Cancer in Cumbria Jennifer Clay Public Health Intelligence Analyst November 2008

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1 Cancer in Cumbria Jennifer Clay Public Health Intelligence Analyst November 2008

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3 Table of contents: Summary... 4 Introduction..6 Cancer Incidence 7 Cancer Mortality Cancer Survival 22 Appendices Appendix 1 26 Appendix Appendix 3 30 Appendix 4 32 Appendix

4 Summary On average each year in Cumbria: 2,600 people are diagnosed with cancer 1,500 people die from cancer 6,000 people are living with cancer Projected annual increase of 500 registrations (incidence) in population aged 65 and over by 2015 increasing by a further 900 by 2031 Cumbria has statistically significantly higher levels of: Cancer mortality: Stomach cancer Colo-rectal cancer Prostate cancer Bladder cancer (men) Brain cancer (women) Is the second major cause of death after coronary heart diseases Causes one in four deaths Lung cancer is the major cause of cancer deaths accounting for almost one in four deaths from cancer Projected 10% growth in male deaths from cancer by 2017 One third of all cancer deaths are to someone aged below 75 years 160 premature deaths will be averted should Cumbria achieve its Saving Lives target Premature cancer mortality is statistically significantly higher in the most deprived parts of Cumbria Annually cancer accounts for 8,000 years of lost life the equivalent of 106 people On average 11 years of life are lost to cancer Cumbria has statistically higher levels of mortality from: Cancer in men Colo-rectal cancer Mesothelioma (men) Testis Ovary Cancer survival in Cumbria: 38% of men are alive 5 years after diagnosis 51% of women are alive 5 years after diagnosis Over 80% of women are alive 5 years after being diagnosed with breast cancer 4

5 Nationally pancreatic cancer has the worst survival rate at 3% Nationally testicular cancer has the highest survival rate at 97% People living in the most deprived areas are less likely to survive cancer There is a 53.3% cancer survival rate for the more affluent parts of Cumbria Cancer survival in the most deprived areas of Cumbria is 39.2% 5

6 Cancer in Cumbria Introduction On average each year in Cumbria: 2,600 people are diagnosed with cancer 1,500 people die from cancer An individual s risk of developing cancer depends on many factors, including age, lifestyle and genetic make-up. It is estimated that up to half of all cancers cases diagnosed in the UK could be avoided if people made changes to their lifestyles, such as stopping smoking, moderate alcohol intake, maintaining a health bodyweight and avoiding excessive sun exposure. More than a quarter of all deaths from cancer (including almost 90% of lung cancer deaths) are linked to tobacco smoking. Estimates suggest that, in the UK, up to 13,000 cases of cancer could be avoided if no-one exceeded a body mass index (BMI) of 25. Research suggests that each of the following increase the risk of certain cancers: alcohol consumption, a low fibre diet, low consumption of fruit and vegetables, high consumption of red and processed meats and higher intake of salt or saturated fats. Excessive exposure to UV radiation (from the sun or sun beds) is the most important modifiable risk factor for skin cancers. A small number of infectious agents, especially certain viruses, play a key role in causing certain types of cancer. It is estimated that inherited factors cause up to 10% of all cancers. Factors such as the age at which a woman has her first child and number of children, affect the risk of the most common female cancers (Cancer Research UK). This is the second report examining cancer within Cumbria. The data used has been collated from several sources including: the Office for National Statistics, North West Cancer Registry, National Cancer e-atlas and Cancer Research UK. Cancer incidence (new cases), mortality and survival will be detailed, with particular emphasis being placed on those cancer sites targeted within World Class Commissioning where better detection and treatment will impact on premature mortality from: lung, breast and colo-rectal cancer. There are over two hundred different types of cancer. These can be malignant or benign. This report will be looking at those cancers classed as malignant and will be referred to as cancer(s) or malignant neoplasm(s) (MN). Cancers are coded using the International Classification of Diseases (ICD10) system with malignant neoplasms falling within the range C00 to C97. Due to the under reporting nationally of non-melanoma skin cancer (C44), this grouping has been excluded from the incidence analysis. Cancer Incidence 6

7 Overall it is estimated that more than one in three people will develop some form of cancer during their lifetime. This compares to an estimated risk of 1 in 27 for people aged up to 50 years. Estimates of the life time risk of developing some of the most common cancers are shown in table 1. These estimates assume no change in the current incidence rates and should be used as an approximate guide only. Table 1: Risk of being diagnosed with cancer by age 65and over a lifetime, England & Wales 1997 % of cohort that develop cancer Males Females by age 65 over lifetime lifetime risk by age 65 over lifetime lifetime risk Bladder in in 79 Brain and CNS in in 207 Breast in 9 Cervix in 116 Kidney in in 162 Large bowel in in 20 Leukaemia in in 127 Lung in in 23 Melanoma in in 117 Multiple myeloma in in 204 Non-Hodgkin lymphoma in in 83 Oesophagus in in 95 Ovary in 48 Pancreas in in 95 Prostate in 14 Stomach in in 86 Uterus in 73 Source: Cancer Research UK Cancer occurs predominantly in older people as shown by the differences between the above cohorts. For example a woman s risk of developing breast cancer by age 65 is less than 6% but the overall lifetime risk is 11%. For men there is a less than 2% risk of developing lung cancer by age 65; this increases to 8% over a lifetime. Bearing in mind that life expectancy is increasing with more elderly people alive today than ever before Cumbria can expect to see an increase in the number of cancers diagnosed each year as a result of the aging population. Cancer data are collected by nine independent regional registries in England. Due to the pattern of patient referral within Cumbria the Primary Care Trust deals two registries. These are: the Northern and Yorkshire Registry, collecting details of patients residing in the north of the county, whilst the North Western Registry deals with those patients in the south of Cumbria. Registry data are dynamic the files are always open and records may be amended when more accurate data becomes available. Consequently figures can change over time so there may well be small discrepancies especially when comparing data from earlier reports. The timeliness of 7

8 Registry data are affected by the many checks carried out on an individual record, therefore the latest data available are for The Northern and Yorkshire Registry share data for North Cumbria with their colleagues in the North Western Registry enabling them to present data for the North West Region in its entirety. Figure 1: Cumbria cancer incidence trend Registraitions (number) Figure I shows the cancer incidence trend for Cumbria. Over the ten year period there has been a 17% increase in the number of reported cases rising from 2,354 cases in 1996 to 2,755 for Average annual age specific incidence rates for Cumbria are shown for the period, 2003 to 2005 in figure 2. This clearly illustrates the association of cancer with an older population. Men aged 65 and over account for 70% of all new registrations. This gives a crude rate of 2,205.3 per 100,000 males aged 65 plus whereas their younger counterparts aged below 65 years have a rate of per 100,000. Figure 2: Cumbria, average annual age specific cancer incidence rate, Women aged over 65 years 4,000 Males account for 60% of all new 3,500 Females registrations. This gives a 3,000 crude rate of 1,516.3 per 2, ,000 females aged 65 and 2,000 over. This compares with a 1,500 rate of per 100,000 1,000 women for the younger cohort. 500 The national cervical and 0 breast screening programmes have lead to the earlier Age group detection of these cancers and account for the higher incidence rate in the younger female population. Screening coverage as at 31 st March 2007 reveals that 82% of women in Cumbria aged between 25 and 64 years have been checked for cervical cancer, this compares to 79% nationally. Figures for breast cancer show that 79% of women locally aged between 53 and 64 years have been screened, this is above the national average of 76%. Age specific incidence rate/100, Number (000's) Cumbria Population projections: persons aged 65 and over (2006 based) Figure 3: Cumbria population (65+) projection The projected increase in the elderly population must be of concern to those planning services for the future. Figure 3 illustrates the projected growth in the Cumbria population aged over 65 8

9 years. This is not an exact science but projections suggest that by 2031 the older population in Cumbria will have grown by some 74%. Even just looking ahead to 2016 there may well be a growth of 28% for this cohort. Looking again to the future, projecting what will happen with regards to the number of new cancer cases is difficult. Applying current rates (based on 1,811 registrations) to the projected growth in the population aged 65 plus suggests an additional 500 cases by 2015, increasing by a further 900 registrations by 2031 as illustrated in figure 4. Figure 4: Projected growth in cancer registrations, population aged 65 and over Number 3,300 3,100 2,900 2,700 2,500 2,300 2,100 1,900 1,700 1, Moving on from the incidence of cancer, figure 6 examines the prevalence (new and existing cases) of cancer in the community. The introduction of the Quality and Outcomes Framework (QOF) gives for the first time the number of people living with a specific condition. Unfortunately QOF data are not available for specific age groups so figure 5 shows the projected prevalence for the total population. Latest figures for 2007/08 show that 1.2% of the population of Cumbria were living with a cancer. Applying this rate to the projected populations shows a 13% increase on current numbers by Figure 5: Projected cancer prevalence, total population Number 6,800 6,700 6,600 6,500 6,400 6,300 6,200 6,100 6,000 5,900 5,800 5, Projected cancer prevalence in Cumbria population (based on 2007/08 QOF rate of 1.2%) 6,722 The data used in figure 5 can be found in appendix Table 2 shows the standardised registration ratios (SRRs) for Cumbria for the period 2001 to These allow local incidence to be compared with the average rate for England (normally 100). A statistical calculation (confidence interval) is applied to 9

10 the resulting SRR which indicates if the figure is higher or lower than would be expected. Those sites that are statistically significantly higher or lower when compared to England are indicated by the use of sad (bad) or happy (good) faces. The table shows that cancer registrations for women are significantly higher: this can be interpreted as women in Cumbria having a statistically significant higher incidence rate for all cancers which is 3% greater than expected. On the other hand men in Cumbria have a significantly lower rate: this would be interpreted as a statistically significant lower rate which is 4% lower than expected. Table 2: Cumbria Standardised Registration Ratios, Cumbria Males Females Site ICD10 Registrations SRR Registrations SRR All cancers ex nmsc C00-C97xC MN Oesophagus C MN Stomach C MN Colon/Rectum C18-C MN Pancreas C MN Trachea, Bronchus, Lung C33-C Mal Melanoma Skin C Mesothelioma C MN Female Breast C MN Cervix Uteri C MN Uterus C MN Ovary C MN Prostate C MN Testis C MN Kidney ex Renal Pelvis C MN Bladder C Brain C Non-Hodgkin's Lymphoma C82-C Leukaemia C91-C Note: 1. Significant at p<0.05. This means we can be 95% certain that the particular SRR is higher or lower than the national level. 2. ".." denotes that data have been suppressed where the number of events is less than 5 or where subtraction from total may be disclosive. Source: Calculated in-house by Performance & Intelligence Section Cumbria has significantly higher incidence of: Stomach cancer Colo-rectal cancer Prostate cancer Bladder cancer (men) Brain cancer (women) Looking towards the district councils that constitute Cumbria table 3 shows those cancers that are significantly higher or lower. A more detailed breakdown of the data can be found in appendix 2. The National Cancer-Atlas can be found at: 10

11 this resource can be used to obtain trend data for local authorities and uses directly standardised rates (DSRs) to compare areas. The use of DSRs allows comparisons to be made between different populations. Direct standardisation takes account of age differences between different populations. Table 3: Statistically significant SRRs, Barrow Allerdale in Furness Carlisle Copeland Eden South Lakeland Significantly higher M F M F M F M F M F M F All cancers Stomach Colo-rectal Mesothelioma Uterus Ovary Prostate Kidney Significantly lower All cancers Lung Mal Melanoma Skin Cervix Kidney Leukaemia Figure 6: Projected increase in cancer incidence by 2015 Earlier the report looked at the All cancers projected number of new cancer Cumbria 31% registrations in the older South Lakeland 41% population. Figure 6 shows the projection for all cancers in the Eden 49% population. Again caution should Copeland 46% be used when quoting these Carlisle 9% figures as they are merely a projection of current numbers. By Barrow in Furness 32% 2015 Cumbria may see a 31% Allerdale 24% increase in the number of 0% 10% 20% 30% 40% 50% registrations. The spread of these is not equally divided across the county. Eden may well see a 50% increase in the number of cases. Currently Eden does have a greater proportion of older residents. At the other end Carlisle is projected to have the lowest increase at 9%. For those cancers featured in the World Class Commissioning document figures 7 and 8 show the projections for colo-rectal cancer and female breast cancer. With the exception of Allerdale projections for lung cancer show a decline in the number of registrations and are not shown here. 11

12 Increases are projected for both cancers with Barrow in Furness carrying the highest increase for colo-rectal cancer with an anticipated growth of 64%. Breast cancer shows the most startling increase probably due to the breast screening programme with a 76% increase overall, Copeland is projected to have a massive increase of 162%. Figure 7: Projected increase in colo-rectal cancer by 2015 Colo-rectal cancer Cumbria 33% South Lakeland 4% Eden Copeland 50% 52% Carlisle 26% Barrow in Furness 64% Allerdale 36% -3% 17% 37% 57% 77% Figure 8: Projected increase in breast cancer by 2015 Female breast cancer Cumbria South Lakeland Eden 53% 76% 84% Copeland 162% Carlisle Barrow in Furness Allerdale 71% 76% 71% The figures the projections are based on can be found in appendix 3. 12

13 Cancer Mortality Cancer is the second major cause of death accounting for 26% of all deaths locally; 1,462 people were registered as dying from cancer in This is just below the national average of 27% of all deaths. Figure 9 illustrates the top 5 cancer sites within Cumbria accounting for over half of all cancer deaths. Lung cancer is responsible for the greatest proportion of cancer deaths with one in four men and one in five women dying from the disease. In the female population breast cancer is the second major cause of death from cancer and is responsible for almost one fifth of deaths in this group. For men colo-rectal cancer is the next major cause of death and is responsible for 12% of male cancer deaths. Figure 9: Cumbria - major cancer sites Males Females 44% 5% 7% 8% 25% 12% Lung Colo-rectal Prostate Oesophagus Pancreas Other sites 44% 3% 5% 8% 21% 18% Lung Breast Colo-rectal Pancreas Oesophagus Other sites The cancer mortality trend is show in figure 10. Slightly more men die from cancer compared to women. Looking ahead projections suggest a 10% increase in the number of male deaths by 2017 with a small increase of 1% for women. Figure 10: Cumbria cancer mortality trend Cumbria : Cancer mortality trend Death (number) Male Female Figure 11 compares the cancer incidence and mortality rate trend. A person diagnosed with cancer may not necessarily die from cancer, if they do, it may not be 13

14 Figure 11: cancer trends crude rate, persons rate per 100, Cumbria: comparison between cancer incidence and mortality % 80% 60% 40% 20% 0% % 2006 Incidence Deaths : Cancer deaths by age group - as a percentage of all deaths 14% 24% 36% in the same year of diagnosis. The table shows that more people are diagnosed each year with some form of cancer than die from a cancer. On average each year there are 1,000 more cancer registrations than deaths. When looking at age at death, in Cumbria on average one third of all deaths are to people aged below 75 years of age. Of these cancer is responsible for two fifths as shown in figure 12. Cancer deaths are more or less equally split 50/50 when looking at deaths below/above 75 years. The Government set a target through Saving Lives, Our Healthier Nation to reduce the number of deaths from cancer for persons aged under 75 years by 20%. Figure 12: Cumbria - age at death Table 4 shows baseline data, progress to date and target rates for reducing premature mortality from cancer. The table is supported by graphs shown in figure 13 displaying the yearly directly standardised mortality rate. If current trends continue all districts within Cumbria will achieve their target Cancer death Other cause 48% 42% 27% 14% 27% 41% < All Age group ages rate and 160 lives will have been saved. Eden has already exceeded its target rate of 106 deaths per 100,000 people. Table 4: Saving Lives, Our Healthier Nation Target Baseline Progress Target 1995/ Area DSR Average Annual Deaths Number DSR Average Annual Deaths Number DSR Average Annual Deaths Number Cumbria Allerdale Barrow-in-Furness Carlisle Copeland Eden South Lakeland <75 14

15 Figure 13: Premature mortality trend for cancer DSR/100,000 DSR/100,000 DSR/100,000 DSR/100,000 DSR/100,000 DSR/100,000 DSR/100, Eng & Wales Cumbria Target Eng & Wales Cumbria Allerdale Target Cumbria Allerdale Barrow in Furness Eng & Wales Cumbria Barrow-in-Furness Target Eng & Wales Cumbria Carlisle Target Eng & Wales Cumbria Copeland Target Eng & Wales Cumbria Eden Target Eng & Wales Cumbria South Lakeland Target Carlisle Copeland Eden South Lakeland

16 To give some idea of cause of death table 14 shows premature mortality from cancer by broad ICD10 headings. More detailed discussion re individual sites will be discussed later within the report. Figure 14: Cancer mortality by chapter heading, Cumbria % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% < Digestive Respiratory Unspecified Lymphoid & blood Breast Male genital Urinary Female genital Brain Mesothelial Skin Mouth and throat Independent Thyroid/endocrine Bone All cancers Deprivation and lifestyle contributes to the risk of developing cancer when looking at health inequalities across Cumbria. Figure 15 shows the directly standardised premature mortality rate for selected cancers by deprivation quintile (IMD 2007) within Cumbria. Figure 15: Health inequalities and premature mortality selected cancer sites DSR/100, All cause premature mortality Quintile DSR/100, Colo-rectal cancer, premature mortality Quintile DSR/100, Lung cancer, premature mortality DSR/100, Female breast cancer, premature mortality Quintile Quintile When compared to the Cumbria average those people living in the worst deprivation (quintiles one and two) have a statistically significantly higher mortality rate from cancer when compared to their more affluent neighbours who have a significantly 16

17 lower rate. The same pattern is echoed in the lung cancer chart. Undoubtedly this re-enforces the link between smoking and those living in the poorer areas. Deaths from colo-rectal cancer and female breast cancer are significantly higher in quintile 1. Another way of looking at premature mortality is to examine the number of years of lost life (YLL). Table 5 examines the number of years by chapter heading. Cancer is responsible for one third of all deaths when looking at mortality in this manner. For the period 2005 to 2007 there were 2,186 cancer deaths in people aged below 75 years of age. In this cohort each person looses an average of 11 years of life. Converting the 24,000 years to actual people would result in 320 lives. These figures are broken down by localities in figure 6. Of the districts Carlisle fares worst with the greatest number of deaths and highest average years of lost life. Table 5: Cumbria premature mortality Chapter YLL Equates to (people) Malignant neoplasm 24,032 34% 320 Diseases of the circulatory system 15,190 22% 203 External cause 12,510 18% 167 Diseases of the digestive system 5,166 7% 69 Diseases of the respiratory system 4,008 6% 53 Diseases of the nervous system 2,844 4% 38 Other causes 6,588 9% 88 Total 70, Table 6: Premature mortality from cancer Area Deaths YLL Average YLL Equates to (people) Allerdale 453 5, Barrow in Furness 337 3, Carlisle 469 5, Copeland 333 3, Eden 187 1, South Lakeland 407 4, Cumbria 2,186 24, In terms of individual cancer sites figures 16 and 17 show the years of lost life for males and females. Here the total numbers of years of lost life for the period 2005 to 2007 are divided by the total number of deaths, resulting in an average number of years of lost life for every death. 17

18 Figure 16: Cumbria average number of YLL, males Premature mortality from cancer : Males MN Testis MM Skin MN Brain Non-Hodgkin's Lymphoma Other cancer MN Kidney ex Renal Pelvis Leukaemia MN Oesophagus All cancers MN Trachea, Bronchus & Lung MN Stomach MN Colon/Rectum Pancreas Mesothelioma MN Bladder MN Prostate Average number of years of lost life Although the number of deaths from testicular cancer is low (less than five) those deaths have resulted in the maximum loss of life - average of 18 years. Figure 17: Cumbria average number of YLL, females Premature mortality from cancer : Females 2005/2007 MN Cervix Uteri MM Skin MN Brain MN Female Breast Leukaemia All cancers MN Ovary Non-Hodgkin's Lymphoma MN Colon/Rectum MN Oesophagus Other cancer MN Kidney ex Renal Pelvis MN Trachea, Bronchus & Lung Mesothelioma Pancreas MN Stomach MN Uterus MN Bladder Average number of years of lost life Cervical cancer is responsible for the maximum loss of life in women - average of 23 years. In both instances this can be interpreted as the cancer developing in a 18

19 younger person, resulting in an increase in the number of years of lost life or in other words - dying younger. Ironically both diseases are treatable and curable. This should serve as a reminder for men of the importance of self examination and, for women to attend their cervical screening examination. In second place another preventable and treatable disease: malignant melanoma of the skin in both men and women, results in an average of 18 years of lost life for each death. Grouping together total number of years of lost life from cancer, reveals that lung cancer accounts for some 23% of the total in men, whilst breast cancer at 24% is the major cause of lost life in women. Listed below are those sites with the greatest number of years of lost life: Lung cancer : 4,854 years Female breast cancer : 2,899 years Colo-rectal cancer : 2,226 years Oesophageal cancer : 1,159 years Brain cancer : 1,129 years Ovarian cancer : 958 years Pancreatic cancer : 941 years Other sites : 9,867 years Moving on from this topic a more in depth analysis of cancer mortality was undertaken. Similar to standardised registration ratios, standardised mortality ratios (SMRS) have been calculated. Table 7 shows the rates for Cumbria by sex; those sites that are statistically significantly higher or lower when compared to England and Wales are again indicated by the use of sad or happy faces. At the time these rates were calculated detailed national data for 2007 were not available. Cumbria has significantly higher mortality rates for: All ages All causes (men) Colo-rectal cancer Mesothelioma (men) Testis Ovary Under 75 years Mesothelioma (men) Colo-rectal cancer (women) 19

20 Table 7: Cumbria Standardised Mortality Ratios, Males All ages Under 75 years Site ICD No. Deaths SMR Deaths SMR All cancers C00-C97 2, , MN Oesophagus C MN Stomach C MN Colon/Rectum C18-C MN Pancreas C MN Trachea, Bronchus, Lung C33-C Mal Melanoma Skin C Mesothelioma C MN Prostate C MN Testis C MN Kidney ex Renal Pelvis C MN Bladder C MN Brain C Non-Hodgkin's Lymphoma C82-C Leukaemia C91-C Females All cancers C00-C97 2, , MN Oesophagus C MN Stomach C MN Colon/Rectum C18-C MN Pancreas C MN Trachea, Bronchus, Lung C33-C Mal Melanoma Skin C Mesothelioma C MN Female Breast C MN Cervix Uteri C MN Uterus C MN Ovary C MN Kidney ex Renal Pelvis C MN Bladder C MN Brain C Non-Hodgkin's Lymphoma C82-C Leukaemia C91-C Note: 1. Significant at p<0.05. This means we can be 95% certain that the particular SRR is higher or lower than the national level. Source: Calculated in-house by Performance & Intelligence Section Statistically significant SMRs for district councils are found in table 8. A more detailed breakdown of the data can be found in appendices 4 and 5. 20

21 Table 8: Statistically significant SMRS, Barrow Allerdale in Furness Carlisle Copeland Eden South Lakeland All ages M F M F M F M F M F M F Significantly higher All cancers Stomach Colon/Rectum Trachea, Bronchus, Lung Mesothelioma Cervix Uteri Prostate Testis Kidney ex Renal Pelvis Significantly lower All cancers Pancreas Trachea, Bronchus, Lung Leukaemia Under 75 years Significantly higher All cancers Oesophagus Stomach Colon/Rectum Pancreas Trachea, Bronchus, Lung Mesothelioma Testis Significantly lower All cancers Trachea, Bronchus, Lung Bladder

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