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Topic on a Page - Cancer

Data Sources:

PHE: National Cancer Intelligence Network (NCIN):

Cancer Commissioning Toolkit

Breast Cancer

Gynaecological Cancers

Haematological Cancers

Head and Neck Cancers

Lung Cancer and Mesothelioma

Upper Gastro Intestinal (GI) Cancers

Urological Cancers

General Practice Cancer Profiles for all Lincolnshire NHS Clinical Commissioning Groups

Public Health England (PHE):

Older People's Health and Wellbeing

Public Health England: Public Health Profiles

Cancer Services

Macmillan Cancer Support

Local Cancer Intelligence

World Cancer Research Fund:

Interactive infographic summarising risk factors for certain cancers

Supporting Information:

Cancer Services in Lincolnshire: Health Scrutiny Committee for Lincolnshire (January 2016)

World Health Organisation (WHO):

Guide to Cancer: Early Diagnosis

Cancer

Department of Health:

Resources: Helping more people survive cancer

Guidance: Commissioning Cancer Services Published: July 2011

Policy: Cancer research and treatment

Guidance: Infographic: improving cancer care

King's Fund:

How to improve cancer survival Published: June 2011

National Institute for Care and Health Excellence (NICE):

Rehabilitation after critical illness in adults [QS158] September 2017

Local Government Briefing: Behaviour Change [LGB7]

Tackling the causes of premature mortality (early death) [LGB26]

Multimorbidity [QS153] June 2017

Suspected Cancer [QS124] December 2017

NHS England (NHSE):

Strategic Clinical Networks

NHS Evidence:

Bladder Cancer

Breast Cancer

Cervical Cancer

Endometrial Cancer

Head and Neck Cancer

Kidney Cancer

Lymphomas

Lung Cancer

Myeloma

Oesophegal Cancer

Oral Cancer

Ovarian Cancer

Prostate Cancer

Skin Cancer

Stomach Cancer

Thyroid Cancer

Cancer Research Uk:

Cancer Strategy for England 2015-2020

Quality Health Limited:

National Cancer Patient Experience Survey (NCPES)

Public Health England

Breast Screening: Consolidated programme standards

Public Health England Cancer Board plan: 2017 to 2021

PHE: Bowl cancer screening programme standards

Cancer patients at increased risk of suicide Published: June 2018

Breast screening: leading a service

Linked Topics:

Topic last reviewed: Apr-18

JSNA Topic: Cancer

Background

Cancer is one of the biggest health challenges in the UK with one in two people expected to develop some form of cancer in their lifetime (Source: BMJ Lifetime risk of cancer 2015).Cancer prevalence rates within Lincolnshire are significantly higher than the national average, with some variation across the county.

An individual's risk of developing cancer depends on many factors, including age, lifestyle and genetic factors. The risk of developing cancer increases with age, with three out of four cases diagnosed in people aged 60 and over. More than one in three of all cases are in people aged 75 and over (Source: Cancer research UK). Although cancer occurs predominantly in older people, it is also the most common cause of death in people under the age of 60 (Source: National Cancer Intelligence Network; Older people and cancer. 2015). It is estimated that more than four in 10 cancer cases could be prevented (Source: Cancer research UK) by lifestyle changes, such as not smoking, cutting back on alcohol, maintaining a healthy body weight, keeping physically active and avoiding excessive sun exposure.

Someone is diagnosed with cancer every two minutes in the UK (Source: Cancer Research UK). Cancer in England is on the rise, with the number of cancer diagnoses expected to reach over 300,000 a year by 2020 (Source: Cancer Research UK). This is echoed in Lincolnshire with an increase in the diagnosis of all cancers. The most common cancers in the UK are breast, lung, bowel and prostate cancers. Of these, bowel cancer is the most common in Lincolnshire. Cancer screening programmes for breast, bowel and cervical cancers are effective at diagnosing patients at an earlier stage of cancer. In Lincolnshire, patients typically present their symptoms at a later stage which reduces the chances of survival as treatments are less effective as cancer advances.

Cancer is a major cause of premature mortality in the UK, accounting for more than one in four of all deaths (Source: NICE). However, mortality rates have been falling since the early 1990s and are expected to continue to decline. The proportion of people in the UK who get cancer but do not die from the disease has increased by about 70% over the past 20 years (Source: Macmillan Cancer Support 2015).

People now live nearly ten times longer after their cancer diagnosis compared to 40 years ago. There are now an estimated 2.5 million people living with cancer in the UK, projected to rise to 4 million by 2030 (Macmillan Cancer Support 2015).

There is a financial burden to living with cancer. One in three loses on average £860 a month in earnings because they are unable to work or have to cut down their working hours (Source: Macmillan Cancer Support 2016).

It is therefore essential that, in addition to maintaining continuing preventative interventions for cancer, people are provided with the support to manage their condition in order to live well, with and beyond cancer.

The impact of cancer on the health and social care sector is significant. The full economic cost of cancer has been estimated at £15.8bn for the UK (Source: National Cancer Intelligence Network e- atlas).

Context

National Strategies, Policies & Guidance

The Independent Cancer Taskforce established in January 2015 published a report titled, Achieving world-class cancer outcomes: a strategy for England 2015-2020, includes over 90 recommendations aimed at achieving a step change in cancer care in this country.

The National Cancer Patient Experience Survey (NCPES,2017) has highlighted variations reported by cancer patients, and set out areas where trusts can make improvements.

The NHS 5 Year Forward view, (October, 2014) sets out a vision for both preventing cancers and early diagnosis, research and innovation, and a specific ambition to improve quality of life for cancer patients.

Implementing the Cancer Taskforce Recommendations (April 2016) examines commission person centred care for people affected by cancer.

Actions for End of Life Care: 2014 – 2016 sets out ambitions for end of life care for adults and children with a framework based on the House of Care model.

The Cancer Drugs Fund provides information on, and a pathway for, cancer drugs not routinely available on the NHS.

NICE: Suspected Cancer: recognition and referral [NG12] (June 2015) Evidence-based recommendations for the identification of children, young people and adults with symptoms that could be caused by cancer. It outlines the appropriate investigations in primary care, and selection of people to refer for a specialist opinion. It aims to help people understand what to expect if they have symptoms that may suggest cancer.

NICE: Cancer: general and other everything NICE has produced on the topic of cancer: general and other. Includes any related guidance, NICE Pathways, quality standards and advice (Updated August 2016).

There are a variety of national policies and strategies which relate to modifiable risk factors for cancer. For further information, strategies and plans please see the applicable JSNA topics.

Food & Nutrition

Obesity (All Ages)

Physical Activity

Smoking Reduction in Adults

Substance Misuse

Local Strategies & Plans

Local plans are being developed to reflect both the National Cancer Strategy and local challenges. The health system cancer programme board coordinates this work in Lincolnshire (facilitated by Lincolnshire West CCG) and is supported by the Cancer Prevention and Early Presentation Steering Group, the Cancer Screening Steering Group, the Living With and Beyond Steering Group; representatives from all four Lincolnshire CCGs, primary care, secondary care, palliative care and the voluntary sector.

The key areas of focus include:

  • Raising awareness of cancer signs and symptoms, and the importance of presenting symptoms at an early stage
  • Encouraging people to access cancer screening services through promotional campaigns
  • Improving access to local services by identifying key issues such as transport and working with providers to provide solutions
  • Supporting the continuous improvement of acute cancer treatments, at United Lincolnshire Hospitals Trust (ULHT) facilities, and other hospitals used by Lincolnshire people and tertiary centres
  • Promoting the development of services to support people living with, and beyond cancer
  • Supporting the continued development of palliative and end of life care services by improving access to services and promoting them to cancer patients and carers

What is the picture in Lincolnshire?

What the data is telling us

Incidence
Cancer incidence rates are provided by the National Cancer Registration and Analysis Service within Public Health England (Source: PHE, CancerStats).

In 2015, Lincolnshire had 4,767 new cases of all cancers, which is the equivalent age standardised rate of 593 cases per 100,000 of the resident population. The Lincolnshire rate is lower than the national rate of 605 per 100,000; however the difference is not statistically significant. Within Lincolnshire the highest rates are in South West Lincolnshire CCG (624 per 100,000) and Lincolnshire East CCG (606 per 100,000); while South Lincolnshire has the lowest rate at 568 per 100,000.

Breast cancers were the most common of all cancers in Lincolnshire, with a rate of 173 per 100,000 resident females, which is higher than the national rate of 170 per 100,000. Rates of breast cancer diagnoses were alarmingly high in South West Lincolnshire CCG in 2015, at 227 per 100,000 and were significantly higher than both Lincolnshire and England. Rates were also seen to be markedly high in North Kesteven, at 212 per 100,000 and very low in South Holland (117 per 100,000).

Incidence of prostate cancer in Lincolnshire was also high, at 171 per 100,000 resident males, however this was lower than the national rate of 176 per 100,000. Lincolnshire West CCG and South Lincolnshire CCG had the highest rates of prostate cancer across the county in 2015, at 182 and 178 per 100,000 respectively. Across district authorities, rates are highest in the more urban districts of Lincoln (207 per 100,000) and Boston (192 per 100,000).

Incidence of lung cancers in Lincolnshire was much lower in 2015 than seen nationally, at 67 per 100,000 compared to 78 per 100,000 across England. Rates varied within the county from 77 per 100,000 in Lincolnshire East CCG to 55 per 100,000 in South West Lincolnshire CCG. Lincoln, East Lindsey and Boston have the highest incidence rates in the county at 86, 80 and 77 respectively. Incidentally these districts also have some of the highest adult smoking prevalence rates across the East Midlands.

The rate of new bowel cancer cases is lower in Lincolnshire at 69 per 100,000 than in England, at 71 per 100,000. There is some variation within the county with South West Lincolnshire CCG having the highest rate (77 per 100,000) and South Lincolnshire CCG having the lowest (62 per 100,000).

Prevalence
Cancer prevalence is based on patients recorded by GPs on a disease register and registered under the Quality and Outcomes Framework (QOF). QOF prevalence is presented as a crude rate per 100,000 registered patients, rather than the resident population. Overall prevalence of cancer in Lincolnshire in 2016/17 was 3.3%, which is significantly higher than the national prevalence rate of 2.6%.

Within Lincolnshire, prevalence is highest in South Lincolnshire and South West Lincolnshire CCG's, both at 3.5%, while Lincolnshire West CCG is lower at 2.9%.

Early detection
Early detection of cancer greatly increases the chances for successful treatment. There are two major components of early detection of cancer: education to promote early diagnosis and screening. Screening refers to the use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms. Examples include breast cancer screening using mammography and cervical cancer screening using cytology screening methods, including Pap smears. (Source: WHO, Early detection of cancer, 2016).

NHS Digital provides data on the percentage of new cancer cases which were diagnosed at stage 1 or 2, for all cancer types (Source: NHS Digital Information Centre, NHS Indicator Portal).

In 2016 the percentage of patients diagnosed at stage 1 & 2 (excluding unknown stages) for all cancers in Lincolnshire STP was 53.6%. This was slightly below the England total which was 53.7%. (Source: Early Diagnosis. 2016, NCRAS).

In 2016/17 Lincolnshire East had the highest number of referrals to the two week wait pathway (3,843 per 100,000 population) compared to Lincolnshire West with the lowest number (3,098.2 per 100,000). Of all these referrals countywide South West Lincolnshire had percentage of which resulted in a cancer diagnosis (55.2%) and Lincolnshire East with the lowest percentage (49.7%). (Source: PHE, Cancer Services Profile).

In 2017 the percentage of patients seen within two week wait standard at United Lincolnshire Hospitals for all suspected tumour groups was 89.1%. This was below the England total which was 94.3%. (Source: PHE, Cancer Services Profile).

In 2016/17 Lincolnshire East (125.6 per 100,000 population) had the highest number of emergency presentations to hospital which resulted in a diagnosis of cancer, with Lincolnshire West lowest (88.1 per 100,000). All CCGs have a higher number of emergency presentations than the national average (87.8 per 100,000) (Source: PHE, Cancer Services Profile).

Screening
Figures for 2016/17 show that 74.4% of females aged 50-70 in Lincolnshire were screened for breast cancer within six months of being invited. The local uptake is higher than seen nationally (72.2%). South Lincolnshire (75.4%) and Lincolnshire West (74.7%) shows a noticeably higher uptake compared to East Lincolnshire (73.2%) and South West Lincolnshire (73.1%).

Cervical screening coverage is defined as the percentage of eligible women aged 25-64 who were screened adequately within a specified period (3.5 years for those aged 25-49, 5.5 years for those aged 50-64). Three quarters (75.8%) of eligible women in Lincolnshire (aged 25-64) were screened in 2016/17, which is higher than the national coverage rate (72.1%). As with having high early detection rates, South Lincolnshire (78%) and South West Lincolnshire (77.6%) CCG's have the highest coverage across the county for cervical cancer.

60.7% of all adults aged 60-69 in Lincolnshire were screened for bowel cancer within six months of being invited, which is significantly better than the national uptake rate of 59%. South Lincolnshire (62.7%) and South West Lincolnshire (62.5%) CCG's have the highest uptake of bowel cancer screening in the county.

Lincolnshire (85.7%) has a lower uptake of the HPV vaccination in females aged 12-13 years than the national rate (87%).

Treatment
The national benchmark for the proportion of new cancer patients whose initial treatment began within 62 days of urgent referral from a GP remains at 85%.

In 2017 the percentage of patients seen within 62 day standard at United Lincolnshire Hospitals for all tumour groups was 70.3%. This was below the England total which was 81.8%.

The percentage of patients seen within the 62 day standard at United Lincolnshire Hospitals (tumour group breast) in 2017 was 94.6%. This was slightly above the England total which was 94.4%.

The national benchmark for the proportion of new cancer patients, whose initial treatment began within 31 days of decision to treat, remains at 96%.

In 2017 the percentage of patients seen within the 31 day standard at United Lincolnshire Hospitals (all tumour groups) was 96.0%. This was below the England total which was 97.6% yet still meeting the 96% target. (Source: NHS England, Cancer Waiting Times)

Survival
Estimates of one year net survival are based on patients diagnosed with one of 24 common cancers in England. To allow the comparison of survival between cancers and between different populations, all age survival estimates are age-standardised. The Office of National Statistics (ONS) report on cancer survival rates for a range of cancers however at local authority and CCG level; these are limited to three cancers, breast, bowel and lung (Source: ONS, Index of cancer survival for CCG's in England).

In 2015, the one year survival rate for all cancers in Lincolnshire was 58.7%, which is comparable to the national survival rate of 59.3%. There is no significant difference in survival rates across the four Lincolnshire CCG's; however South West Lincolnshire CCG is marginally lower at 56.3%.

Survival estimates for breast cancer are by contrast much higher, with 96.5% of women in Lincolnshire and 96.7% nationally surviving at one year. South Lincolnshire CCG has the lowest survival rate at 95%, while the Lincolnshire West CCG has the highest at 97.2%.

Overall, survival rates for bowel cancer are lower than for breast cancer, at national rates of 80.4% of all adults surviving to one year, and 79.3% in Lincolnshire.

Along with liver and pancreatic cancer, lung cancer has one of the lowest survival rates of all cancers among adults. Rates in Lincolnshire (38.9%) are significantly worse than the national survival rates (40.7%). Although not a direct cause for all cases of lung cancer, smoking is a key contributing factor. Smoking prevalence and quit rates in Lincolnshire are significantly worse than the national average, which over time could contribute to reduced survival rates in the local population.

Mortality
In 2016, one in three deaths in England was under the age of 75, with cancer being the highest cause of premature death in adults in England. Published figures on premature mortality rates are available from Public Health England's Public Health Profile; however rates were not available for CCG's. For CCG rates, local analysis of record level primary care mortality data was undertaken using the same method of direct age standardisation (Source: NHS Digital, Primary Care Mortality Database).

Between 2014 and 2016, the premature mortality rate in Lincolnshire for all cancers was 133.8 per 100,000. The rate is higher for men (146.2) than for women (121.9) and Lincolnshire rates are lower than the national averages. Lincolnshire East CCG has the highest rates of premature mortality from cancer, while South Lincolnshire CCG has the lowest mortality rates. The most common causes of cancer related premature deaths are smoking, alcohol and poor diet (Source: PHE, Healthier Lives profile).

Premature mortality considered preventable are deaths considered preventable if, in the light of the understanding of the determinants of health at the time of death, all or most deaths from the underlying cause could potentially be avoided by public health interventions in the broadest sense. Cancers considered preventable include breast, cervical, lung, mouth/throat/oesophageal, skin and mesothelioma.

Between 2014 and 2016, the rate of premature mortality from cancers considered preventable in Lincolnshire was 74.6 (rate per 100,000) people, which is lower than the national rate (79.4). Preventable mortality from cancer is higher for men (78.2) than for women (71.2), in line with national patterns.

Lung cancer is by far the most common cause of cancer deaths nationally, with published rates being shown for all ages. Between 2014 and 2016, lung cancer killed 59 per 100,000 people of all ages; while the rate for Lincolnshire was comparable at 56 per 100,000. Alarmingly, lung cancer deaths are noticeably higher in Lincoln (72 per 100,000) and East Lindsey (65) compared to the rest of Lincolnshire, however these rates are not significantly different compared to the national average.

Nationally, 15% of all cancer deaths in women are from breast cancer, second to lung cancer (21%). Breast cancer mortality rates are higher in Lincolnshire (35 per 100,000) than nationally (34 per 100,000). Again, Lincoln has higher than average mortality rates due to breast cancer (47 per 100,000).

Potential years of life lost (PYLL) is one of the main measures of premature mortality. It is used to compare the relative contribution of different causes of premature death within a population, and can therefore be used by health planners to define priorities for the prevention of such deaths. PYLL is presented as a directly age standardised rate per 100,000 registered patients. Data for Lincolnshire is only published at CCG level; therefore an aggregate rate for the county is not available.

Between 2012 and 2014, PYLL rates due to cancer across Lincolnshire were higher than the national equivalent of 620.5 per 100,000. The highest rates were in Lincolnshire East (668.9) and Lincolnshire West (672.8) CCG's; while South Lincolnshire and South West Lincolnshire had lower rates of 637.3 and 627.8 respectively (Source: NHS Digital Information Centre, NHS Indicator Portal).

NHS 'Rightcare' Commissioning for Value packs, providing data, evidence and tools to help healthcare providers improve the way care is delivered for their patients and populations. Local data suggests that Lincolnshire spends more than the UK average on cancer with below average outcomes.

Trend

  • Trends over time show that since 2010, national incidence rates of all cancers increased and reached a peak of 626 per 100,000 in 2013, and have since fallen to 605 in 2015. In Lincolnshire, rates have seen a steady decline from 627 in 2010 to 593 in 2015, a 5.4% drop. Lincolnshire West CCG has seen the biggest net reduction of 9.5% between 2010 and 2015 (642 to 581), while South West Lincolnshire CCG has seen an increase in incidence rates (3.9%) from 601 in 2010 to 624 in 2015 (Source: NHS Digital Information Centre, NHS Indicator Portal).
  • Trends show that since 2012/13, cancer prevalence has risen across all areas of Lincolnshire, in line with the national picture. Lincolnshire has consistently had higher cancer prevalence than the national average throughout this period. This disparity is due to a number of reasons, the main reason being that the rates provided are not age standardised so will vary between different demographic profiles. There are also reported differences in data source and recording with there being no single standard system for maintaining GP patient data (Source: PHE, Cancer Services profiles).
  • Early diagnosis rates at stages 1 or 2 have increased markedly both nationally and locally between 2013 and 2015. In Lincolnshire, early diagnosis has improved from 31.7% to 51.3%. The largest increase was seen in South West Lincolnshire CCG, from 26.8% in 2013 to 56% in 2015 (Source: NHS Digital Information Centre, NHS Indicator Portal).
  • Long term trends between 2000 and 2015 show that one-year survival rates for all cancers have increased by a quarter nationally from 47.4% to 59.3%. In Lincolnshire, rates increased by a fifth from 48.7% to 58.7%. Lincolnshire East and South Lincolnshire CCG's saw the greatest net increases of 26.7% and 26.2%, while South West Lincolnshire CCG saw the smallest long term increase of 9.5% (Source: NHS Digital Information Centre, NHS Indicator Portal).
  • Age-standardised mortality rates for cancer (for all persons under-75) fallen in Lincolnshire by 5.5% from 141.4 per 100,000 in 2010 -12 to 133.5 in 2014-16. Lincolnshire West and South West Lincolnshire CCG's have seen the greatest net reduction in premature mortality rates of 7.5% and 6.5% over the same period. Premature mortality has increased for men living in South West Lincolnshire CCG, from 140.3 per 100,000 in 2010-12 to 144.4 in 2014-16; while rates for women in the same CCG area have fallen by 15.9% from 128.2 per 100,000 in 2010-12 to 107.8 in 2014 -16 (Source: NHS Digital, Primary Care Mortality Database).
  • Mortality rates for cancer (for all persons under-75) considered preventable, has reduced in England by 19.2% since 2001/03 from 98.3 per 100,000 to 79.4 per 100,000 in 2014/16. Lincolnshire has had a similar reduction of 17.3% from 90.2 per 100,000 in 2001/03, to 74.6 per 100,000. Lincolnshire rates have been significantly better than the national average since 2009/11 (Source: PHE, Public Health Outcomes Framework).
  • Nationally, emergency presentations which result in a diagnosis of cancer are falling; 93.9 per 100,000 in 2012/13 down to 87.8 per 100,000 in 2016/17. In Lincolnshire all CCGs remain above this average with Lincolnshire East consistently the highest 118.9 per 100,000 in 2012/13 and 125.6 per 100,000 in 2016/17.

Key Inequalities

  • Cancer incidence and mortality are generally higher in deprived groups compared with affluent groups, older compared with younger people and men compared with women.
  • Conversely, breast cancer has higher incidence in more affluent groups, but mortality is higher in less affluent women.
  • Part of the variance in mortality rates can be attributed to delayed diagnosis amongst deprived groups, older people (at least for breast cancer) and certain BME groups (at least for breast cancer). The contribution of delayed diagnosis to poorer survival rates and higher mortality amongst men than women is still uncertain.
  • A recent inquiry into Geographical Inequalities and Breast Cancer finds that while more women than ever before are surviving breast cancer, stark geographical inequalities exist across England in screening, early detection and access to treatment and services. This picture is reflected in Lincolnshire.
  • There are significant inequalities in cancer mortality within wards along the east coast of Lincolnshire. Some wards in and around Mablethorpe and Skegness are amongst the most deprived 10 percent of neighbourhoods in the country. These areas also have low uptake of the cancer screening programmes.
  • The picture for ethnic minority groups varies according to cancer type and ethnic group. In general, incidence is lower amongst ethnic minority groups. Lincoln, Boston and South Holland have the greatest proportion of foreign-born residents, especially those from EU accession states. Zero hours contracts are particularly high within South Holland district, which correlates to concentrated migrant area populations. Qualitative evidence suggests that those who cannot afford to take time off of work for appointments and treatments may be diagnosed at later stages, or may not attend their treatment (Source: EPOC Lincolnshire Annual Cancer Report 2016).
  • Levels of public awareness of cancer signs and symptoms are generally low, but even lower in groups such as deprived communities, some BME groups and men. This may contribute to lower uptake of screening, later presentation when symptoms arise and lower survival rates (Source: Robb, K. et.al, 2009, British Journal of Cancer).
  • Improvements in mortality have been slower in older people than in younger people. Older people with cancer receive less intensive treatment than younger people. In many cases this may be clinically appropriate. However, there is increasing evidence that under-treatment of older people may occur (Source: Macmillan Old Age Excuse Report 2015).
  • The modifiable risk factors for cancer are known to vary with socio-economic deprivation. A report published in 2014 by the National Cancer Intelligence Network (NCIN) highlights the variation observed in incidence and mortality figures with socio-economic deprivation, age, and gender. It concluded that if the more deprived groups had the same rates as the least deprived, there would have been around 15,300 fewer cases and 19,200 fewer deaths per year across all cancers combined in the most recent 5-year period. For further information on key inequalities relating to the modifiable risk factors please consult the relevant JSNA topics.
  • A recent Macmillan report provides an insight into the experience of cancer patients' final months and years. It finds that cancer patients approaching the end of their life face repeat emergency visits and the situation is worse for patients who are most socioeconomically disadvantaged.
  • There are a range of strategies and programmes to address health inequalities. The Marmot Review, a strategic review of health inequalities, identified six policy objectives for addressing health inequalities; for example, strengthening the role and impact of ill health prevention.

Current Activity & Services

  • There are a wide range of interventions to address cancer, including prevention, ongoing management and treatment.
  • The health system cancer programme board has oversight and works to develop the cancer pathway. This includes prevention, diagnosis, treatment, survivorship and end of life care. Public health are facilitating a multi partner early diagnosis and prevention action plan which supports the population of Lincolnshire to understand and lower risk, attend screening and present vague symptoms.
  • Diagnostic redesign is being undertaken to support more effective referral and treatment within the lung, prostate and bowel pathways.
  • The Macmillan Living With And Beyond Cancer Programme is working to ensure that people diagnosed with cancer are living as healthy and active a life as possible during and after treatment. The programme is being led by Lincolnshire West CCG and Macmillan Cancer Support.
  • The East Midlands Cancer Alliance helps to improve health outcomes for cancer patients across the region. They provide local support for national drivers such as earlier diagnosis. They also share best practise, provide expert clinical advice, and help to address any unwarranted variation across the region.

Prevention:

  • NHS England run the cancer screening programmes for breast, bowel and cervical which aim to identify cancer at an earlier stage.
  • The countywide cancer screening health inequalities group plans and delivers a programme of improvements around increasing uptake and addressing health inequalities within screening programmes. This is a partnership group across NHS England, Public Health England, Lincolnshire County Council Public Health, Lincolnshire CCGs and Cancer Research UK.
  • Quit 51 is responsible for administering the tobacco control alliance function and providing stop smoking services across Lincolnshire.
  • There are a range of prevention and treatment services to address overweight and obesity. These are usually presented within a four-tiered model or pathway (Tiers 1-4). The JSNA Obesity (All Ages) Topic contains further information on weight management.
  • Addaction deliver alcohol and drug treatment services as well as a recovery service in partnership with Double Impact.
  • The NHS Health Check Programme is a screening and risk management programme that aims to identify people aged 40-74 years, who have a high risk of developing long term conditions.
  • Making Every Contact Count (MECC) is an approach to behaviour change that utilises the millions of day to day interactions that organisations and people have with others to encourage changes in behaviour.
  • Public Health England's 'One You' programme helps adults across the country to avoid future diseases caused by modern lifestyles.

Treatment and Management:

  • The 'two week wait' is a fast track route through which a GP can refer directly to ULHT if they suspect cancer. The GP must send an electronic referral to the hospital, the hospital is required to see the patient within two weeks.
  • A vague symptoms pathway is being piloted across Lincolnshire; this aims to refer patients who currently don't meet the criteria for emergency referrals but have symptoms that are clinically concerning.
  • United Lincolnshire Hospitals NHS Trust (ULHT) has a range of specialist teams and local diagnostic and treatment teams who work with cancer patients. These teams comprise of doctors from differing specialties – surgery, medicine, oncology (cancer treatment), radiology (x-ray), pathology (examination of specimens) and nurse specialists, administration support and other professionals such as dietitians in some teams.
  • ULHT has a comprehensive range of radiotherapy and chemotherapy treatments at Lincoln County Hospital, with chemotherapy also provided at Pilgrim Hospital, Boston and Grantham and District Hospital. Inpatient and outpatient cancer care is provided across the Trust for the more common cancers and in specific areas for the more specialised cancers. All patients diagnosed with cancer are reviewed by cancer teams to agree the most beneficial course of treatment and to plan future care. Mobile chemotherapy is also offered on a bus which travels across the county.
  • St Barnabas Hospice provides a range of services for those living with cancer and their carers. They have an 11 bed hospice in Lincoln which serves the county, a six bedded hospice within Grantham Hospital and offer a hospice at home service. They also provide day therapy for anyone over-18 with a life limiting illness, offer guidance services on welfare benefits and provide a family support service.
  • The Independent Living Team is a joint service provided by Lincolnshire Community Health Service NHS Trust and Lincolnshire County Council. They provide short-term support, which may be a few days or weeks to help people remain in their own home safely, for example during a period of illness, or after a stay in hospital.
  • Macmillan palliative and end of life care offer specialist services, to help people manage the complex needs associated with living with a life-threatening illness. They act as a specialist resource, and influence patient care by providing specialist education and training to other professional staff and students. They are members of an integrated team, working with partners and providers.
  • The Macmillan Information and Support Centres at Pilgrim Hospital Boston and Lincoln County Hospital offer information regarding cancer and available services, together with emotional support for patients, their families/ carers and for staff.
  • The Butterfly Hospice is purpose-built, with a six-bed inpatient unit in Boston. It works in partnership with Lincolnshire Community Health Services NHS Trust (LCHS) and the Butterfly Hospice Trust and provides free, high quality palliative, end of life and respite care in an informal and homely environment for adults with life-limiting illness.

Unmet Needs & Gaps

  • Smoking prevalence in Lincolnshire is still too high. The current smoking cessation services would not be adequate if clinical services referred all those who would benefit from the service.
  • There are some gaps in addressing overweight and obesity across the four-tiered model (Tiers 1-4). For example there is currently no Tier 3 service in Lincolnshire to provide specialist multi-disciplinary obesity services.
  • There are a large number of people who are at high risk due to modifiable risk factors.
  • It is essential that work takes place to continue to raise the awareness of the signs and symptoms of all cancers, and the importance of presenting them to a doctor at an early stage to increase chances of survival from the disease.
  • Workforce capacity issues for secondary care are affecting outcomes both in the initial diagnosis and treatment of patients, and the long term follow up of survivors.

Local Views & Insights

  • The Early Presentation of Cancer programme audited some of the people who have previously engaged with the programme, who said they felt their knowledge and understanding of cancer had been developed by the education programme and they continue to pass on the message in their communities.
  • Macmillan has funded the Living with and Beyond Cancer programme out of a recognised local need for support after treatment ends. The programme is currently engaging with the public on the state of cancer services in Lincolnshire.
  • There is a cross community cancer improvement programme that is working with the regional cancer alliance to improve outcomes and performance.
  • Healthwatch carried out a survey on screening programmes available in Lincolnshire; feedback was positive on the services offered. Lincolnshire residents often did not take up invitations to attend a screening appointment due to embarrassment, fear or time factors (i.e. not having appointments available when needed).
  • In 2017 the cancer patient experience survey rated ULHT 8.39/10 for how they would rate their care. This was below the England total score which was 8.74. This ranks fourth lowest in the country of all hospital trusts.

Risks of not doing something

  • An increase in premature mortality rates and a decrease in survival rates.
  • More people presenting late to their doctor, leading to poorer outcomes for the patient. This also results in high healthcare costs. E.g. an early stage colon cancer patient would incur approximately £3,400 in NHS treatment costs on average, whereas a late stage patient would incur £12,500.
  • A further decline in people attending cancer screening programmes.
  • The National Audit Office has estimated cancer services cost the NHS approximately £6.7bn per annum in 2012/13. The Five Year Forward View (FYFV) projections indicate that this will grow by about 9% a year, implying a total of £13bn by 2020/21. The recommendations set out in the 2015 National Cancer Strategy will cost an estimated £400m per annum, of which approximately £300m per annum may already be included within the FYFV baseline projections. However, in the medium term, implementation of these recommendations should contribute substantially in excess of £400m per annum to the projected £22bn funding gap (Source: NCIN, 2015).
  • Macmillan reported that as many as 500,000 people living with and beyond cancer have one or more physical or psychosocial consequences of their cancer or its treatment that affects their lives on a long-term basis. Not supporting patients post treatment could impact further on their health and the services available in Lincolnshire.

What is coming on the horizon?

  • Regional Cancer Alliances will be the key to affecting the transformational change needed to achieve world-class cancer outcomes for their populations, as set out in the Cancer Taskforce strategy. The establishment of Cancer Alliances will put clinical leaders across primary, secondary and tertiary care in the driving seat for improving quality and outcomes across cancer pathways, based on shared data and metrics. Each Alliance will take on responsibility for the local cancer agenda as well as planning for the local delivery of the recommendations from the Taskforce report.
  • Implementing the five year Sustainability and Transformation Plan for local health service funding requires health providers to deliver services that meet the needs of local populations as well as supporting the Five Year Forward View vision, which includes a ‘radical upgrade’ in prevention. This provides the opportunity to invest resources in preventative work programmes that will result in financial savings to the NHS through contributing to primary and secondary prevention outcomes. The STP prevention plan has prioritised the need for a number of lifestyle services which, subject to being commissioned, will support reducing the risk of cancer.
  • Improvements to cancer pathways, including opportunistic screening, earlier diagnosis mechanisms and improved treatment.

What should we be doing next?

We should continue taking action to implement the Joint Health and Wellbeing Strategy for Lincolnshire. The key areas for continued development are:

  • The prevention agenda, particularly addressing obesity, smoking and alcohol use, needs to continue as a priority.
  • Undertake population level education to raise awareness of prevention, possible symptoms and risk factors.
  • For people who are living with cancer self-care is essential. Self-care is a core part of the STP and will continue to be developed.
  • It is essential that people who have or have had cancer are provided with good quality healthcare. Cancer is a core part of the planned care component of the STP, which will continue to be developed.
  • Continued personal development sessions to be delivered to health professionals.
  • Work closely with the CCGs to enable targeted work in areas of high need.
  • Gathering robust data on long term conditions which are co- morbidities of cancer.
  • Use modelling to accurately identify cost savings of providing prevention initiatives in correlation to cancer treatment.
  • Undertake review of spend, and outcomes relating to cancer prevention, diagnosis and treatment between Lincolnshire and other comparator areas.
  • Continue to work closely with the cancer alliance.
  • Continue to provide a consistent approach across screening programmes and quality assurance across the screening pathway.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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