Cancer

Introduction

“Cancer is a generic term for a large group of diseases that can affect any part of the body. One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs. This process is referred to as metastasis. Metastases are the major cause of death from cancer”

- (WHO, 2012, see reference 1)

It is a leading cause of death and accounted for 7.6 million deaths worldwide (around 13% of all deaths) in 2008 (see reference 1). Four in ten people will be diagnosed with cancer at some point in their lives. Almost half of the incidences of cancer are unavoidable (see reference 2). UK survival rates are poorer than our peers. If the UK survival rate equalled Europe’s best there would be an estimated 5000 fewer deaths per year, if they met the world’s best there would be 10000 fewer deaths per year in the UK (see reference 3).

Cancer mortality contributes to 25% of gap in life expectancy between Haringey and England. Reducing cancer mortality is therefore a key contributor to outcome 2 of the Haringey Health and Wellbeing Strategy (see reference 4) “A reduced gap in life expectancy”. After smoking, the biggest impact on inequalities in mortality is late diagnosis of cancer (see reference 3). Therefore lives can be saved by earlier diagnosis and by primary prevention. This approach is consistent with the national and London initiatives for primary prevention, as in the Cancer Reform Strategy (CRS), and National Awareness and Early Diagnosis Initiative (NAEDI) (see reference 5), supported by the London Health Improvement Board.

There are more than 200 different types of cancer. This chapter focuses on the four commonest: breast, lung, large bowel (colorectal) and prostate – that together account for over half (54%) of all new cases (see reference 3).

Links to sections on tackling life expectancy gap, smoking, diet and nutrition, physical activity and cancer screening can be found in other sections.

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Key issues and gaps

Cancer incidence has been rising steadily nationally and in Haringey and is predicted to rise further. Together with increased survival this poses a demand on resources.
UK survival rates are poor compared to peers. Haringey survival rates are particularly poor for colorectal cancers (1 year survival) and breast cancers (5 year survival) (see reference 6).
There are considerably higher mortality rates from cancer in east Haringey than in the west. Rates are also higher amongst under 75 males than males nationally.
Most risk factors for cancer show inequalities by socio-economic group, ethnicity and geography. Primary prevention, particularly reducing smoking, is effective in reducing the life expectancy gap. Local services need to be strengthened, particularly obesity prevention and weight management for adults and children.
Systematic early diagnosis and intervention will improve survival and impact on the life expectancy gap and inequalities in cancer outcomes. There are a number of local time limited programmes and national and London initiatives to promote early diagnosis. These need to be made more sustainable. Alongside this a continued improvement in cancer screening rates, particularly for bowel cancer is important.
There is a changing landscape for commissioning, with an increased role of Clinical Commissioning Groups alongside the cancer commissioning network. Key issues to be addressed are high rates of emergency admissions (leading to poor survival), a high proportion of patients without staging of disease and only one in two cancers diagnosed through the two week wait system. Clear pathways, service specifications and outcome monitoring need to be developed and implemented.

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Who is at risk and why

Tobacco use, obesity, diet, physical activity and alcohol consumption are preventable risk factors of cancer (see reference 7). Age, gender and for some cancers, ethnicity, are important fixed risk factors (see reference 8). Incidence and mortality from cancer increases with age and men are at a higher risk and more likely to die than women. Also overall incidence of cancer in the minority ethnic groups is lower than the White British population. However certain ethnic groups are at high risk of specific cancers e.g. Black African and Black Caribbean men have higher incidence of prostate cancers (see reference 7).

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The level of need in the population

Risk factors

The prevalence of modifiable risk factors in Haringey is not evenly distributed. Smoking is the greatest modifiable risk factor for cancer, commoner in lower socio-economic groups and certain risk groups e.g. people with mental health problems. Still 1 in 4 adults smoke in Haringey. Childhood obesity and adult obesity, alcohol misuse are also more prevalent in certain black and minority ethnic (BME) groups, lower socio-economic groups and on the east of Haringey.

Incidence (see references 3 and 6)

Incidence is the number of new cases in a given time period.

Incidence rates have been increasing nationally, in London and in Haringey from 1985 to 2008 (Figure 1).
The incidence of cancer in Haringey is high amongst males in Haringey compared to the country as a whole. Incidence rates for males in Haringey, compared to England are higher for bronchus and lung and prostate cancers, but lower for colorectal and skin cancers.
Incidence rates are lower amongst Haringey females compared to Haringey males, and are also lower than females nationally. For women rates in Haringey are higher than England for colorectal cancers but lower for other cancers. Of note, the incidence of skin cancer is higher for females than males in Haringey.
Haringey incidence rates have increased for colorectal, breast and prostate cancer; declined for bronchus and lung cancers and remain relatively static for skin cancers.

Figure 1: Incidence of all cancers – 1985-2008

Source: Thames Cancer Registry

Mortality (see references 3 and 6)

Addressing the 9 year male life expectancy gap is outcome 2 of the three outcomes of the Haringey Health and Wellbeing Strategy.
Cancer contributes to 25% percentage of the life expectancy gap between males in Haringey and England (see reference 4) ( Figure 2) Of this, lung cancer mortality in Haringey is responsible for approximately 6% of the life expectancy gap, bowel cancer 4% (mortality rate significantly higher than England) and breast cancer approximately 0.5-1%. After smoking, the biggest impact on mortality is late diagnosis of cancer. Therefore lives can be saved by earlier diagnosis – particularly breast, colorectal and lung.
Between 2007 and 2009 there were 1,044 cancer related deaths in Haringey. The highest proportions of deaths were for trachea, bronchus and lung cancer (20%); breast cancer (9.7%); prostate cancer (7.7%); colon cancer (5.8%) and pancreatic cancer (5.6%). A further 27.7% were for cancers other than those in the top 10 causes of death.
Death rates have fallen in Haringey for both males and females amongst all ages and the under 75 age group. This mirrors the national and London picture. Mortality rates for males and females in Haringey fluctuated above and below national rate. Recent data (2006-8) shows Haringey females significantly lower, and males significantly higher than England (Figure 3 and 4) (see reference 2). Generally death rates amongst males are higher than females.
There are considerably higher mortality rates from cancer in the east of the borough than in the west (Figure 5).
Rates of colorectal cancer in males are high compared to England, as are breast cancer mortality rates amongst females (see reference 6).

Figure 2: Male life expectancy gap between Haringey and England – by cause of death (2006-8)

Source: London Health Observatory

Figure 3: All age cancer directly standardised mortality ratio 1993 - 2008

Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 4: All age cancer directly standardised mortality ratio 2006-2008

Source: National Clinical and Health Outcomes Knowledge Base (NCHOD)

Figure 5: Under 75 standardised mortality ratio for all cancers in Haringey 2005-2009

JSNA-premature-mortality-cancer
Source: Commissioning Support for London

Survival (see references 3 and 6)

Survival rates are used as a proxy indicator of early or late diagnosis and effective treatment

Survival rates have improved year on Haringey which has mirrored national trends.
Data on survival for all cancers, available for NHS North Central London (NCL) shows: 1 year survival rates are good for males and females in NCL compared to England although NCL females fair worse compared to London.
5 year survival rates for NCL are also better for NCL males but NCL females fair worse than London and England.
Haringey survival rates vary by cancer such that 1 year survival rates in Haringey are better than England for trachea, bronchus and lung cancers and breast and prostate cancers and worse for colorectal cancers.
5 year survival rates are better for trachea, bronchus and lung and colorectal cancers but lower for breast cancers.

Staging (see references 3 and 6)

Between 2003 and 2007, approximately 30% of all cancers were diagnosed at stage 1. This compares favourably with boroughs in NCL.
Early detection rates vary from cancer to cancer such that 20% of trachea, bronchus and lung and colorectal cancers were diagnosed at stage 1, compared to 35% for breast and 50% for prostate and skin cancers.
Over 35% of cancer is diagnosed at an unknown stage in Haringey. North Central London is generally poor on this indicator.

Two week wait (see references 3 and 6)

About 1 in 2 cancers in Haringey are not diagnosed through 2 week waits (fast track system for suspected cancers) in Haringey, similar to London and England.

Further epidemiological description of cancer in Haringey is available in two other documents: A review of epidemiology of Cancer in Haringey, Haringey Public Health, May 2011 (see reference 6); Cancer Commissioning Strategy 2011/12- 14/15, North Central London and West Essex (NCL & WE) Cancer Commissioning Network (see reference 3).

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Current services in relation to need

Prevention

The Cancer Reform Strategy (see reference 8) emphasises the importance of prevention, particularly reducing smoking, and the inequalities in the distribution of modifiable risk factors. Smoke Free Enfield and Haringey provides a comprehensive service to help approximately 2000 smokers a year stop smoking. They work in conjunction with the newly formed Enfield and Haringey Tobacco Control Alliance addressing wider tobacco control issues such as extending and enforcing smoke free policies and targeting high risk groups (see smoking JSNA section).

Weight management services to support adults and children who are obese or overweight are limited in Haringey. There will be development of community weight management this year but funding is time limited. Physical inactivity and alcohol misuse are other key risk factors (see relevant section of JSNA). The Health Trainer Scheme gives support to change unhealthy lifestyle, mainly on the east of borough.

Early detection and intervention

After reducing smoking, early detection and intervention of cancer will have the greatest impact on survival. The NAEDI initiative has supported a number of programmes to raise public and professional awareness of common cancers e.g. bowel cancer. This is also a priority of the London Health Improvement Board moving forward. Locally a scheme “Haringey Life Savers” works with 4 GP practices and community groups to raise awareness of the four commonest cancers. All these programmes work with partners and focus on the most deprived communities, however most have short term funding (see references 9 and 4). A local GP, as Primary Care Cancer Lead for Haringey supports educational activities and raises professional awareness for early detection, treatment and care.

Cancer screening programmes

Trends in cancer screening have all improved in recent years (figure 6) and shows variation by GP practice. Social marketing, mosaic information and a recent health equity audit on breast cancer screening are informing local action plans to increase uptake of breast, bowel and cervical cancer screening programmes. These include a health trainer working specifically on this issue in Haringey.

Figure 6: Cancer screening uptake in Haringey 2007-2011

Source: NHS Haringey

Treatment and care

Cancer Service Commissioning is undertaken by the NCL & WE Cancer Network. They have developed a NCL & WE Cancer Commissioning Strategy that supports the London wide strategic framework of earlier diagnosis along with centralisation of some specialist cancer services and the consistent delivery of other services as locally as possible. Haringey residents obtain general and specialist hospital care in a range of providers including: North Middlesex Hospital, Whittington Health, University College London Hospitals, Royal Free Hospital and Great Ormond Street. Providers of community services include Whittington Health. Treatments include surgery, chemotherapy, radiotherapy and palliative care (see reference 3). NICE guidance (see reference 10) provides best practice and inform care pathways. However survival rates are still poor for some cancers, 35% of cancers have unknown stage at diagnosis, there are high rates of emergency admissions and there are inequalities in treatment and outcomes of care.

Resources

The budget for cancer services is embedded in acute contract budgets. Cancer is one of the largest areas of commissioning expenditure, has a large patient population and future need and demand for services is likely to increase. In 2010/11 Haringey spent £43 million (programme budgeting expenditure) on cancers and tumours and is in the highest quintile for PCT expenditure. It is important to maximise outcomes and ensure equity of provision according to need (see reference 2).

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Service users and carers opinion

A consultation exercise with the patient partnership group of NCL and WE Cancer network identified key issues that informed the vision for cancer care outlined in the strategy. Issues raised include: an emphasis on early diagnosis through improved public awareness and better clinical recognition of symptoms, local access to chemotherapy, support for cancer survivors and holistic palliative care. Londoners, including within this network, have poorer experience of cancer care than other regions – this is supported through a number of surveys (see reference 3).

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Expert opinion and evidence base

Improving Outcomes: A Strategy for Cancer, Gateway reference 15108. Department of Health, 12 January 2011 (see reference 11)
Cancer Reform Strategy, Achieving local implementation – second annual report. Department of Health, December 2009 (see reference 12)
Cancer Commissioning Guidance (amended). Department of Health, December 2009 (see reference 7)
Cancer Reform Strategy. Department of Health, 2007 (see reference 8)
The NHS Cancer Plan. Department of Health, 2004 (see reference 13)
How to reduce excess mortality from cancer in areas with the worst health and highest levels of deprivation - Guide for Health and Wellbeing Boards and GP Commissioning Consortia. Health Inequalities National Support Team and the National Cancer Action Team, 2011 (see reference 14)
London Cancer Services: a proposed model of care. Commissioning Support for London (see reference 15)
North Central London and West Essex Cancer Commissioning Strategy 2011/12-14/15 (see reference 3)
Haringey Health and Wellbeing Strategy 2012-15. Haringey Council, 2012 (see reference 4)
Tackling the Life Expectancy Gap: briefing paper for the cross party working group. Haringey Council, 2011 (see reference 9)

NICE guidance (external link)

Improving outcomes guidance (IOG) NICE (various Cancer sites)
Referral for suspected cancer: CG27
Colorectal cancer: CG131
Lung cancer: CG121
Diagnosis and treatment of lung cancer: (CG24)
Early and locally advances breast cancer diagnosis and treatment (CG80)
NICE improving supportive and palliative care for adults with cancer

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Projected service use in 3-5 years and 5-10 years

Cancer cases are projected to increase in London by 5% and in England by 33% by 2022 (see reference 3).

In addition as more people are living with and surviving cancer, the increase in the need for cancer services and follow up care will be greater (see reference 3).

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Unmet needs and service gaps

Prevention

There are inequalities in the distribution of lifestyle factors within Haringey (see JSNA sections on smoking, physical activity, alcohol, adult obesity, childhood obesity, diet and nutrition).
There is a comprehensive NHS stop smoking service in Haringey. However services should link more closely with patients with long term conditions, including cancer and more closely target those at highest risk or high nicotine dependency e.g. people with mental health problems.
The exercise referral scheme for patients with long term conditions has only one further year of funding secured and only operates in east Haringey.
There are limited weight management services and obesity prevention services within Haringey.

Early intervention

Cancer survival rates are improving nationally and locally but one year survival rates are poor for colorectal cancers. Mortality rates are higher in the east than the west of Haringey.
Programmes aimed at early diagnosis and raising public and professional awareness of common cancers (including NAEDI programmes) need to be made more sustainable. This will assist with improving survival rates and proportion of cancers seen through the two week wait system.
Cancer screening rates have improved in recent years. However rates are still low, particularly for bowel cancer and there is variation between general practices. Community and primary care based programmes need to continue to focus on those population groups or practices with lowest uptake.

Treatment and Care

Cancer incidence is predicted to rise, together with increasing survival this will lead to increase need and demand for services.
Survival rates are improving but five year survival is particularly poor for breast cancers.
There are high rates of emergency admissions, suggesting late diagnosis and there are inequalities in treatment and outcomes of care (see reference 2).
Evidence based, cost-effective, clinical and commissioning care pathways need to be developed and monitored against key outcomes to ensure systematic delivery of care.

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Recommendations for commissioning

Cancer contributes 25% of the life expectancy gap in men in Haringey. Outcome 2 of the Health and Wellbeing Strategy “A reduction in the life expectancy gap” (see reference 4) sets five priorities: reduce smoking, increase physical activity, reduce alcohol misuse, reduce early death from cardiovascular disease and cancer particularly in the east and support people with long term conditions to live a healthier life.

The NCL WE strategy has five key goals: prevention, detect earlier stage disease, effective and efficient clinical pathways, survivorship and follow up care and end of life care (see reference 3).

Delivering these goals and priorities are the drivers for cancer commissioning in Haringey.

Key recommendations for commissioning are:

Maximise impact of tobacco control and smoking cessation programmes those at highest risk. Ensure the stop smoking service supports patients with long-term conditions and support the implementation of [Commissioning for Quality and Innovation (CQUINs)] (incentives to hospitals to support smoking cessation).
Strengthen weight management, obesity prevention and physical activity programmes targeting those at highest risk.
Continue to improve uptake of breast, cervical and colorectal cancer screening, including addressing variation between practices and populations. Continue community based programmes – targeting those least likely to attend.
Increase awareness of signs & symptoms of cancer to enable people to visit their GP earlier. Develop sustainable initiatives including community health champions such as Haringey Life Savers and NAEDI initiatives working with key target groups.
Continue to strengthen GP education to raise awareness, supported by the Haringey GP Cancer Lead.
Develop cancer commissioning pathways and associated service specifications to deliver uniformly high standards of care and improve equity of outcomes. Monitor these against key performance indicators. Key issues to address include: (see reference 2).
- Reduction in emergency presentations as these have very poor survival
- Improvement in access to services – rapid investigation and treatment, irrespective of geography or social group
- Improve recording and reporting of staging of cancers
- Improve patient experience of cancer services through better coordination and less fragmentation of services; especially in hard to reach groups
- Improve efficiency and deliver sustainably affordable services
- Consolidate and centralise specialist cancer services.
Implement best practice for End of Life Care, including within nursing and residential homes.
Develop and implement new models of survivorship and follow up care.

Targeting services according to the needs of different populations, evaluation and monitoring should be tenets of commissioning to ensure inequalities in risk factors, access to care and outcomes of cancer care are reduced.

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