Introduction
This chapter considerers the prevalence of cancer in Nottingham City, the prevention of cancer, cancer screening and treatment and palliative care services. The chapter also considers the inequalities related to cancer incidence and mortality. Key lifestyle risk factors such as smoking, obesity in adults and children, physical activity and alcohol, as well as End of Life Care are considered in separate chapters.
Cancer is a disease caused by normal cells changing so that they grow in an uncontrolled way. There are more than 200 different types of cancer. Cancer is now one of the biggest health challenges in the UK with one in three people expected to develop some form of cancer in their lifetime. Approximately 308,000 new cases of cancer are diagnosed each year in the UK with the most common cancers being breast, lung, colorectal and prostate cancers (Cancer Research UK, 2012). In Nottingham, there were 1,259 new cases in 2012.
The five main types of cancer are, skin, breast, lung, large bowel (colorectal) and prostate, which account for the 54% of all new cancers in England excluding the non-melanoma skin cancers.
Mortality from cancer is high with just under 141,600 deaths in England resulting from cancer in 2013 (HSCIC Indicator Portal). The incidence of cancer has remained stable for the past ten years and mortality rates have decreased illustrating the improvements in outcomes as we have gained a better understanding of the biological mechanisms of the evolvement of the different types of cancers.
Cancer is the highest cause of premature death in Nottingham City. Premature deaths are deaths that occur before a person reaches 75 years. Premature deaths account for 35% of all deaths and 47% of all cancer deaths and are therefore an important local health priority for Nottingham City (HSCIC Indicator Portal, all ages 1+, 2013). In the City, there are at least 5,521 people living with cancer (QOF registers 2014/15). This is based on the number of people on GP lists with a diagnosis of cancer recorded since 2003.
Unmet needs and gaps
General
- The Independent Cancer Taskforce strategy 2015-2020 contains key recommendations to transform cancer care to meet and manage future demand for services
- Involvement of communities and patients is essential to ensure services are relevant and meet the needs of individuals and communities
Prevention
- Approximately 40% of cancers are preventable through healthy lifestyles and behavioural, however, Nottingham’s population has high rates of smoking, obesity and other risk factors for cancer
- Most modifiable lifestyle risk factors such as smoking and obesity are higher in areas of deprivation.
- Smoking is the single largest preventable risk factor for cancer.
- There is significant community level resource which already has a role in promoting and supporting lifestyle changes. Opportunities could be taken to explore this work more specifically in a cancer prevention context, in order to enhance incorporate cancer health messages through making every contact count.
Early diagnosis
- Public awareness of the signs and symptoms of cancer and uptake of cancer screening opportunities are key factors in increasing the early detection and presentation of cancers, yet late presentation is high amongst those living in areas of deprivation and in certain BME communities.
Screening
- In Nottingham the uptake of bowel screening is poor and cervical screening is decreasing
- There is a lack of knowledge of the reasons for poor uptake of bowel screening in different communities
- There is a lack of information which describes who does not uptake screening which hinders efforts to increase uptake
Treatment
- Increasing incidence of cancer and early diagnosis guidelines will put a significant pressure on services to investigate and treat patients within agreed timescales
- Site-specific referral pathways lead to delays in full investigation and subsequent diagnosis for patients with non-specific symptoms
- There is a lack of data regarding stage of cancer at diagnosis available from providers. This makes targeting work to increase knowledge of signs and symptoms and promote early diagnosis in populations challenging to deliver and measure
Survivorship
There is gap in services to fully support all individuals living with and beyond cancer.
Recommendations for consideration by commissioners
General
- Ensure full implementation of the Independent Cancer Taskforce strategy 2015 -2020
- Ensure community and patient engagement and involvement is a core component of commissioning and service activity
Prevention
- Support health improvement strategies and services that address key cancer risk factors in at-risk populations. This should include smoking, diet and nutrition, alcohol, physical activity and HPV vaccination programmes.
- Ensure local strategies, health improvement programmes and communications and make explicit the link between prevention factors and cancer risk; and should target ‘at risk’ groups
- Making Every Contact Count programmes should include clear cancer prevention, screening, symptom awareness and early diagnosis messages and be extended to include the community and NHS workforce, including screening providers and secondary care.
Early diagnosis
- Increase awareness of the signs and symptoms of cancer and promote early presentation to health services in different communities where incidence of cancer is high and late presentation is an issue.
Screening
- Increase the uptake of national cancer screening programmes – in particular bowel and cervical – working with GP practices and targeting and engaging populations groups where screening rates are lowest
- Undertake a health equity audit to understand the population and practice characteristics associated with low uptake of the bowel screening programme
- Undertake engagement work to understand the factors influencing variation in access to bowel cancer screening and early presentation to inform interventions to increase screening uptake
Treatment
- Ensure sufficient capacity within services to meet referral and treatment national targets and guidelines
- Address gaps in service pathways for patients with non-specific symptoms including the piloting of a multi-disciplinary diagnostic centre.
- Work with provider trusts and Public Health England to ensure regular and timely data regarding stage of cancer at diagnosis and route to diagnosis including ethnicity data
- Undertake a health equity analysis of route to diagnosis and staging data to identify target groups / areas to improve early diagnosis of cancer
Survivorship
- Meet the requirements set out in the Independent Cancer Taskforce strategy 2015-2020 for those living with and beyond cancer including:
- Ensure full development and implementation of the Macmillan Cancer Support programme
- Implementation of the recovery package in primary and community care
- Consideration and development of recommendations from the Open Space event
