Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales · 2015-11-14 · 4 Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales Summary Lung cancer is

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Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales

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Project team

Dr Dyfed Wyn Huws, Dr Ceri White, Rebecca Thomas, Tamsin Long, Ciarán Slyne, Julie

Howe, Helen Crowther

Acknowledgements

A special thanks to all the Welsh Cancer Intelligence and Surveillance Unit’s staff,

especially the registration team without whom the data used within this report would not

be produced.

Thanks to the following people for their help with this publication: Dr Kate Brain, Dr

Clare Elliot, Dr Judith Greenacre, Dr Ciarán Humphreys, Professor Richard Neal, Isabel

Puscas, Hannah Thomas and Janet Warlow

Definitions Age-standardised rates and EASR

Age-standardisation adjusts rates to take into account how many old or young people

are in the population being looked at. When rates are age-standardised, you know that

differences in the rates over time or between geographical areas do not simply reflect

variations or changes in the age structure of the populations. This is important when

looking at cancer rates because cancer mainly affects older people. Throughout this

report we use European Age Standardised Rates (EASR) using the 2013 European

Standard Population (ESP) unless otherwise specified.

Statistical significance

If a difference between rates or survival between populations is statistically significant, it

means that that difference is unlikely to have occurred due to chance alone, and that we

can be more confident that we are observing a ‘true’ difference. In this report we use the

conventional arbitrary cut-off of less than a 5% chance to mean statistically significant.

Just because a difference is statistically significant doesn’t necessarily mean that it is

large or important - that can depend on our judgement and other things.

Relative Survival

This is a way of comparing the survival of people who have a specific disease – in our

case, cancer - with the survival experienced by the general population, over a certain

period of time. It is calculated by dividing the percentage of patients with the disease

who are still alive at the end of the period of time (e.g. one or five years after diagnosis)

by the percentage of people in the general population of the same sex and age who are

alive at the end of the same time period. The relative survival rate shows whether the

disease shortens life. We use relative survival in this report.

Publication Details

Title: Lung Cancer in Wales - Lung cancer survival and survival by stage

Date: 28 January 2015

ISBN: 978-0-9928835 8-4

Contact:


16 Cathedral Road

Cardiff CF11 9LJ

Email: [email protected]

Website: www.wcisu.wales.nhs.uk

© 2015 Public Health Wales NHS Trust

Material contained in this document may be reproduced without prior permission

provided it is done so accurately and is not used in a misleading context.

Acknowledgement to Public Health Wales NHS Trust to be stated.

Copyright in the typographical arrangement, design and layout belongs to

Public Health Wales NHS Trust. Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales

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Contents

Summary .................................................................................................. 4

Key findings .............................................................................................. 6

1 Why prioritise lung cancer? ..................................................................... 12

2 Lung cancer survival in Wales and the rest of the Europe ........................... 13

3 Lung cancer survival trends in Wales ....................................................... 20

4 How is area deprivation related to survival? .............................................. 25

5 Survival in different lung cancer types ..................................................... 27

6 Variation in lung cancer by stage at diagnosis ........................................... 30

7 Health board populations and lung cancer survival .................................... 33

8 Explaining variations and inequalities in survival ....................................... 35

References .............................................................................................. 38

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Summary Lung cancer is one of the four most common cancers in Wales and the

commonest cancer worldwide. Each year in Wales, lung cancer is responsible for more deaths than bowel and breast cancers combined.

Survival from lung cancer is poor compared to most other common cancers. Around half of all people with lung cancer in Wales die from the disease within

six months of diagnosis, almost three-quarters within a year. Almost a third of women in Wales survive at least one year, only a quarter of men do so – a mere

6.5 per cent of people survive for five years or more. Survival in Wales is almost the lowest in Europe – 28th out of 29 countries in the

Eurocare study. If the best lung cancer survival in the Eurocare study applied in Wales during 2012, an approximate estimate of well over 340 more people

might have survived at least a year, and over 190 more people might survive at least five years. One-year lung cancer survival in Wales is consistently the lowest of all UK countries for men and women – the slight increases since 1999

are the smallest in the UK, although there was a decrease for men in Northern Ireland.

Survival dramatically decreases with increasing age. One-year survival in the 45-

54 year-old group is almost twice that in the 75+ age group in Wales, although most cases occur between ages 65 to 79.

Lung cancer stage at diagnosis is strongly related to one-year survival. Lung cancer can be cured or survival improved if it is diagnosed early, although many

other factors play a part in addition to early diagnosis. Overall, survival varies little by area deprivation, unlike the wide inequalities in

incidence, but the survival by stage at diagnosis does vary by area deprivation. For potentially treatable stage 1 lung cancer one-year survival is 91 per cent in

the least deprived areas of Wales but is only 74 per cent in the most deprived areas.

There are other inequalities. There is a seven percentage point difference in survival between health board residents with the highest (Betsi Cadwaladr) and

lowest (Aneurin Bevan) one-year lung cancer survival for 2010-2012. And residents of Cwm Taf have the highest stage 1 one-year survival (86.2 per cent) - over eight percentage points higher than stage 1 survival for Wales, and

almost 15 percentage points higher than the lowest health board population (Cardiff and Vale).

In conclusion, poor lung cancer survival in Wales appears to be due to a number of factors that need to be better understood, mapped and quantified. There are

inequalities and variations within Wales and compared with the rest of the UK and many other European countries. Earlier diagnosis across the population is

needed and may be possible, but this is limited by the lack or type of lung cancer symptoms. Once someone presents to the NHS in Wales with a suspicion

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of lung cancer there may be key issues that lie along the patient’s pathway, including:

- a low surgical resection rate of early stage patients

- too many patients presenting as emergencies - variations in lung cancer staging practices - GPs and patients delaying referral

- GP access to specialist advice - waiting times for x-rays

Our ageing population and higher prevalence of other illnesses may also play a part. We will be examining some of these issues later in our series of reports on

lung cancer in Wales.

Finally, lung cancer can be prevented. Smoking accounts for around 36 cases per week in Wales, mainly in smokers but also in non-smokers. Around 9 cases per week can be linked to other factors such as radon, asbestos, particulate air

pollution and occupational exposure, and silicosis, again in smokers and in non-smokers. The risk from radon and asbestos is greatly multiplied by the addition

of smoking. Effective population-level measures exist to control tobacco and most of the other risk factors.

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Key findings

1. Why prioritise lung cancer? Lung cancer is one of the four most common cancers in Wales and the

commonest cancer worldwide. There were 2,370 new cases diagnosed in

Wales during 2012, equivalent to around 45 cases each week, and accounting for 13 per cent of all new cancer cases.

Lung cancer is the third most common cancer in men, and the second most

common cancer in women in Wales. The number of new cases in women is

approaching the number in men. We estimate that for 2012, Wales’ women had the third highest incidence rate of 40 European countries.

Lung cancer can be prevented. Smoking accounts for around 36 cases per

week in Wales, mainly in smokers but also in non-smokers. Around 9 cases

per week can be linked to other factors such as radon, asbestos, particulate air pollution and occupational exposure, and silicosis, again in smokers and in

non-smokers. The risk from radon and asbestos is greatly multiplied by the addition of smoking. Effective population-level measures exist to control tobacco and most of the other risk factors.

Each year in Wales, lung cancer is responsible for more deaths than bowel

and breast cancers combined.

2. Lung cancer survival in Wales and the rest of Europe

Lung cancer has a very low survival rate

Survival from lung cancer is poor compared to most other common cancers. Around half of all people with lung cancer in Wales die from the disease

within six months of diagnosis, almost three-quarters within a year.

Lung cancer can be cured or survival improved if it is diagnosed early, although many other factors play a part in addition to early diagnosis.

Survival in Wales is almost the lowest in Europe

Wales had the 28th lowest lung cancer one-year and five-year survival rates in both men and women of 29 countries in the Eurocare study.

If the European average lung cancer survival in the Eurocare study applied in

Wales during 2012, an approximate estimate of

o over 120 more women might have survived at least a year

o about 135 more men might have survived at least a year o over 65 more women might survive at least five years

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o about 50 more men might survive at least five years

If the best lung cancer survival in Europe in the Eurocare study applied in Wales during 2012, an approximate estimate of

o well over 155 more women might have survived at least a year o well over 185 more men might have survived at least a year

o over 113 more women might survive at least five years o about 77 more men might survive at least five years

One-year lung cancer survival in Wales is consistently the lowest

of all UK countries for men and women – the slight increases since 1999 are the smallest in the UK, although there was a decrease

for men in Northern Ireland

During all periods between 1999 and 2009, one-year lung cancer survival rates in Wales remained the lowest of all the UK countries for both men and

women, but the differences were small.

Although one-year survival increased by only a few percentage points across

the UK countries for women, the smallest absolute increase was in Wales.

One-year survival in men increased across the UK, except for a decrease in Northern Ireland – of the increases, Wales had the smallest.

There was little improvement in five-year survival across UK countries between 1999 and 2005 - it remains very low in all the countries, although

Northern Ireland has the highest for men and women, but with little difference between the other countries.

3. Lung cancer survival trends in Wales

Almost a third of women in Wales survive at least one year, only a

quarter of men do so – a mere 6.5 per cent of all survive for five years or more Most people with lung cancer die within the first year after diagnosis or are

diagnosed at the time of death.

Only 28 per cent of people diagnosed with lung cancer in Wales during 2007

to 2011 survived at least a year.

Of people diagnosed between 2003 and 2007, a mere 6.5 per cent survived

for five years or more.

There was an increase in one-year survival in both sexes from 2000 to 2011, but the size of the absolute increase in women was over one and a half times that in men so that most recently almost a third of women survive at least

one year, but only a quarter of men do so.

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There was almost no increase in five-year survival from 2000 to 2007 in either men or women, although the survival in women remained slightly

higher than men.

Survival dramatically decreases with increasing age

There is a clear pattern of decreasing one-year and five-year survival with increasing age.

One-year survival in the 45-54 year-old group is almost twice that in the 75+ age group, although most cases occur between ages 65 to 79.

There has been a gradual improvement in one-year survival in all age groups.

One-year survival is lower in men than women for all age groups - the difference is largest in the 55-64 year-old age group (9.8 percentage points),

and smallest in the 75+ age group (2.6 percentage points) in 2007-2011.

4. How is area deprivation related to survival?

Overall, survival varies little by area deprivation, unlike the wide inequalities in incidence, but the survival by stage at diagnosis

does vary by area deprivation

The relationship of survival from lung cancer with deprivation is different to that of incidence, with little or no gradient in overall one-year or five-year

survival as area deprivation increases.

However, survival does vary by area deprivation for different lung cancer

stages at diagnosis (see below).

5. Survival in different lung cancer types

One-year survival from non-small cell lung cancer is higher than small cell lung cancer, but the difference is small

In men, small cell lung cancer one-year survival has been consistently lower

than non-small cell.

In women, small cell one-year lung cancer survival is now lower than non-small cell, but was previously higher than it.

Women’s one year survival from small cell lung cancer is higher than both non-small cell and small cell in men.

There have been smaller improvements in one-year small cell survival

compared to non-small cell for men and women.

Five-year survival is poor in both types, but is worse for small cell than non-

small cell in men and women.

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Whereas most recently, five-year survival for non-small cell lung cancer is

higher in women than men, the opposite is true for small cell lung cancer, although in 1999-2003 small cell survival was higher in women.

6. Variation in lung cancer by stage at diagnosis Lung cancer stage at diagnosis is strongly related to one-year

survival

One-year survival for stage 1 disease (78 per cent) is approximately five-and-a-half times that from stage 4 disease (14 per cent).

One-year survival is modestly higher for women than men for all stages apart

from stage 2 where survival is more similar, but slightly higher in men.

For potentially treatable stage 1 disease one-year survival is 23 per cent higher in the least deprived areas compared to the most

deprived

For stage 1 disease although almost three-quarters survive at least one year in the most deprived areas of Wales, there is a steep gradient with 91 per

cent surviving in the least deprived areas – that is 23 per cent or 17 percentage points higher. There is a ten percentage point variation for stages 2 and 3 also, but no clear gradient moving from most to least deprived areas.

7. Health board populations and lung cancer survival The highest health board one-year survival rate is for the Betsi

Cadwaladr population - the only one statistically significantly higher than Wales’ survival with no health board significantly

lower There is a modest seven percentage point difference in survival between

health board residents with the highest (Betsi Cadwaladr) and lowest

(Aneurin Bevan) one-year lung cancer survival (2010-2012).

The highest survival in Betsi Cadwaladr (34.7 per cent) is the only one that is

statistically significantly higher than the 2010-2012 one-year survival for Wales (30.9 per cent), and no health board is statistically significantly lower.

When each stage at diagnosis is considered separately wider differences in

one-year survival between health board area of residence are apparent.

Residents of Cwm Taf have the highest stage 1 one-year survival (86.2 per

cent) - over eight percentage points higher than stage 1 survival for Wales, and almost 15 percentage points higher than the lowest (Cardiff and Vale).

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8. Explaining variations and inequalities in survival Poor lung cancer survival in Wales appears to be due to a number

of factors that need to be better understood, mapped and quantified. They Possibly include:

- a low surgical resection rate of early stage patients

- too many patients presenting as emergencies - variations in lung cancer staging practices

- GPs and patients delaying referral - GP access to specialist advice - waiting times for x-rays

Our ageing population and higher prevalence of other illnesses may also play

a part. We will be examining some of these issues later in our series of reports on lung cancer in Wales.

Presentation at an earlier stage is one predictor of improved survival – the

survival rates by stage for Wales show this with survival rapidly decreasing in

later stages.

As in most other countries, the majority of people diagnosed with lung cancer in Wales present at a late stage – a major factor in the overall low survival from lung cancer.

One explanation for the predominance of late presentation is the natural

history of the disease - it can move from stage 1 to 4 very quickly and without treatment even stage 1 disease can be rapidly fatal. Symptoms tend to be absent, non-specific, or have little relationship to disease stage.

The International Cancer Benchmarking Partnership (ICBP) 1 study showed

the proportion diagnosed at an early stage for non-small cell lung cancer was slightly lower in the UK and Denmark compared to Australia, Canada, Norway and Sweden. All had the majority of cases diagnosed at a later stage.

Similarly, within Wales the variation in stage at diagnosis between health board populations is not very wide.

Reasons for Welsh patients presenting slightly later than elsewhere are not

entirely understood. The ICBP 2 study showed that in Wales and the rest of

the UK, people are more likely than people in Australia, Canada, Denmark, Norway and Sweden to say that embarrassment and not wanting to waste

the doctor’s time would stop them going to the doctor with a possible cancer symptom. Yet most people in the UK and Wales held positive views about cancer, for example the benefits of early diagnosis and improved cancer

outcomes. However, negative beliefs about cancer, such as “cancer is a death sentence”, were prevalent among people with lower levels of education or

living in deprived areas of Wales. There is evidence that negative beliefs may be linked to delayed presentation.

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Once patients present to primary care, other reasons for slightly later stage at diagnosis in Wales may lie at the GP and hospital care boundary along with

access to diagnosis. The ICBP 3 study (about to be published) showed that GPs in Wales, compared with those in other UK countries and Canada,

Australia and Scandinavia, opted to investigate potential symptoms of lung cancer at a later stage. They also reported longer waiting times for x-rays, poorer access to specialist advice, and less ability to hasten tests if cancer is

suspected.

If stage at diagnosis was the only major factor affecting survival then areas or countries with different stage distributions - and so different overall lung cancer survival - should still expect survival for each stage to be similar. But

there is wide variation in survival by stage between Welsh health board populations and between countries, as shown in the ICBP 1 study - UK

survival figures were among the lowest at all stages compared to the other countries. Add to that stage distribution varies little between them but there is wide variation in overall survival, then factors other than stage distribution

must play a part.

The point of access to the NHS at the time of diagnosis appears to be a factor, over and above the stage at diagnosis. Around half the people

diagnosed with lung cancer present as an emergency and have worse outcomes than other routes into the NHS in Wales. This proportion of emergencies is higher than in England.

One of the major issues in relation to survival is timely access to potentially

curative treatment for people with early stage disease if they wish and are suitable. This may include surgery, radiotherapy or chemotherapy, depending on cancer type. UK countries have low surgical resection rates compared to

some other European countries. Wales has a significantly lower surgical resection rate than either England or Scotland. It is not clear why this is, but

other existing illnesses (co-morbidity), general health, surgery not being offered to older people, patient choice or access to and capacity of specialist surgical services may all play a part, as well as differences in staging

practices.

An ICBP team is examining the effect of access to treatment on the international variation in survival rates. We are participating in the ICBP 5 study to examine the contribution of co-morbidity.

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1 Why prioritise lung

cancer? Lung cancer is one of the four most common cancers in Wales and the

commonest cancer worldwide. There were 2,370 new cases diagnosed in Wales during 2012, equivalent to around 45 cases each week, and accounting for 13

per cent of all new cancer cases. Lung cancer is the third most common cancer in men, and the second most

common cancer in women in Wales. The number of new cases in women is approaching the number in men. We estimate that for 2012, Wales’ women had

the third highest incidence rate of 40 European countries1. Lung cancer can be prevented. Smoking accounts for around 36 cases per week

in Wales, mainly in smokers but also in non-smokers. Around 9 cases per week can be linked to other factors such as radon, asbestos, particulate air pollution

and occupational exposure, and silicosis, again in smokers and in non-smokers. The risk from radon and asbestos is greatly multiplied by the addition of

smoking. Effective population-level measures exist to control tobacco and most of the other risk factors.

Each year in Wales, lung cancer is responsible for more deaths than bowel and breast cancers combined.

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2 Lung cancer survival

in Wales and the rest of

Europe

Lung cancer has a very low survival rate Survival from lung cancer is poor compared to most other common cancers. And

survival from lung cancer in Wales is almost the lowest in Europe.

At present around a half of the people diagnosed with lung cancer in Wales die

from the disease within six months of diagnosis, almost three-quarters within a year (figure 1).

Figure 1: Kaplan- Meier survival curve for lung cancer 2003-2007 in Wales

Source: Welsh Cancer Intelligence and Surveillance Unit’s National Cancer Registry

Lung cancer can be cured or survival improved if it is diagnosed early, although many other factors play a part in addition to early diagnosis. Unfortunately most

people are diagnosed at a late stage. There are many reasons for this although more research is needed to fully understand why. We discuss this further at the

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end of this report. Research evidence is emerging on what is effective in improving earlier diagnosis and improving survival.

Potentially curative or survival-prolonging treatments include surgery,

radiotherapy or chemotherapy depending on cancer type and many other factors. Some of these and other interventions may also be used for palliative purposes in many people with lung cancer.

Survival in Wales is almost the lowest in Europe

Survival from lung cancer is universally low across Europe but there is still wide

variation between countries. The highest one-year survival rate amongst men is in Belgium which is almost twice as high as the lowest in Bulgaria(figure 2).

We take part in the Eurocare2 study which showed that for the 29 European countries studied, Wales had the 28th lowest lung cancer one-year and five-year

survival rates in both men and women (figures 2 to 5). Figure 2: Men’s one-year lung cancer survival in Wales is 28th lowest out of 29 European

countries

Source: Eurocare

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Figure 3: Women’s one-year lung cancer survival in Wales is 28th lowest out of 29

European countries

Source: Eurocare

The Eurocare study showed that one-year relative survival for women in Wales

was 27 per cent lower than the European average or over 11 percentage points less. It was a third (or 15 percentage points) lower than Austria, the country with a national cancer registry that had the best survival. If the European

average survival applied in Wales, then using our latest figures, over a 120 more women with lung cancer diagnosed in 2012 might have survived at least a year.

And if the best survival applied that could mean well over an extra 155 surviving at least a year.

The one-year survival for men in Wales was lower than women, in common with the other countries in the Eurocare study. It was 29 per cent - or 11 percentage

points - lower than the European average for men. It was almost 36 per cent - or 15 percentage points - lower than Austria, the country with a national cancer registry that had the best survival for men. If the European average survival

applied in Wales, then using our latest figures, about 135 more men with lung cancer diagnosed in 2012 might have survived at least a year. And if the best

survival applied that could mean well over an extra 185 surviving at least a year.

A similar pattern is seen for five-year survival, although the differences are even greater. Survival in Wales is over a third lower than the European average in men, but for women in Wales five-year survival from lung cancer is 40 per cent

lower than the European average. Survival of men in Wales is just over half that of Austria, the country with a national cancer registry with the highest and less

than half that of Austria for women.

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Figure 4: Men’s five-year lung cancer survival in Wales is 28th lowest out of 29 European

countries

Source: Eurocare

Figure 5: Women’s five-year lung cancer survival in Wales is 28th lowest out of 29 European countries

Source: Eurocare

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If this European average five-year survival for women applied in Wales, using our latest figures, over 65 more women with lung cancer diagnosed in 2012

might have survived at least five years. And if the best survival applied, that could mean more than an extra 113 surviving at least five years.

If this European average five-year survival for men applied in Wales, using our latest figures, about 50 more men with lung cancer diagnosed in 2012 might

have survived at least five years. And if the best survival applied that could mean about 87 extra men surviving at least five years.

Although survival is not as high as in Austria, Sweden is another country with a high quality national cancer registry that is consistently higher than the

European average one-year and five year survival rates, for both men and women. Belgium, Switzerland, France, Germany and Italy consistently feature

above the European average survival, but they have numerous regional registries that may not have whole population coverage.

The International Cancer Benchmarking Partnership module 1 study3 found that international differences in lung cancer survival were wider in older age groups.

One-year lung cancer survival in Wales is consistently the lowest

of all UK countries for men and women – the slight increases since 1999 are the smallest in the UK, although there was a decrease

for men in Northern Ireland

One-year survival from lung cancer increased for women in all UK jurisdictions between 1999 and 2009i (figure 6). It also increased for men in all the UK jurisdictions except for Northern Ireland, which decreased slightly.

For women, the largest absolute increase in one-year survival occurred in

Northern Ireland (4.7 percentage points), and the smallest was in Wales (2.3 percentage points). For men, the largest increase was in Scotland (3.1 percentage points), and the lowest increase was again in Wales (2.4 percentage

points), although there was also the small decrease in Northern Ireland (-0.19) percentage points).

Most recently during the period we examined, women in Northern Ireland and

Scotland had similar one-year survival rates which are the highest of UK jurisdictions. For women, Wales had the lowest survival with a widening gap between the other jurisdictions. Scotland had the highest one-year survival for

men – even higher than for Wales’ women. The lowest survival of all was amongst men in Wales, but the absolute difference with Scotland’s men was still

small (3.5 percentage points by the end of the period). During the whole of this period, one-year lung cancer survival rates in Wales

remained the lowest of all the UK jurisdictions for both men and women (figure 6).

i Latest comparable years for all UK jurisdictions

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Figure 6: Trends in one year survival for lung cancer in the United Kingdom.

Source: UKCIS 4.5b: April 2013 update

There was little improvement in five-year survival across the UK between 1999 and 2005, and it remains very low in all UK jurisdictions (figure 7).

Women in Northern Ireland have the highest five-year survival rate. Women in England, Scotland and Wales have very similar rates for the latest period, with

most improvement in Scotland. Although men in Wales remain with the lowest five-year survival, the difference with England and Scotland is small, and it improved slowly by similar amounts in Wales and England. Meanwhile, five-year

survival decreased slightly in men Northern Ireland and Scotland.

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Figure 7: Trends in five year survival for lung cancer in the United Kingdom.

Source: UKCIS 4.5b: April 2013 update

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3 Lung cancer survival

trends in Wales

Almost a third of women in Wales survive at least one year, only a quarter of men do so – a mere 6.5 per cent of all survive for five

years or more

More recent survival data is available for Wales than the comparative UK figures. Most people with lung cancer die within the first year after diagnosis or are diagnosed at the time of death (figure 8). Only 28 per cent of people diagnosed

with lung cancer in Wales during 2007 to 2011 survived at least a year. Of people diagnosed between 2003 and 2007, a mere 6.5 per cent survived for five

years or more. There has not been much improvement in lung cancer survival in Wales.

Although one-year survival improved by almost a fifth between 2000 and 2011, this was only equivalent to 4.5 percentage points. Survival in women is higher

than men. There was an increase in both sexes, but the size of the absolute increase in women was over one and a half times that in men, increasing the gap between them.

Figure 8: One- year lung cancer survival is increasing very slowly, but improvement is more in women than men.


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Five-year survival from lung cancer is very low and considerably lower than one-

year survival, emphasising the fact that survival from lung cancer is poor and that most deaths are early after diagnosis. There was almost no increase in five-

year survival from 2000 to 2007 (figure 9) in either men or women, although the survival in women remained higher than men. Figure 9: Hardly any change in five- year lung cancer survival in Wales between 2000-

2007.


Survival dramatically decreases with increasing age A person’s age at the time of lung cancer diagnosis is strongly associated with

survival. There is a clear pattern of decreasing one-year and five-year survival with increasing age (figures 10 and 11). One-year survival in the 45-54 year-old

group is almost twice that in the 75+ age group, although most cases occur between ages 65 to 79.

An improvement in one-year survival has occurred in all age groups, although the numbers are small in the youngest. The lack of clear trends in improvement

of five-year survival occurs across all age groups. The ratio of five-year survival in the youngest to oldest age group is larger than for one year survival

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Figure 10: Rapidly decreasing one-year survival with increasing age, but with small

improvements in all age-groups


Figure 11: Little improvements in five-year lung cancer survival in all age-groups


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One-year survival is lower in men than women for all age groups (figure 12). The gradient of decreasing survival with increasing age is similar for both sexes,

with survival being around 1.8 times higher at 45-54 years compared to 75+ in both men and women. The difference in survival between men and women is

largest in the 55-64 year-old age group (9.8 percentage points), and smallest in the 75+ age group (2.6 percentage points). Figure 12: One-year lung cancer survival is lower in men than women for all age-groups

Source: Welsh Cancer Intelligence and Surveillance Unit’s National Cancer Registry. 2007-2011 time period. Five-year survival is higher in women than men in all age groups apart from 15-44 year olds (figure 13), although the latter group is based on very few cases.

The gradient of decreasing survival with increasing age is steeper than for one-year survival in men and women, being steepest in men. Differences between

the sexes are smaller than for one-year survival for each age group.

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Figure 13: Five- year survival is generally less in men across age-groups but differences

are less than for one-year survival

Source: Welsh Cancer Intelligence and Surveillance Unit’s National Cancer Registry. 2003-2007 time period.

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4 How is area

deprivation related to

survival

Overall, survival varies little by area deprivation, unlike the wide

inequalities in incidence, but the survival by stage at diagnosis does vary by area deprivation The incidence of lung cancer is much higher in more deprived areas of Wales

compared to the least deprived. The relationship of survival from lung cancer with deprivation is different with little or no gradient as area deprivation

increases (figure 14). Figure 14: Kaplan-Meier survival curve for lung cancer in Wales 2003-2007


For the latest period (2007-2011) there was almost no gradient in one-year survival between the most and least deprived areas of Wales (figure 15). But during 1999-2003 there was a small difference between the least and the most

deprived areas of Wales with a gradient in-between.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 1 2 3 4 5

Pro

port

ion

su

rviv

ing

Survival in years

Least deprived Next least deprived Middle deprived Next most deprived Most deprived

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Figure 15: The small gradient of decreasing one-year survival with increasing area

deprivation in 1999-2003 was almost gone by 2007-2011

Source: Welsh Cancer Intelligence and Surveillance Unit’s National Cancer Registry Five-year survival is universally low across all levels of area deprivation with

little or no positive or negative relationship to it (figure 16). Figure 16: Small variation in five –year survival between different levels of area

deprivation has no clear gradient


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5 Survival in different

lung cancer types

One-year survival from non-small cell lung cancer is higher than

small cell lung cancer, but the difference is small The survival profile of non-small cell lung cancer dominates overall lung cancer survival rates as it is far more common than small cell lung cancer.

Nevertheless, small cell lung cancer still accounts for 11 per cent of all lung cancer cases in Wales4 and a detailed knowledge of its survival is important.

Small cell lung cancer has a lower one-year survival than non-small cell lung cancer (figure 17). But for the most recent period of 2007-2011 the difference

between them was only 4.4 percentage points. This gap had widened from only 1.1 percentage points in 1999-2003.

The pattern is different for men and women. In women at the beginning of the period, one-year survival from small cell lung cancer was actually higher than

from non-small cell (figure 17). Survival then increased for both types in women, but by more for non-small cell lung cancer, so that survival was slightly

higher than small cell by the latest period. In men survival from small cell lung cancer was worse throughout the period – by 2007-2011 there was over a six percentage point difference between them. In fact, women’s survival from small

cell lung cancer was higher than men’s survival from non-small cell lung cancer throughout the period.

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Figure 17: One year survival is higher in women than in men for small cell and non-

small cell lung cancer, the difference is greater for small cell, but women’s non- small cell survival is the most improved

Source: Welsh Cancer Intelligence and Surveillance Unit’s National Cancer Registry Five-year survival is poor for both non-small cell and small cell lung cancer, but

is worse for small cell in both men and women (figure 18).

Whereas five-year survival for non-small cell is higher in women than men, the opposite is by now true for small cell lung cancer. After an initial worsening in small cell survival in women, from 2001-2005 it appears to be increasing

gradually in both men and women. There is no appreciable improvement in non-small cell five-year survival in either men or women.

We participate in the International Cancer Benchmarking Partnership (ICBP) studies. The first module looked at survival from lung cancer by type diagnosed

2004-2007 in six countries – UK, Australia, Canada, Denmark, Norway and Sweden. One-year small cell and non- small cell lung cancer survival varied

widely between the countries. Survival from non- small cell lung cancer ranged from a low of 30 per cent in the UK to 46 per cent in Sweden. Non-small cell survival was relatively low in Denmark, intermediate in Norway and higher in

Australia and Canada. The UK also had the lowest one-year small cell survival, Sweden and Australia had the highest.

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Figure 18: Five- year survival for small cell and non- small cell lung cancer is very low

but worse for small cell


30


6 Variation in lung

cancer survival by stage

of diagnosis

Lung cancer stage at diagnosis is strongly related to one-year

survival

The stage of lung cancer at the time of diagnosis is strongly related to one-year survival (figure 19). The one-year survival of stage 1 disease (least advanced) in

Wales is almost 78 per cent for people diagnosed 2010-2012. This is five-and-a-half times the survival from stage 4 disease (most advanced) at 14 per cent one-year survival. Unfortunately, most people with lung cancer in Wales have a

late stage of disease at the time of diagnosis, although the proportion in each stage varies considerably across the country5. Survival for those with an

unknown stage of disease is relatively low, suggesting that the true stage in this group tends to be advanced, although many other factors are probably involved.

One-year survival is higher for women than men for all stages apart from stage 2 where survival is similar. The differences are modest approaching a seven

percentage point advantage over men in survival for stage 3 disease3.

The all-stage one-year survival for Wales for this latest three year period of 2010 to 2012 is just over 30 per cent, which is consistent with the gradually increasing trend in one-year survival in successive five-year periods we reported

earlier in this publication (figure 19). The gap between better survival in women than men also continues to increase for this latest three year period.

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Figure 19: Earlier stage at diagnosis is strongly related to better one-year survival


For potentially treatable stage 1 disease one-year survival is 23 per cent higher in the least deprived areas compared to the most

deprived

As for 2007-2011(figure 15) the all-stage one-year survival for 2010-2012

shows no relationship with area deprivation (figure 20). When survival by stage is considered, variation by area deprivation becomes apparent. For stage 1

disease although almost three-quarters survive at least one year in the most deprived areas of Wales, there is a steep gradient with 91 per cent surviving in the least deprived areas – that is 23 per cent or 17 percentage points higher.

There is a ten percentage point variation for stages 2 and 3 also, but no clear gradient moving from most to least deprived areas.

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Figure 20: There is a steep gradient of worse survival as area deprivation increases for

stage 1 lung cancer


33


7 Health board

populations and lung

cancer survival

The highest health board one-year survival rate is for the Betsi

Cadwaladr population

There is some modest variation in one-year survival between the health board area of residence of people diagnosed with lung cancer.

For all stages combined (2010-2012) there was just over a seven percentage point difference in survival between the health board area with the highest and

lowest one-year survival (figure 21). Apart from the residents of Betsi Cadwaladr health board, that had the highest survival of 34.7 per cent - the only one

statistically significantly higher than Wales’ survival of 30.9 per cent, with no health board significantly lower.

When each stage at diagnosis is considered separately wider differences in one-year survival between health board area of residence are apparent. Only three

years of population-level lung cancer data is available with stage information from 2010 to 2012. 2013 data will be available soon. As most of Powys residents are treated out of area - generally in England - we have not historically received

stage information on their cases. A significant proportion of Betsi Cadwaladr patients are also routinely diagnosed or treated in the north west of England,

which probably explains why we currently do not know the stage of a large proportion (figure 21). We are working with Public Health England to receive staging information in the near future.

Stages 1 and 2 are the most important as people diagnosed at these stages are

potential candidates for curative treatment for lung cancer, depending on several other factors. Residents of Cwm Taf have the highest stage 1 one-year survival at 86.2 per cent. This is over eight percentage points higher than the stage 1

survival for Wales, and almost 15 percentage points higher than Cardiff and Vale residents with the lowest stage 1 survival. Because only a minority of lung

cancer patients are diagnosed at stage 1, the smaller numbers in each health board means that chance alone may explain some of the observed differences between each other and with the Wales survival rate. The higher survival of

unknown stage patients who live in the Betsi Cadwaladr area may reflect cases currently notified to us from hospitals in England but without known stage

information passed on to us.

34


The size of the variation in survival is similar for stage 2 disease with different health boards having higher and lower values, but as for stage 1 disease, there

is a high probability that chance alone explains the observed differences. Figure 21: Residents of the Cwm Taf health board have the highest stage 1 lung cancer survival, residents of Cardiff and Vale health board have the lowest


35


8 Explaining variations

and inequalities in

survival

In conclusion poor lung cancer survival in Wales appears to be due to a number

of factors that need to be better understood, mapped and quantified. There are inequalities and variations within Wales and compared with the rest of the UK and many other European countries. Earlier diagnosis across the population is

needed and may be possible, but this is limited by the lack or type of lung cancer symptoms. Once someone presents to the NHS in Wales with a suspicion

of lung cancer there may be key issues that lie along the patient’s pathway, including:

- a low surgical resection rate of early stage patients - too many patients presenting as emergencies

- variations in lung cancer staging practices - GPs and patients delaying referral

- GP access to specialist advice - waiting times for x-rays

These and other factors may help explain population-level differences in lung cancer survival between demographic groups and geographic areas in Wales, as

well as the international survival differences that exist. Presentation at an earlier stage is one predictor of improved survival – the

survival rates by stage for Wales show this, with survival rapidly decreasing in later stages. As in most countries, the majority of people diagnosed with lung

cancer in Wales present at a late stage – a major factor in the overall low survival from lung cancer5 .

One explanation for the predominance of late presentation is the natural history of the disease - it can move from stage 1 to 4 very quickly6 and without

treatment even stage 1 disease can be rapidly fatal7. Symptoms tend to be absent, non-specific, or have little relationship to disease stage8.

The International Cancer Benchmarking Partnership (ICBP) 1 study3 showed the proportion diagnosed at an early stage for non-small cell lung cancer was slightly

lower in the UK and Denmark compared to Australia, Canada, Norway and Sweden. All had the majority of cases diagnosed at a later stage. Similarly, within Wales the variation in stage at diagnosis between health board

populations is not very wide (see above).

36


The reasons for Welsh patients presenting slightly later than elsewhere are not entirely understood. The ICBP 2 study3 showed that in Wales and the rest of the

UK, people are more likely than people in Australia, Canada, Denmark, Norway and Sweden to say that embarrassment and not wanting to waste the doctor’s

time would stop them going to the doctor with a possible cancer symptom. Yet most people in the UK and Wales held positive views about cancer, for example the benefits of early diagnosis and improved cancer outcomes. However,

negative beliefs about cancer, such as “cancer is a death sentence”, were prevalent among people with lower levels of education or living in deprived areas

of Wales. There is evidence that negative beliefs may be linked to delayed presentation.

Once patients present to their GP, other reasons for slightly later stage at diagnosis in Wales may lie at the GP and hospital care boundary, along with

access to diagnostic tests. The ICBP 3 study (Neal R, personal communication email, 14th January 2015) showed that GPs in Wales, compared with those in other UK countries and Canada, Australia and Scandinavia, opted to investigate

potential symptoms of lung cancer at a later stage. They also reported longer waiting times for x-rays, poorer access to specialist advice, and less ability to

hasten tests if cancer is suspected. Several studies have shown that in general practice three or more consultations occurred before being referred in about a

third of patients diagnosed with lung cancer910. But this percentage varied across different types of cancer, suggesting that this had more to do with the diagnostic difficulty of different cancers rather than variations in clinical practice. A recent

qualitative study of significant event audits of the diagnosis of lung cancer in general practice in England found that there were issues around communication

between primary and secondary care, as well as a patient preference for delayed referral11.

If stage at diagnosis was the only major factor affecting survival then for areas or countries with different stage distributions - and so different overall lung

cancer survival - we should still expect survival for each stage to be similar. However, our analyses show that health board stage distribution is only partly correlated with overall one-year survival for each health board. A key feature is

the variation between the health boards in the survival for each separate stage at diagnosis (figure 21). The ICBP module 1 study also found similar variability

in survival by stage between countries. Denmark had low survival for patients with early stage disease, but average survival for those with more advanced disease. The UK survival figures were among the lowest at all stages compared

to the other countries. In Canada patients had high survival at early stages of lung cancer but relatively poor survival at advanced stages of lung cancer.

The very low overall one-year lung cancer survival in Wales and other UK countries compared to Sweden, for example, does not seem to be wholly

explained by differences in stage distribution. The proportion of patients diagnosed at an early stage for non-small cell lung cancer was only slightly lower

in the UK compared to Sweden. Similarly, there is variation in the stage distribution between Welsh health board populations, but it is not great in terms of proportions in stages 1 and 2 that may be potentially treatable. Although

variations in the accuracy and completeness of recording stage at diagnosis may

37


partly explain the observed differences in survival by stage at diagnosis, overall, the findings suggest factors other than stage at diagnosis are important.

The point of access to the NHS at the time of diagnosis appears to be a factor,

over and above the stage at diagnosis. Around half the people diagnosed with lung cancer present as an emergency and have worse outcomes than other routes into the NHS in Wales12. This proportion of emergencies is higher than in

England13 .

We know that without treatment even stage 1 disease can be rapidly fatal. Early diagnosis alone is not enough. One of the major issues in relation to survival is timely access to potentially curative treatment for people with early stage

disease if they wish and are suitable. This may include surgery, radiotherapy or chemotherapy, depending on cancer type. UK countries have low surgical

resection rates compared to some other European countries. Wales has a significantly lower surgical resection rate than either England or Scotland. For 2012 data, the average surgical resection rate for confirmed non-small cell lung

cancer in England and Wales combined was 21.9 per cent14. For Scotland it was 20.5 per cent. But for patients seen by clinical teams in the South Wales Cancer

Network area (that covers a large proportion of the Welsh population) it was only 15.8 per cent and for the North Wales Cancer Network covering the Betsi

Cadwaladr health board area, it was 18.4 per cent. It is not clear why this is, but other existing illnesses (co-morbidity), general health, differences in staging practices, surgery not being offered to older people, patient choice or access to

and capacity of specialist surgical services may all play a part.

An ICBP team is examining the effect of access to treatment on the international variation in survival rates. We are participating in the ICBP 5 study to examine the contribution of co-morbidity.

38


References

1 J. Ferlay et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013; 49(6); 1374-1403

2 De Angelis R et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE-5 -

a population-based study. Lancet Oncol 2013;15:23-34. Available at: http://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(13)70546-1.pdf [Accessed: 20th Jan 2015]

3 Walters S et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007. Thorax 2013;68:551-64. Available at: http://thorax.bmj.com/content/68/6/551.full.pdf+html [Accessed: 20th Jan 2015]

4 Wao H et al. Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis. Systematic Reviews 2013;2:10. Available at: http://www.systematicreviewsjournal.com/content/pdf/2046-4053-2-10.pdf [Accessed: 19th Jan 2015]

5 Public Health Wales. Lung cancer in Wales. A detailed analysis of population trends of incidence and

stage at diagnosis up to and including 2012. Cardiff: Public Health Wales NHS Trust; 2014. Available at:

http://www.wcisu.wales.nhs.uk/sitesplus/documents/1111/141214%20LUNG%20CANCER%20IN%20W

ALES%20FINAL.pdf [Accessed: 20th Jan 2015]

6 Detterbeck FC1, Gibson CJ. Turning gray: the natural history of lung cancer over time. J Thorac Oncol 2008;3:781-92.

7 Ades AE et al. Symptom lead time distribution in lung cancer: natural history and prospects for early diagnosis. Int J Epidemiol 2014;43:1865-73

8 Forbes LJL et al. Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? Br J Cancer 2013; 108:292-300. Available at:

http://www.nature.com/bjc/journal/v108/n2/pdf/bjc2012542a.pdf [Accessed: 20th Jan 2015]

9 Lyratzopoulos G et al. Measures of promptness of cancer diagnosis in primary care: secondary analysis

of national audit data on patients with 18 common and rarer cancers. Br J Cancer 2013; 108:686-90. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593564/pdf/bjc20131a.pdf [Accessed: 20th Jan 2015]

10 Lyratzopoulos G et al. Variation in number of general practitioner consultations before hospital referral

for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012;13:353-65.

11 Mitchell ED, Rubin G, Macleod U. Understanding diagnosis of lung cancer in primary care: qualitative synthesis of significant event audit reports. Br J Gen Pract 2013;63:e37-46. Available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529291/pdf/bjgp63-e37.pdf [Accessed: 20th Jan 2015]

12 Bailey R, Huws DW. Early diagnose initiative at the Welsh Cancer and Intelligence Surveillance unit.

Presented at Cancer Research UK Early Diagnosis Workshop 2013 Oct 22. Powerpoint presentation.

[Unpublished]

13 Ellis-Brookes et al. Routes to diagnosis for cancer-determining the patient journey using multiple routine data sets. BR J Cancer 2012: 107:1220-1226. Available at:Routes to diagnosis for cancer - determining the patient journey us... - PubMed - NCBI [Accessed: 19 January 20015]

14 Health and Social Care Information Centre. National Lung Cancer Audit: 2012 Patient Cohort [Online]. 2013. Available at: http://www.hscic.gov.uk/searchcatalogue?productid=13406&q=title%3a%22Lung+cancer%22&infotype=0%2fAudit&sort=Relevance&size=10&page=1#top {Accessed: 20th Jan 2015]

http://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(13)70546-1.pdf

http://thorax.bmj.com/content/68/6/551.full.pdf+html

http://www.systematicreviewsjournal.com/content/pdf/2046-4053-2-10.pdf

http://www.wcisu.wales.nhs.uk/sitesplus/documents/1111/141214%20LUNG%20CANCER%20IN%20WALES%20FINAL.pdf

http://www.wcisu.wales.nhs.uk/sitesplus/documents/1111/141214%20LUNG%20CANCER%20IN%20WALES%20FINAL.pdf

http://www.nature.com/bjc/journal/v108/n2/pdf/bjc2012542a.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593564/pdf/bjc20131a.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529291/pdf/bjgp63-e37.pdf

http://www.ncbi.nlm.nih.gov/pubmed/22996611

http://www.ncbi.nlm.nih.gov/pubmed/22996611

http://www.hscic.gov.uk/searchcatalogue?productid=13406&q=title%3a%22Lung+cancer%22&infotype=0%2fAudit&sort=Relevance&size=10&page=1#top

http://www.hscic.gov.uk/searchcatalogue?productid=13406&q=title%3a%22Lung+cancer%22&infotype=0%2fAudit&sort=Relevance&size=10&page=1#top

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