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Topic on a Page - Cancer

Data Sources:

PHE: National Cancer Intelligence Network (NCIN):

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:

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

Multimorbidity [QS153] June 2017

Suspected Cancer [QS124] December 2017

Lung cancer: diagnosis and management [NG122] Published March 2019

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: Bowel cancer screening programme standards

Cancer patients at increased risk of suicide Published: June 2018

Breast screening: leading a service

End of Life Care:

End of Life Care: Professional and Public Resources

Linked Topics:

Topic last reviewed: Mar-19

JSNA Topic: Cancer

Background

Cancer is one of the greatest 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, on average, 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 a third of new 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). However, it is possible to reduce lifetime risk of getting cancer and it is estimated that more than four in 10 cancer cases could be prevented through lifestyle changes, such as not smoking, cutting back on alcohol, maintaining a healthy body weight, keeping physically active and avoiding excessive sun exposure. (Source: Cancer Research UK)

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 leading to the diagnosis of patients at an earlier stage of cancer. In Lincolnshire, patients typically present their symptoms at a later stage of cancer 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 a quarter of all deaths in the UK. However, mortality rates have decreased by around a tenth (9%) in the UK. (Source: Cancer Research UK)

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 (Source: Macmillan Cancer Support 2015).

There is a financial burden to living with cancer. One in three people with cancer lose 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).

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 NHS Long Term Plan (January 2019) sets out clear commitments on cancer, prioritising diagnosing cancers at an earlier stage, preventing more cancers and promoting further research into cancer.

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

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

The NHS 5 Year Forward view, (October, 2014) sets out a vision for 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 the commissioning of 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

Lincolnshire West is the lead commissioner for Cancer on behalf of the Lincolnshire STP. The programme aims to provide better outcomes for all cancer patients from pre- diagnosis, diagnosis, living with cancer through to palliative and end of life care. The programme focusses on a number of areas including screening and prevention, acute diagnostic and treatment phase through to living with cancer and end of life.

The cancer board have facilitated and supported the development of a number of local plans to deliver the programme:

  • The Cancer Prevention and Early Diagnosis Plan (March 2019) outlines action required on preventative opportunities, increasing earlier diagnosis and secondary prevention.
  • Operational plans to improve performance; this support the continuous improvement of acute cancer treatments at United Lincolnshire Hospitals Trust (ULHT) facilities, along with other hospitals and tertiary centres used by Lincolnshire people.
  • The Living With and Beyond Cancer Strategy (2017-19) articulates how the needs of people living with cancer across Lincolnshire will be met, the programme approach, principles and values. The second strategy (2019-2021) is due to be delivered in May 2019 and will focus on the delivery of the programme.
  • The Palliative and End of Life Care Strategy (2018) outlines the continued development of palliative and end of life care services by improving access to services and promoting them to cancer patients and carers.

The Lincolnshire Joint Health and Wellbeing Strategy (2018) has a strong focus on prevention and early intervention, with a recognition of the need to embed this across all health and care services.

What is the picture in Lincolnshire?

What the data is telling us

Incidence

Cancer incidence rates for all cancers and for specific cancer groups are provided by the National Cancer Registration and Analysis Service within Public Health England and cover a pooled three-year period from 2014-2016. All rates are standardised using the latest ONS resident population estimates (Source: PHE, Cancer Services, NCRAS)

Between 2014 and 2016, Lincolnshire had 14,483 new cases of all cancers, which is the equivalent age standardised rate of 601.5 cases per 100,000 population, which is similar to the national rate of 610.4 per 100,000 population. Of these new cases, 52.4% were male and 47.6% were female. Overall cancer incidence is highest in Lincolnshire East CCG (621.9 per 100,000 population) and lowest in Lincolnshire West CCG (581.7 per 100,000 population). At district local authority level cancer incidence is highest in East Lindsey (632.6 per 100,000 population) and lowest in North Kesteven (563.3 per 100,000 population) (Source: PHE, NCRAS).

Between 2014 and 2016, there were 2,132 new cases of breast cancer among all females which is equivalent to rate of 169.7 per 100,000 population. Rates of breast cancer diagnoses were highest in Lincolnshire East CCG (177.8 per 100,000 population) and South West Lincolnshire CCG (176.7 per 100,000 population). Rates for Lincolnshire are similar to the national rate of 170.7 per 100,000 population. (Source: PHE, NCRAS).

There were 2,066 new cases of prostate cancer among males in Lincolnshire during 2014- 16, which represents a rate of 176.5 per 100,000 population, and is similar to the national rate of 178.1 per 100,000 population. Despite having fewer numbers of new cases compared to breast cancers, the equivalent rate places prostate cancer as the most commonly diagnosed cancer type in Lincolnshire. Rates of prostate cancer diagnoses are highest in South Lincolnshire CCG (186.3 per 100,000 population) and South West Lincolnshire CCG (182.2 per 100,000 population). (Source: PHE, NCRAS).

There were 1,731 new cases of lung cancer in Lincolnshire between 2014 and 2016, of which 58.2% were male and 41.8% were female, which mirrors the national picture. This equates to a rate of 71.6 per 100,000 people, 88.5 per 100,000 males and 54.7 per 100,000 females. New lung cancer cases are significantly higher in Lincolnshire East CCG (80 per 100,000 people, 101.3 per 100,000 males, 58.7 per 100,000 females). All other CCG areas are similar to Lincolnshire and national rates. (Source: PHE, NCRAS).

There were 1,679 new cases of bowel cancer (colorectal) in Lincolnshire between 2014 and 2016, of which 55.4% were male and 44.6% were female, which mirrors the national picture. This represents a rate of 69.4 per 100,000 people, 82 per 100,000 males and 56.9 per 100,000 females. Incidence of bowel cancer is highest in Lincolnshire East CCG (72 per 100,000 people, 82.9 per 100,000 males, 61 per 100,000 females). All other CCG areas are similar to Lincolnshire and national rates. (Source: PHE, NCRAS).

Prevalence

Cancer prevalence is calculated utilising data from patient data 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 2017/18 was 3.5%, which equates to 27,467 registered patients. The rate for Lincolnshire is also significantly higher than the national prevalence of 2.7%.

Within Lincolnshire, cancer prevalence rates are highest in South Lincolnshire and South West Lincolnshire CCG's, both at 3.7%, while Lincolnshire West CCG has the lowest cancer prevalence of 3.1%. (Source: PHE, Cancer Services)

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 detected at stage 1 or 2, for all cancer types.

In 2016 52% of new cases of cancer were detected at stage 1 & 2 (excluding unknown stages) in the Lincolnshire STP area. This was slightly below the England total of 52.6%. (Source: NHS Digital, CCG Outcome Indicators Set)

In 2017/18 Lincolnshire East CCG had the highest rate of two week wait referrals for suspected cancer (4,056 per 100,000 population) compared to Lincolnshire West with the lowest number (3,479 per 100,000 population). The detection rate for all cancers resulting from a two week wait referral are highest in South Lincolnshire CCG (57.5%) and South West Lincolnshire CCG (55.4%), and lowest in Lincolnshire East (50.8%) and Lincolnshire West (54.7%). (Source: PHE, Cancer Services)

In 2017/18 the percentage of patients seen within the two week wait standard at United Lincolnshire Hospitals for all suspected tumour groups was 88.1%. This was below the national rate of 94.1%. (Source: NHS England, Cancer waiting times)

In 2017/18 rates of emergency presentations to hospital resulting in a diagnosis of cancer were highest in Lincolnshire East CCG (119 per 100,000 population). Presentation rates across other CCGs are comparable to the national rate of 85 per 100,000 population. (Source: PHE, Cancer Services Profile)

Screening

Figures for 2017/18 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 (71.7%). South Lincolnshire CCG (77.5%) and South West Lincolnshire CCG (76.9%) show the highest uptake across Lincolnshire, while uptake is lowest in Lincolnshire East CCG, at 72.9%.

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 (75.1%) of eligible women in Lincolnshire (aged 25-64) were screened in 2017/18, which is higher than the national coverage rate (71.7%). As with having high early detection rates, South Lincolnshire (78.3%) and South West Lincolnshire (76.9%) CCGs have the highest coverage across the county for cervical cancer screening.

In 2017/18, 60% 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 56.1%. South Lincolnshire (62.3%) and South West Lincolnshire (61.7%) CCGs have the highest uptake of bowel cancer screening in the county. (Source: PHE, Cancer Services)

In 2016/17, HPV vaccination coverage for one dose in females aged 12-13 years old is 81.6% which is lower than the national coverage rate of 87.2%. (Source: PHE Public Health Outcomes Framework)

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 2017/18 the percentage of patients seen within the 62 day standard at United Lincolnshire Hospitals for all tumour groups was 71.3%. This was below the England total which was 82.2%.

Nationally in 2017/18, 97.2% of patients were treated within 31 days of receiving a diagnosis for cancer. Locally, 94.8% of patients were began treatment at United Lincolnshire Hospitals for all cancers within 31 days of a diagnosis. (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 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 CCGs 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 CCGs; however South West Lincolnshire CCG is marginally lower at 56.3%. (Source: ONS: Index of cancer survival for CCGs in England)

In contrast, survival estimates for breast cancer are 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%. (Source: ONS: Index of cancer survival for CCGs in England)

Overall, survival rates of all adults surviving to one year, for bowel cancer are lower than for breast cancer, with national rates at 80.4% and 79.3% in Lincolnshire. (Source: ONS: Index of cancer survival for CCGs in England)

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. (Source: ONS: Index of cancer survival for CCGs in England)

Mortality

Between 2015 and 2017, 32% of deaths in England were of people aged under 75, with cancer being the highest cause of premature death in adults in England. Published figures on mortality rates are available from the PHE Public Health Mortality Profiles; however, rates are not available for CCGs.

Between 2015 and 2017, the premature mortality rate in Lincolnshire for all cancers was 133 per 100,000 population, which is comparable to the regional and national rates of 135.8 and 134.6 per 100,000 population respectively. When broken down by gender, premature mortality rates for all cancers are significantly higher for men (147.6 per 100,000 population) than women (118.9 per 100,000 population). (Source: PHE: Mortality Profiles

Premature mortality considered preventable data describes 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 (including mesothelioma), mouth/throat/oesophageal, and skin.

Between 2015 and 2017, the rate of premature mortality from cancers considered preventable in Lincolnshire was 74 per 100,000 population, which is significantly lower than the regional and national rates of 78.9 and 78 per 100,000 population respectively. Preventable mortality from cancer in Lincolnshire is higher for men (79.6 per 100,000 population) than for women (68.6 per 100,000 population), in line with national patterns. (Source: PHE: Mortality Profiles)

In 2017 21% of all cancer deaths in England and 19.5% of cancer deaths in Lincolnshire were from lung cancer. Between 2015 and 2017, all age lung cancer mortality rates in Lincolnshire were 74 per 100,000 people, which is significantly better than the regional and national rates of 78.9 and 78 per 100,000 population respectively. At district level, Lincoln has the highest lung cancer mortality rates across the county, at 68.9 per 100,000 which is significantly worse than the regional and national equivalents. (Source: PHE: Mortality Profiles)

Nationally 15% of all cancer deaths in women are from breast cancer, second to lung cancer (21%). Breast cancer mortality rates are significantly better in Lincolnshire (18.2 per 100,000 population) than regional (20.5 per 100,000 population) and national rates (20.6 per 100,000 population). (Source: PHE: Mortality Profiles)

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. (Source: PHE: Mortality Profiles)

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) CCGs; while South Lincolnshire and South West Lincolnshire had lower rates of 637.3 and 627.8 respectively (Source: NHS Digital, CCG Outcomes Indicator Set).

NHS 'Rightcare' Commissioning for Value packs, provide 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 national incidence rates of all cancers has fluctuated but overall show a net increase from 507.5 per 100,000 registered patients in 2012/13 to 520.8 per 100,000 registered patients in 2016/17. In Lincolnshire, incidence rates of all cancers have followed a similar trend, increasing from 619.9 per 100,000 in 2012/13 to 629 per 100,000 registered patients in 2016/17. At CCG level, cancer incidence rates have mostly increased, with the exception of Lincolnshire East CCG, where rates have fallen from 673.1 per 100,000 registered patients in 2012/13 to 665.3 per 100,000 registered patients in 2016/17. South Lincolnshire has seen the biggest increase of 11.5% from 616.1 per 100,000 in 2012/13 to 686.9 per 100,000 patients in 2016/17. (Source: PHE, Cancer Services)

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 factors; the predominant 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 as there is no single standard system for maintaining GP patient data. (Source: PHE, Cancer Services)

Early diagnosis rates at cancer stages 1 or 2 have increased markedly both nationally and locally between 2012 and 2016. In Lincolnshire, early diagnosis has improved from 28.2% in 2012 to 48.2% in 2016. The largest increase was seen in Lincolnshire West CCG, from 23% in 2012 to 48% in 2016. (Source: NHS Digital, CCG Outcome Indicators Set)

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% respectively, while South West Lincolnshire CCG saw the smallest long term increase of 9.5%. (Source: NHS Digital Information Centre, NHS Indicator Portal)

Nationally, two-week wait referrals resulting in a cancer diagnosis have decreased from 9.4% in 2012/13 to 7.6% in 2016/17. In Lincolnshire, all CCGs have seen a decline in two- week wait referrals resulting in a cancer diagnosis, with the largest decrease seen in Lincolnshire East CCG, which has fallen from 12.2% in 2012/13 to 7.8% in 2016/17. (Source: NHS England, Cancer waiting times)

Mortality rates for cancer (for all persons under-75) have fallen in Lincolnshire by 8% from 141.4 per 100,000 population in 2010-12 to 133 per 100,000 population in 2015-17 in line with national trends. Premature cancer mortality has followed a similar pattern for men and women, decreasing by 4.1% and 12.6% respectively over the same period. (Source: Public Health Mortality Profiles)

Mortality rates for cancer (for all persons under-75) considered preventable, has reduced in Lincolnshire by 9.3% from 81.6 per 100,000 population in 2010-12 to 74 per 100,000 population in 2015-17. Lincolnshire has had a similar reduction of 17.3% from 90.2 per 100,000 population in 2001/03, to 74.6 per 100,000 population. Lincolnshire rates for men and women have followed a similar trend over the same period. (Source: Public Health Mortality Profiles)

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.
  • Cancer mortality in England is more common in people living in the most deprived areas; there are around 19,000 extra deaths from cancer, per year, in England because of socio-economic variation. Lung cancer has by far the largest number of excess deaths (9,900 people per year (Source: Cancer Research UK). In Lincolnshire our most deprived areas also have the highest smoking rates (For further information on the impact of smoking please refer to the JSNA topic Smoking Reduction in Adults).
  • Conversely, breast cancer has higher incidence in more affluent groups, but mortality is higher in less affluent women. Women are more likely than men to attend health appointments but embarrassment, family commitments/time and rurality often play a part in not going to see a GP at an earlier stage. Risk of breast cancer can be reduced by maintaining a healthy weight and reducing intake of alcohol.
  • 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 in February 2018 by the All-party Parliamentary Group on Breast Cancer into Geographical Inequalities and Breast Cancer found 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 BAME 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 for older people than for 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: The Age Old Excuse: The Under Treatment of Older Cancer Patients 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) highlighted 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 as linked in the left hand navigation menu
  • A recent Macmillan report (The final injustice: Variation in end of life care in England: 2017) provides an insight into the experience of cancer patients' final months and years. The report finds that cancer patients approaching the end of their life face repeat emergency visits with the situation 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 group 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 delivers 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 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), nurse specialists, administrative 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 The 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. In addition they 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 The Pilgrim Hospital Boston and Lincoln County Hospital offer information relating to cancer and available services, together with emotional support for patients, their families/ carers and for staff.
  • The Butterfly Hospice is a purpose-built 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. This programme is currently in delivery phase, taking a proactive approach to meeting the needs of people living with cancer.
  • There is a cross community cancer improvement programme that is working with the East Midlands 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 (e.g. not having appointments available when needed).
  • In 2017 the cancer patient experience survey rated ULHT 8.39/10 for their care. This was below the England average score of 8.74, ranking ULHT fourth lowest of all hospital trusts in the country.

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 would also result in higher healthcare costs. For example, 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. (Source: Cancer Research UK)
  • A further decline in people attending cancer screening programmes.
  • The National Audit Office 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, leading to a total cost 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 in excess of £400m per annum to the projected £22bn funding gap. (Source: NCIN, 2015)
  • Macmillan reported in Cured-But at what cost? that as many as 500,000 people living with and beyond cancer in the UK have one or more physical or psychosocial consequence of their cancer or its treatment which 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?

  • The East Midlands Cancer Alliance has aligned with the Lincolnshire STP to identify priorities for 2019/2020. These focus on improving prevention, developing clinical pathways and supporting the Living with Cancer programme.
  • Implementing the five year Sustainability and Transformation Partnership for local health service funding requires health providers to deliver services that meet the needs of local populations; in addition 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 prioritises 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.
  • The Joint Health and Wellbeing Strategy for Lincolnshire identified obesity as one of the priorities. A committee to develop this, deliver on actions has been set up and will work across the health system.
  • Lincolnshire County Council is currently commissioning an Integrated Lifestyle Service (ILS) which will provide services across four main areas: smoking cessation, weight management, physical exercise and excess alcohol consumption.

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.
  • Support the uptake of Human Papilloma Virus immunisation by local young women and promote the new offer for Year 8 boys beginning in September 2019.

 

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

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