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All Cancer JSNA November 2016

Overview There are more than 200 types of cancer, each with different causes, symptoms and

treatments. Although survival is improving, more than a quarter of deaths in the UK are

caused by cancer. An individual's risk of developing cancer depends on many factors,

including age, lifestyle and genetic make-up. Some of these factors can be changed to

reduce the chance that someone develops cancer. The single most important thing someone

can do to reduce their chance of getting cancer is to stop smoking.

According to the latest data, around one in 70 people in Kingston are living with cancer. On

average more than 12 people a week are diagnosed with cancer in Kingston. Men are

slightly more likely to develop, and die from, cancer than women. The number of people

diagnosed with cancer is going up over time; however the death rate is falling. This is likely

to be related to earlier detection and better treatment.

Prostate cancer is the most common type of cancer in men in Kingston, while breast

cancer is the most common type in women. Lung cancer is relatively common in both men

and women, and because survival with the disease is low, it is Kingston’s biggest cancer

killer.

The earlier that cancer is detected, the better chance a patient has of a cure. Survival rates

in the UK are lower than other countries in Europe, so we know that there is definite potential

to improve our cancer services. Education campaigns to encourage patients to see their

doctor with the very first signs of cancer are underway and there are currently three NHS

cancer screening programmes (breast cancer screening, cervical cancer

screening and bowel cancer screening). Excellent cancer care requires that community

health providers and hospital team’s work together to ensure that patients with cancer are

tested, diagnosed and given appropriate treatment for their disease as quickly as possible.

Introduction Cancer is not just one disease but a group of conditions. In fact there are more than

200 types of cancer, each with different causes, symptoms and treatments. Cancer

is important because these diseases when grouped together are a large cause of

disability and death. More than 331,000 people were diagnosed with cancer in 2011

in the UK, one person every two minutes.

More than one in three people in the UK will develop some form of cancer

during their lifetime

Cancer survival rates in the UK have doubled in the last 40 years

Half of people diagnosed with cancer now survive their disease for at least ten

years

However, more than a quarter of deaths in the UK (29%) were caused by

cancer in 20111.

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Risk factors

An individual's risk of developing cancer depends on many factors, including age,

lifestyle and genetic make-up.

More than 40% of all cancers in the UK are linked to tobacco, alcohol, diet,

being overweight, inactivity, infection, radiation, occupation, post-menopausal

hormones, or breastfeeding for less than six months1

Cigarette smoking is the single most important cause of preventable death in

the UK1.

Key drivers for change

Improving results for cancer patients and reducing the number of cancer deaths was

the focus of the Department of Health Cancer Strategy 20112. Several indicators

related to cancer are available to assess performance at a national and local level

within the NHS3, The Public Health Outcomes Framework 2013 and the Clinical

Commissioning Group Outcomes Indicator Set4.

The Five-Year Cancer Commissioning Strategy For London states cancer as a

commissioning priority because of:

variation in outcomes across the capital

poor reported patient experience

survival times which lag behind our European counterparts.

1Cancer Research UK. All cancers combined key facts . 2014 . Available

from http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/Allcancerscombined/

2 Department of Health. Improving outcomes: a strategy for cancer. London: Department of Health; 2011.

Available

fromhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213785/dh_123394.pdf

3 Department of Health. NHS Outcomes Framework;Available

from: https://www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015. Accessed 21-Apr-14

4NHS England. CCG Outcomes Indicator Set 2014/15-at a glance. NHS England. December 2013. Available

from http://www.england.nhs.uk/wp-content/uploads/2013/12/ccg-ois-1415-at-a-glance.pdf

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Local Picture

People diagnosed with cancer (incidence)

Between 2009 and 2011, 1,924 people were diagnosed with cancer in Kingston. 932 were

female (48.4%) and 992 were male (51.6%)1.

This is an average of 641 people a year or more than 12 a week

The rate in Kingston is similar to the rate in the rest of London, however it is lower

than the rate in England overall

The variation seen may be due to a number of complex and interrelated differences

between London and the rest of the country. These may include lifestyle, socio-

economic, genetic, occupational, environmental and healthcare factors.

People living with cancer (prevalence)

In the latest available data 1.4% of the Kingston population (2,701 people) were registered

to be living with cancer 2.

This is similar to the proportion in London of 1.4%

This is lower than the proportion in England of 1.9%. The difference is probably

connected with the lower incidence of cancer (see above) and the generally younger

population in Kingston compared to England overall.

Deaths from cancer (mortality)

Between 2010 and 2012 cancers caused a total of 816 deaths in Kingston3. 375 of these

people were under 75 years 4 and 195 under 65 years5 meaning cancer is a major cause of

premature death.

Men are significantly more likely to die of cancer than women. This is true in Kingston

and across the country

The death rate is lower in Kingston than in London and England.

Types of Cancer

Table 1 - Percentage of cancer incidence by cancer site

Site 2008-2012

Urology 21.8%

Breast 17.1%

Lower Gastro-Intestinal 13.4%

Lung 11.3%

Haematology 9.5%

Upper Gastro-Intestinal 8.3%

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Gynae 5.2%

Skin 4.1%

Head and neck 2.7%

Other 2.6%

Brain/Central Nervous System 1.7%

Endocrine 1.2%

Sarcoma 0.9%

All sites 100%

Table 2 - Percentage of cancer mortality by cancer site

Site 2008-2012

Lung 21.8%

Upper Gastro-Intestinal 14.7%

Urology 14.1%

Lower Gastro-Intestinal 12.6%

Haematology 8.6%

Breast 8.2%

Other 8.2%

Gynae 5.1%

Brain/Central Nervous System 2.2%

Head and Neck 1.9%

Skin 1.7%

Sarcoma 0.4%

Endocrine 0.3%

All sites 100%

Trends over time

Trend data (see figures 1 and 2) show that incidence (new diagnosis rate) of cancer is slowly

rising in England and London, while mortality (death rate) is falling.

Generally Kingston is following these regional and national trends.

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Figure 1 - Incidence of All Cancer 1993-20116

Figure 2 - Mortalities of All Cancer 1993-20127

There are likely to be several reasons for the falling rate of deaths from cancer

despite more cancers being diagnosed, and these would include earlier detection

and better treatment

The trends seen above are an average for all cancers together. However it is

important to note that the picture is not the same for each type of cancer.

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Figures 3 and 4 show the percentage change in mortality for the top 20 commonest causes

in cancer death in both men and women in the UK.

The most striking feature of the figures for both men and women is the rise in deaths

from liver cancer. The chance of developing liver cancer is related to several factors

linked to lifestyle e.g. sexual behaviour, use of substances (both of which can be

associated with Hepatitis B or C infection), as well as long term alcohol consumption

and smoking.

Figure 3 - Percentage change in European age standardised mortality rates for UK

males 2000-2002 to 2009-20118

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Figure 4 - Percentage change in European age standardised mortality rates for UK

females 2000-2002 to 2009-20118

Survival with Cancer

Cancer survival rates in the UK have doubled in the last 40 years. This can generally be

attributed to faster diagnosis and improvements in treatment9.

Table 3 - One year survival10

Kingston London England

69.2% 68.5% 68.2%

One year cancer survival in Kingston is similar to the London and English average

One year survival rates are a good indicator of whether cancer is being diagnosed

early and whether there is access to optimal treatment available

In general one year cancer survival rates lag behind the best in Europe so there is

room for improvement.

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Table 4 - Five year survival10

Kingston London England

Unavailable 47.8% 47.9%

Five year survival is generally slightly high in women than men

Survival rates continue to fall beyond five years after diagnosis for many types of

cancer.

Deaths at home

In the period 2010 to 2012, 22.9% of people who died from cancer in Kingston did so

at their home address - this does not include people who died in communal

establishments11

The rate is similar to London, but lower than the figure in England overall.

1 Health and Social Care Information Centre. Incidence of all cancers: Directly age-standardised registration rates

(DSR), all ages. Period: 2009-2011 (Pooled rates). V11_V1. Dec 2013. 2 Health and Social Care Information Centre. Prevalence: all cancers, all ages. Period: 2012-13. V13_V1. Dec

2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11E_676PC_13_V1_D.xls.

3 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration

rates (DSR), all ages. Period: 2010-2012 (Pooled rates). V11_V1. Dec 2013.

4 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration

rates (DSR), 75 years. Period: 2010-2012 (Pooled rates). V11_V1. Dec

2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11B_075DR0074_12_V1_D.xls.

5 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration

rates (DSR), 65 years. Period: 2010-2012 (Pooled rates). V11_V1. Dec

2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11B_075DR0064_12_V1_D.xls

6 Health and Social Care Information Centre. Incidence of all cancers: Directly age-standardised registration rates

(DSR), all ages, annual trend. Period: 1993-2011. V12_V1. Dec

2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11A_077DRT00++_11_V1_D.xls.

7Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration

rates (DSR), all ages, annual trend. Period: 1993-2012. V12_V1. Dec 2013.

8 Cancer Research UK. Cancer mortality for common cancers (figures 2.6 and 2.7) . 2014 . Available

from http://www.cancerresearchuk.org/cancer-info/cancerstats/mortality/cancerdeaths/uk-cancer-mortality-

statistics-for-common-cancers

9 Cancer Research UK. Cancer survival statistics. 2014. Available from http://www.cancerresearchuk.org/cancer-

info/cancerstats/survival/

10 Office for National Statistics. A Cancer Survival index for Clinical Commissioning Groups, Adults Diagnosed

1996-2011 and Followed up to 2012. ONS December 2010.

11 Health and Social Care Information Centre. Deaths at home from all cancers: Percent and Indirectly age-

standardised registration rates (ISR). Period: 2010-2012 (Pooled) V12_V1. Dec

2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11C_191PC_12_V1_D.xls.

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What Works

Prevention

Prevention offers the most cost-effective long-term strategy for the control of cancer1.

An individual's risk of developing cancer depends on many factors, including age,

lifestyle and genetic make-up

Some of these factors may be modified to reduce the risk of getting cancer

Although there are some things we can’t control about our cancer risk, decades of

research have clearly shown that by living a healthy life, people can reduce the risk

of developing the disease

Figure 5 shows the number of cancer cases in the UK that could be prevented by

eliminating known lifestyle and environmental factors, like being a non-smoker,

keeping ahealthy weight, drinking less alcohol, eating a healthy, balanced diet, and

avoiding being exposed to certain infections or radiation2

Cigarette smoking is the single most important cause of preventable cancer in the UK

Cancer Research UK estimates that that more than four in ten cancer cases could be

prevented by lifestyle changes.

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Figure 5 - Lifestyle factors affecting the incidence of cancer

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Early detection of cancer

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.

Education

National public education campaigns are underway to encourage people to present to their

GP earlier with possible symptoms of cancer. The best recognised of these from recent

years are the Be Clear on Cancer Campaigns. These are yet to be fully evaluated but further

information for patients can be found at the NHS website and for professionals at the Cancer

Research UK website.

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.

Great care must be taken when developing and implementing screening programmes

that they do not result in more harm than good

UK policy is led by the UK National Screening Committee

There are currently three national screening programmes for cancer:

o Breast cancer screening

o Cervical cancer screening

o Bowel cancer screening

Treatment of cancer

The main goals of a cancer diagnosis and treatment programme are to cure or considerably

prolong the life of patients and to ensure the best possible quality of life to cancer survivors.

The most effective and efficient treatment programmes are those that:

are provided in a sustained and equitable way

are linked to early detection, and

adhere to evidence-based standards of care and a multidisciplinary approach4.

Diagnosis

The first critical step in the management of cancer is to establish the diagnosis. The national

cancer waiting times standard is for urgent referrals for suspected cancer to be seen within

two weeks5.

Major treatment modalities

Choice of treatment requires careful consideration of each individual case. Major treatment

modalities include surgery, radiotherapy and systemic therapy (chemotherapy). Individual

patients may be suitable for one of, a combination of, or none of these options. The national

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cancer waiting times standard is for first treatment to be given within 31 days of diagnosis of

cancer and a maximum of 62 days from the initial GP referral5.

End of life care

Palliative care improves the quality of life of patients and families who face life-threatening

illness, by providing pain and symptom relief, spiritual and psychosocial support from

diagnosis to the end of life and bereavement6. The National Institute for Health and Care

Excellence (NICE) has issued best practice guidance on supportive and palliative care

services for patients with cancer.

1 World Health Organisation. Cancer prevention. 2014. Available from http://www.who.int/cancer/prevention/en/

2 Cancer Research UK. All cancers combined Key Facts .2014. Available

from http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/Allcancerscombined.

3 Adapted by the author from: Cancer Research UK. Attributable risk - comparing the causes of cancer poster.

Cancer Research UK. December 2011.

4 World Health Organisation. Treatment of cancer .2014. Available from http://www.who.int/cancer/treatment/en/

5 NHS Commissioning Board. Everyone counts: Planning for Patients 2013-14. NHS England December 2012.

Available from: http://www.england.nhs.uk/wp-content/uploads/2012/12/everyonecounts-planning.pdf

6 World Health Organisation. Palliative care is an essential part of cancer control. 2014. Available

from http://www.who.int/cancer/palliative/en/

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Current Services

Prevention

A range of primary prevention initiatives available locally focus on promoting a

healthy lifestyle, by stopping smoking, tackling obesity, encouraging a healthy

diet and increasing physical activity.

Screening

Breast cancer screening– Coordinated in Kingston by The South West London

Breast Screening Service.

Cervical cancer screening – All women aged between 25 and 64 are invited for

cervical screening.

Bowel cancer screening – St George’s Healthcare is the southwest London Bowel

Cancer Screening Centre.

Primary Care Services

Primary care practitioners are usually responsible for the recognition of symptoms

and signs that could relate to cancer. The role of GPs often continues beyond a

diagnosis of cancer to include follow up, the management of coexisting conditions,

involvement in end of life care and wider psychological and social support

(See Community Voice)

Kingston Clinical Commissioning Group (CCG) has appointed a Lead GP with

responsibility for improving early diagnosis of cancer within primary care. It has also

worked with the Cancer Commissioning Team to encourage education sessions for

GP practices in the borough using practice profiles to highlight areas where there is

variation from the norm

High numbers of patients diagnosed as an emergency may indicate late diagnosis

and is associated with poor survival1. 20% of patients in Kingston are diagnosed with

cancer through emergency routes. This is similar to the England average 2

The ‘Be Clear on Cancer’ campaign has been promoted within the borough to

encourage patients to visit their GP for assessment if they have symptoms which

could be related to cancer.

Secondary Care Services

Kingston patients have a choice of where to be referred for management of their suspected

cancer.

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There are cancer services available from Kingston Hospital which includes inpatient

surgery, day case surgery and chemotherapy treatments

The Sir William Rous Unit in Kingston Hospital opened to patients in June 2008. It

provides a specialist service for those with cancer or those concerned they may have

cancer (Also see community voice)

Kingston hospital links with tertiary services provided at the Royal Marsden

Hospital and at St Georges Hospital

Occasionally, people with cancer will need to be admitted to manage their condition.

In 2013 -14:

there were 1,120 cancer related admissions for patients registered in Kingston

59.9% of admissions were to Kingston Hospital

20.8% were admitted to the Royal Marsden Hospital

12.9% were admitted to St Georges Hospital3 .

End of life care

Various organisations provide end of life care, advice and support for patients, families and

carers. This subject was covered in detail in the 2013 Kingston Annual Public Health Report

(See Chapter 4.6 for more information).

The Five year Cancer commissioning Strategy for London outline how commissioning

responsibilities from April 2013 brought changes to the NHS:

CCGs have responsibility for the commissioning of common cancer services as well

as early diagnosis, services for patients living with and after cancer as well as end of

life care

NHS England has responsibility for the direct commissioning of specialist services

including chemotherapy and radiotherapy, primary care and cancer screening

Public Health teams within Local Authorities take on responsibility for prevention and

population awareness of cancer signs and symptoms.

1 National Cancer Intelligence Network. Routes to Diagnosis - NCIN Data Briefing. National Cancer Intelligence

Network. 2014 . Available from: http://www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis

2 Cancer Commissioning Toolkit

3 Secondary Users Service information.

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Community Voice

A patients experience is an integral part of an individual’s diagnosis, treatment and ongoing

care and support when looking at cancer. In Kingston, there are few specific pieces of work

that have focused solely on Kingston residents and their views and/or experiences of cancer

prevention or treatment. The National Cancer Patient Experience Survey 2015 for Kingston

Hospital NHS Foundation Trust revealed that respondents gave an average rating of 8.4 for

their care (on a scale of zero - very poor to 10 - very good). The following questions are

included in phase 1 of the Cancer Dashboard developed by Public Health England and NHS

England:

74% of respondents said that they were definitely involved as much as they wanted

to be in decisions about their care and treatment

87% of respondents said that they thought the GPs and nurses at their general

practice would support them through their treatment

When asked how easy or difficult it had been to contact their Clinical Nurse Specialist

respondents said that it had been ‘quite easy’ or ‘very easy’

83% of respondents said that, overall, they were always treated with dignity and

respect they were in hospital

60% of respondents said that hospital staff told them who to contact if they were

worried about their condition or treatment after they left hospital definitely did

everything they could to support them while they were having cancer treatment.

As Kingston works collaboratively within the South West London Cancer Network (SWLCN)

there are a number of wider surveys that have captured the Kingston voice. All of these are

used collectively to highlight the issues that are key for individuals when considering how to

commission services locally.

The Cancer Awareness Measure (CAM) Survey in South West London 20101 looks at

cancer awareness amongst the residents of South West London between May and August

2010. A total of 5,009 resident people were interviewed across South West London.

The majority of South West London residents report having been affected by cancer in some

way, either personally or through friends or family having the disease. One in ten residents

(12%) has personally had cancer themselves. Female residents aged 45 to 54 from white

ethnic groups working in managerial, higher administrative or professional occupations have

been found to be more likely to have been affected by cancer. Over half of residents (54%)

reported having a close family member having had cancer.

Cancer impacts far wider than just the individual with the condition, the reach it has on family

and friends is significant. This highlights the importance of raising awareness and support

within the wider community. Public awareness of signs and symptoms and readiness to seek

help are discussed in the individual cancer chapters: Breast, Bowel, Prostate, and Lung.

A Primary Care Audit was undertaken in 2010 across South West London. The purpose of

this was to inform decisions about how best to support primary care professionals and

ensure the earliest diagnosis. During the period April to June 2010 the SWLCN undertook

such an audit as part of the National Awareness and Early Diagnosis Initiative.

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A person’s cancer pathway begins when they recognise and then act on signs and

symptoms. A person who has a type of cancer with easily recognisable symptoms will

present sooner. For example, breast cancer signs are more recognisable than those of colon

cancer. Sometimes, despite recognising symptoms, people are reluctant to present to

primary care. This report highlights the percentages of patients that were diagnosed at

different stages as well as avoidable delays across all cancers. These are areas that could

warrant further exploration to understand the barriers that prevent people from earlier

diagnosis and seeking help earlier.

A number of national surveys provide useful insight into a number of issues surrounding

cancer services and treatment. The 2014 National Cancer Experience Survey highlights that

patients in London consistently describe a lower quality of patient experience than the UK as

a whole.

1IPSOS MORI CAM reports in: Baseline Assessments of Breast, Lung, Colorectal and Urology Related Cancers

South West London Cancer Network 2010 NOTE Information presented in this section from Ipsos MORI is to be

treated as confidential and is subject to copyright.

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Recommendations

Kingston Public Health, Royal Borough of Kingston

1. Promote healthy lifestyles across all public health activities to prevent cancer and

support a reduction in health inequalities

2. Commission evidence-based primary prevention programmes focussed on the key

risk factors linked to cancer, with particular focus on vulnerable groups

3. Promote local awareness of the signs and symptoms of cancer using consistent key

messages

4. Support Kingston Clinical Commissioning Group (Kingston CCG) in commissioning

high quality cancer services services in the borough

Kingston CCG

5. Work with London Cancer Alliance (West and South) to improve local cancer

services

6. Promote healthy lifestyles through primary care to prevent cancer and support a

reduction in health inequalities

7. Implement measures to improve the early detection of cancer. This may include GP

education and commissioning services in line with South West London and national

best practice commissioning guidance to reduce variation and improve overall quality

8. Continue to invest in the Kingston GP cancer lead that provides local leadership and

co-ordination for early detection activities

9. Work with NHS England screening commissioners to facilitate the pathway from

screening to treatment and to achieve the 62 day pathway

10. Work with local acute trusts and community service providers to improving patient

experience

11. Improve support to people living with and beyond cancer as a long term condition

Kingston Health and Wellbeing Board

12. Work with local community groups and the local CCG to target hard to reach groups.

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GLOSSARY

CCG Clinical Commissioning Group

CCT Cancer Commissioning Toolkit

Other Needs Assessments

Cancer needs assessment: Joint Strategic Needs Assessment for Kingston (2010-11)

http://www.kingston.gov.uk/downloads/file/736/cancer_needs_assessment_joint_strategic_n

eeds_assessment_for_kingston_2010-11

SWLCN Baseline Assessment links

Baseline Assessment of Breast Cancer South West London Cancer Network 2010

Baseline Assessment of Colorectal Cancer South West London Cancer Network 2010

Baseline Assessment of Urology related Cancer South West London Cancer Network 2010

Baseline Assessment of Lung Cancer South West London Cancer Network 2010

Useful links for professionals:

National Cancer Strategy

https://www.gov.uk/government/publications/the-national-cancer-strategy

The National Cancer Intelligence Network

http://www.ncin.org.uk

Office for National Statistics: Cancer Statistics

http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Cancer

National Awareness and Early Diagnosis Initiative for England – NAEDI

http://www.cancerresearchuk.org/cancer-info/spotcancerearly/naedi/

Local Authority Health Profiles

http://www.apho.org.uk/default.aspx?QN=P_HEALTH_PROFILES

Help and Information:

Kingston CCG Website

http://www.kingstonccg.nhs.uk/

NHS Choices

http://www.nhs.uk/conditions/Cancer/Pages/Introduction.aspx

Cancer Research UK

http://www.cancerresearchuk.org/cancer-help/

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Macmillan Cancer Support

http://www.macmillan.org.uk/Cancerinformation/Cancerinformation.aspx

Many different organisations support those who are affected by cancer. Many of these

specialise in certain types of cancer. Speak to your GP if you have concerns about your

health or need more information on a specific problem.