five-year cancer survival have been identified as areas for improvement in the NHS Outcomes Framework (Department of Health 2010) and the National Cancer Strategy commits to saving an additional 5,000 lives by 2015 (Department of Health 2011).

Cancer-rate of 5 most common cancers-trends overtime_ 

Figure 3 : Trends over time for the top 5 cancers in Bath and North East Somerset PCT 2000-2010. 14

The leading causes of death from cancer for women are breast, lung, upper gastro-intestinal, bowel and ovary. The leading causes of death from cancer for men are lung, upper gastro-intestinal, bowel and prostate. 15

Lung Cancer is the most common cancer mortality cause in under 75s in Bath and North East Somerset Avon, followed closely by breast cancer. Bowel cancer mortality is the third cause of cancer premature mortality followed by the cancer of the brain and the Central Nervous System (CNS). Prostate Cancer is only the fourth most common cause of premature cancer mortality, despite being the 2nd most common cancer in terms of incidence. 16

Whilst there was a general falling trend of cancer mortality rates in under 75s between 1995/97 and 2007/9, Upper GI cancers (Gastrointestinal cancers)  mortality rates in the male population of B&NES  increased by 15.5% mortality over this period. 17

This cancer is associated with dietary factors - in particular, the upper GI cancers are more frequent in population groups that smoke and drink alcohol, and a specifically high prevalence is seen in some ethnic groups, such assouth Asians and east Africans, associated with chewing tobacco. 18

Cancer and inequalities 19

The 1999 White Paper, Saving Lives: Our Healthier Nation, set out a challenging inequalities target, requiring that “a 20% reduction in cancer mortality in under 75s is accompanied by a reduction in the inequalities gap of at least 6% between the fifth of areas with the worst health and deprivation indicators and the population as a whole.”

Socio-economic Inequality

Nationally, incidence and mortality is higher for the more deprived groups in most cancers, apart from breast, prostate, malignant melanoma, and cancer of the testis, which display a higher incidence in the more affluent groups. 20

In 2005-09 there were large variations in cancer mortality rates in under 75year olds by wards in Bath and North East Somerset. Female cancer mortality in under-75s varied from 10 in Odd Down to 150 in Lynecombe, compared to the average number of deaths for Bath and North East Somerset of just over 95. The difference between these two extreme wards in female cancer mortality is statistically significant; however, across the whole area it is difficult to note a significant trend.

The trends in premature cancer mortality in Bath and North East Somerset have over time been fairly stable. This means that the gap in cancer premature mortality between the least deprived and the most deprived has not been decreasing as we would hope, as seen in figure 3.

Cancer - mortality rates by income deprivation- line graph 

Figure 4: Premature cancer mortality by income deprivation quintile, B&NES, 2000-2010. 21

An association between deprivation and cancer screening programmes is also observed with communities living in more deprived areas having a lower percentage uptake of the cancer screening programmes.

NHS spend on cancer 22

The total (gross) spend on cancer (and tumours); including prevention and health promotion, in England in 2010/11 was £5.81 billion. 23

The Department of Health’sProgramme Budgeting data show that across the ASW (Avon, Somerset and Wiltshire) Cancer Network in 2008/9, 6.4% of the total budget is spent on cancer care (a slight increase from 6.2% in 2006/7), which is just above the national average. 24 Bath and North East Somerset Primary Care Trust spent 7.2% of its budget on cancer care in 2008/9.

In 2010/11 the budget spent on cancer as a proportion of the total NHS expenditure per 100,000 own population (unified weighted population) in BANES was £12.6 million, which is a decrease compared to 2009/10, which was £13.2 million. 

Are we meeting the needs?

Risk Factors 25

The ongoing work on modifying unhealthy lifestyle behaviour (Smoking, Alcohol, food and exercise) would have had some impact on the risk levels of people in Bath and North East Somerset developing cancer. Also, due to the nature of time-lag of the effect of these interventions, this work will have a further impact on cancer mortality in the population over the years to come. For example the fall in Smoking prevalence has been greater in men than women reflecting the focus of the stop smoking campaigns in the last decades and this is portrayed in the lung cancer trends: falling amongst the male but still going up amongst the female population.

In addition to Smoking, Alcohol and [[Obesity and Physical Activity|obesity]] (including food and physical activity association) are both associated with cancer incidence and mortality. Trends in Alcohol attributable hospital admissions and deaths have been going up in our population overall.

Upwards trends in both alcohol and obesity will have a detrimental effect on cancer mortality and to an extent lessen the effect of reduced smoking prevalence rates in our population.

Cancer screening 26

There are, currently, three population based cancer screening programmes in Bath and North East Somerset, in line with the National NHS Cancer Screening Programmes: cervical screening, breast screening and bowel screening. The local bowel screening programme, organised with Swindon and Wiltshire, was implemented in February 2009. The cervical and breast screening have been in place for decades (cervical screening since 1964, breast screening since 1989).

The relationship between screening and cancer mortality is defined by a time-lag, at least 3-5 years (as per screening rounds) between the two. The impact of screening on cancer mortality is evidenced for cervical screening, it is being reviewed for breast screening and still to be evidenced for bowel screening.

This relationship is compounded by overall healthcare-seeking behaviour, in that the population groups that are at highest risk of developing or the least likely to present early with symptoms of suspected cancer are usually the groups that have the lowest coverage (participation) in screening programmes. Hence the effect of screening in reducing mortality in these groups is lower.

The minimal national coverage target (70% of eligible screening population) for breast and cervical cancer are met across Bath and North East Somerset’s four Primary Care Trusts; the optimal target (which is the same as the previously set regional minimal target of 80%) has also been met by B&NES PCTs. However, the minimal target for bowel cancer screening of 60% has not been met. There are differences in screening coverage by ethnicity and deprivation.

Diagnosing cancers

Two-week-wait referrals

According to the guidelines of the National Institute for Health and Clinical Excellence (NICE), patients presenting potential cancer symptoms to their GP should have tests within two weeks of their referral (the two week wait pathway).

The average percentage of new cancers which were diagnosed following a two week wait referral in Bath and North East Somerset is lower (worse) than the England average. There is a lot of variation between GP Practices in Bath and North East Somerset, with 2 Practices having significantly higher rates than the England average, and 5 GP Practices with significantly lower rates (see figure 4). These lower rates may be a result of people with potential cancer symptoms not going to their GPs, leaving it late, or GP referral patterns. 27

Cancer -new cancers diagnosed following 2 week wait referral- bar graph 

Figure 5: Percentage of new cancers which were diagnosed following a two week wait referral compared with Bath and North East Somerset and England average 28

(Click here for a larger image of Figure 4)

In 2008/9 a high proportion of two-week-wait referrals were subsequently found to have cancer at the Royal United Hospital in Bath, 23%, compared to a national average of 12%. 29

The relatively high rate for RUH was probably a reflection of the low utilisation of the two-week-wait referral in the BANES area in 2008/9, 50% Age Standardised Rate of all cancer diagnosis (where 100% is the Avon average), compared to 110% North Somerset, 100% South Gloucestershire, and 95% Bristol. 30 The low utilisation of the two-week-wait referral in BANES’s is further supported by the relatively high emergency admission diagnosis of cancers in the BANES area. 31

Emergency diagnosis 32

Diagnosing cancer as an emergency admission is associated with worse outcomes and lower survival. In the Avon, Somerset and Wiltshire Cancer Network (ASWCN), bowel (colorectal), lung, paediatrics and upper gastrointestinal cancers are the most frequently diagnosed cancers via emergency admission, ranging from 17% to 21% of all cancer diagnosis, respectively. 33

A recent national study 34 reveals that approximately 23% of cancer patients in England were first diagnosed via emergency presentations. It also showed an age association, with the very youngest (under 24 years) and the very oldest (over 75 years) being the most prominent. It also showed an association with deprivation and that emergency presentation is strongly associated with poorer survival.

Bath and North East Somerset Primary Care Trust had the highest Age Standardised Rate of cancers diagnosed via emergency presentation in Avon in 2008/9. When 100% represents the average Standardised Rate of cancers diagnosed via emergency presentation in Avon, B&NES represents a rate of 122%, significantly higher than the other three PCTs, as South Gloucestershire was 88% of this average, Bristol 90%, and North Somerset 85%.

GP visits 35

The average number of GP visits before a diagnosis in Bath and North East Somerset was 1.7 (data for 2007). What is indicative of a potential delayed diagnosis, however, is the number of diagnoses of cancers made after three or more GP visits, in BANES 15% of diagnosed cancers in 2007 were referred after 3 or more visits to a GP, this compares to 14% in South Gloucestershire, 18% in Bristol, and 20% in North Somerset.

Cancer waiting times 36

Current data on waiting times (ASW Network Cancer Waiting Times Reports – Jan to March 2012, and April to June 2012) do not raise any serious concerns with Bath and North East Somerset achieving above the national target of 93% for the two-week wait referrals at 94.6% between April to June 2012.

Hospital management of cancer 37

The NHS Atlas of variation 2009/10 38 shows that for emergency cancer bed-days Bath and North East Somerset is in the medium (3rd) quintile nationally at 11.2 days. The average length of stay for elective breast surgery in 2009/10 in BANES was 2.71 days which is in the middle quintile (3rd) nationally.

Cancer survival 39

Improving Outcomes: A Strategy for Cancer noted that if Britain matched mean European survival, about 6,000-7,500 deaths in under 75s would be avoided per year; this figure represents approximately 6% of our current national premature cancer deaths.

Rates of one-year survival are generally considered as an indicator of late diagnosis.40 One-year and five-year survival rates were examined in a 2010 report by the ASW (Avon, Somerset, and Wiltshire) Cancer Network. The analysis compared the data for 1998-2002 (five-year pooled data) with 2003-2007: 41

  • Breast –there was a significant improvement in all four Primary Care Trusts (PCTs) in the one-year survival over the time, as well as, though to a lesser degree, in the five-year survival.
  • Prostate cancer – Though there was an improvement in surbvival rates in the other three PCTs (South Gloucestershire,North Somerset and Bristol), there was a slight decrease in survival in Bath and North East Somerset -1.0%.
  • Colorectal cancer – one-year survival shows a rather varied picture for our local PCTs, in that: biggest improvement for Bath and North East Somerset (3.7%), South Gloucestershire (1.7%), North Somerset (0.6%), with a large drop in survival for Bristol (-2.9%).
  • Lung cancer - The greatest improvement in one-year survival has been made in lung cancer: Bath and North East Somerset had a 16.3% increase in one-year survival, Bristol 6.5%, North Somerset 5.4%, and South Gloucestershire 4.7%. However, even though these increases in one-year survival seem very optimistic it should be noted that it is only B&NES that has matched and overtaken the national average increase of 9.7%.

End of life care for cancer patients 42

Cancer accounts for around a third of all deaths. The proportion of cancer deaths at home is slightly higher than for all deaths (national averages around 22% vs 17%).

Bath and North East Somerset has a co-ordinated End of Life Care Pathway across the Local Authority and NHS which is used by all multi-disciplinary teams, incorporating evidence-based practice and guidelines related to the care and support of the dying patient in the last days of life.

The Palliative Care Home Support Service (Bristol and South Gloucestershire) provides personal care and emotional support for patients who wish to be at home in their final days or weeks of life. The service was set up and continues to operate with a focus on prioritising their work to support patients with deprived socio-economic circumstances.

There are concerns, expressed by our clinical colleagues that unnecessary hospital re-admissions occur during/at the end-of-life period; for example, anecdotally it is reported that close to 80% of urological cancer patients are re-admitted in the end-of-life period (assessed by the patient’s clinician). Similarly, there are concerns that major surgeries are undertaken in patients at the end of life.

What can we realistically change?

 National Institute for Health and Clinical Excellence (NICE) guidance

  • 1. NHSchoices (2012) Cancer, Information on cancer and useful links, http://www.nhs.uk/conditions/cancer/pages/introduction.aspx (viewed on 01/02/13)
  • 2. Cancer Mortality Trends 1992-2020, Macmillan 2013 http://www.macmillan.org.uk/Documents/AboutUs/Newsroom/Mortality-trends-2013-executive-summary-FINAL.pdf 
  • 3. National Cancer Intelligence Network (2012) General Practice Profiles for Cancer (2010/11), www.ncin.org.uk/cancer_information_tools/profiles/gp_profiles.aspx (downloaded 28/03/13)
  • 4. HSCIC (Health and Social Care Information Centre) (2013) Quality and Outcome Framwork 2012-2013 Practice level, http://www.hscic.gov.uk/catalogue/PUB12262 
  • 5. HSCIC (Health and Social Care Information Centre) (2013) Quality and Outcome Framwork 2012-2013 Practice level, http://www.hscic.gov.uk/catalogue/PUB12262 
  • 6. HSCIC (Health and Social Care Information Centre) (2013) Quality and Outcome Framwork 2012-2013 Practice level, http://www.hscic.gov.uk/catalogue/PUB12262 
  • 7. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 8. National Cancer Intelligence Network (2012) General Profiles for Cancer (2010/11), www.ncin.org.uk/cancer_information_tools/profiles/gp_profiles.aspx (downloaded 28/03/13)
  • 9. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 10. NHS Information Centre Indicator Portal (1993-2010) Mortality from all cancers (malignant neoplasms ) (ICD9 140-208 adjusted,ICD10 C00-C97): Directly age-standardised rates (DSR) All ages; annual trends; MFP (downloaded 02/04/2012) https://indicators.ic.nhs.uk/webview/
  • 11. NHS Information Centre Indicator Portal (1993-2010) Mortality from all cancers (malignant neoplasms ) (ICD9 140-208 adjusted,ICD10 C00-C97): Directly age-standardised rates (DSR) All ages; annual trends; MFP (downloaded 02/04/2012) https://indicators.ic.nhs.uk/webview/
  • 12. NHS Information Centre Indicator Portal (1993-2010) Mortality from all cancers (ICD9 140-208 adjusted, ICD10 C00-C97): Directlyage-standardised rates (DSR) Less than 65 years; annual trends; MFP (downloaded 02/04/2012) https://indicators.ic.nhs.uk/webview/
  • 13. Kings Fund (2011) How to improve cancer survival: Explaining Englands Relatively Poor Rates http://www.kingsfund.org.uk/sites/files/kf/How-to-improve-cancer-survival-Explaining-England-poor-rates-Kings-Fund-June-2011.pdf 
  • 14. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 15. ONS (2010) Mortality statistics: deaths registered in 2010 (Series DR) Table 5.2 Underlying cause, sex and age-group, 2010: chapter ii: Neoplasms
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  • 17. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
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  • 19. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 20. National Cancer Intelligence Network (2010) Evidence to March 2010 on cancer inequalities in England
  • 21. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 22. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 23. 2010-11 Programme Budgeting PCT Benchmarking Tool. http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743#_1 accessed 24 Feb 2012
  • 24. http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743#_3 ; accessed on 16 Aug 2011
  • 25. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 26. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 27. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 28. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 29. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 30. Awareness and Early Diagnosis Baseline Assessment 2010 Refresh. ASWCS. June 2011
  • 31. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 32. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 33. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 34. National Cancer Intelligence Network (2010) Routes to Diagnosis – NCIN Data Briefing http://www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis.aspx
  • 35. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 36. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 37. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 38. NHS Atlas of variation 2009/10 (2010) http://www.sepho.org.uk/extras/maps/NHSatlas2011/atlas.html
  • 39. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset
  • 40. The All Party Parliamentary Group on Cancer (2009) Report of Inquiry into Inequalities in Cancer.
  • 41. L Elliss-Brookes et al. (2011) LAEDI refresh 2010. ASWCN
  • 42. Gjini. A (2012) Cancer mortality in Bath and North East Somerset and the rest of Avon: its burden and inequalities, NHS Bath and North East Somerset