JSNA Factsheet Template Tower Hamlets Joint Strategic Needs Assessment

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1 JSNA Factsheet Template Tower Hamlets Joint Strategic Needs Assessment Executive Summary This fact sheet considers breast cancer, with a particular emphasis on breast screening and raising awareness of breast cancer symptoms as a way of detecting breast cancer early, reducing mortality and improving survival. (Other forms of cancer; lung, colorectal, prostate and cervical cancer are described in other factsheets) The incidence of breast cancer is lower within Tower Hamlets than both London and England as a whole. In Tower Hamlets breast cancer is the second most common cancer after lung cancer The mortality rate from breast cancer is slightly higher compared to the London rate but similar to the England rate, 1 year survival for breast cancer is the 6 th worst in the country and breast cancer 5 year survival is the 11 th worst in the country. The NHS Breast Screening Programme offers breast screening to all women aged 50 70, with the aim of identifying breast cancer earlier and reducing breast cancer mortality. The Improving outcomes: A strategy for cancer 2011 acknowledged that cancer screening remains an important way to detect cancer early with around a third of breast cancers now being diagnosed through screening; it has a commitment to extend the breast screening programme to women aged and by The success of the breast screening programme is monitored in terms of coverage. 1 Screening coverage is currently 67.6% (March 2011) in Tower Hamlets lower than the national minimum standard of 70%. Targeting interventions at groups with low uptake have been recognised as a way to address low attendance. Recommendations Improve breast screening coverage each year as stated in the Tower Hamlets breast cancer screening Delivery plan: by 2011/12 to reach 68% target coverage and by 2012/13 to reach 70% target coverage The implementation of extended age for breast screening and years by April Use social marketing approached to develop breast awareness interventions to increase early diagnosis of breast cancer Increasing early presentation by raising public awareness of breast cancer symptoms and the importance of seeking medical advice early 1. What is Breast Cancer? Breast cancer is a malignant tumor in the breast. Malignant cancer attacks the tissues in which it first started 1 Coverage is defined as the percentage of women resident and eligible for screening at a particular point in time who had a test with a recorded result within 3 years. Page 1 of 11

2 and has the potential to spread to other parts of the body. Breast Cancer is the most common cancer in the UK with over 45,000 women diagnosed every year. Of all cancers 31% are diagnosed breast cancers. Over 12,000 women die from breast cancer each year, making it the second most common cause of death from cancer in women. Of all cancers deaths 17% are from breast cancer. For women aged years breast cancer is the most common cause of death. The incidence of breast cancer also increases with age with 80% of cases occuring in post menopausal women. 1% of those diagnosed with breast cancer are men, which is around 300 cases each year. It is not clear exactly what causes breast cancer but there are many risk factors, some already well established and some still being investigated. Age is strongly linked with breast cancer, with the risk of breast cancer increasing with age, although some women are at higher risk of familial breast cancer, which can occur in younger women. There is a higher risk of breast cancer in the south of England and in Wales than in the north of the UK. The incidence of breast cancer is higher in white women compared with women of Asian ethnicity 2. However, there is some evidence that breast cancer occurs in black women at a younger age and occurs in more aggressive form. 3 The risk of breast cancer also appears to be higher in women from more affluent groups, compared with those from lower socio economic groups. It is more common in women who have had no or fewer children and those who have not breastfed. Modifiable risk factors include obesity, high consumption of animal fats and high fat dairy products, alcohol consumption and long term use of Hormone Replacement Therapy. 2. What is the local picture? National Compendium of Clinical and Health Indicators database has been used to identify the data below. Breast cancer incidence The most recent data for incidence (new breast cancer registrations) is from the period The incidence of breast cancer in Tower Hamlets is significantly lower than both London and England. Within Tower Hamlets there were 206 new cases of breast cancer diagnosed. There was an average of cases of breast cancer per 100,000 of the population (directly standardised rates DSR) in Tower Hamlets compared to in London and nationally 4. Nationally the incidence rate for breast cancer increased steadily between 1993 and 2005 and has decreased slightly since then. The incidence of breast cancer within Tower Hamlets has increased between and has decreased since then (Figure 1). Mortality from breast cancer The most recent data for mortality is from the period The death rate from breast cancer in Tower Hamlets is slightly higher but not significantly higher than England. Within Tower Hamlets there were 63 deaths 2 National Cancer Intelligence Network (2009) Cancer incidence and survival by Major Ethnic Groups, England, Bowen RL et al, Early onset of breast cancer in a group of British back women 2008, British Journal of Cancer 2008 Volume 98 Issue 2. Page 2 of 11

3 from breast cancer. There was an average deaths from breast cancer per 100,000 of the population (DSR) in Tower Hamlets compared to in London and nationally 5. Mortality from breast cancer among all ages in Tower Hamlets shows a significant increase from ( ) to ( ). Between 2007 and 2009 there were 35 premature deaths (people under 75 years of age) from breast cancer in Tower Hamlets. The death rate from breast cancer for women under 75 years was lower in Tower Hamlets (18.64) compared to London (19.34) and the national rate (20.05). Breast cancer survival Nationally and locally survival rates are improving. However survival is significantly higher amongst women from affluent areas compared to women living in deprived areas, and this is reflected in Tower Hamlets, so that despite lower incidence, mortality rates are not significantly lower in Tower Hamlets compared with London and England. As with all cancers, later diagnosis is a likely factor in poor survival, with one year survival being a good proxy measure for early diagnosis, and the main predictor of 5 year survival. Tower Hamlets has the 6 th worst one year survival for breast cancer in the country. Of women diagnosed between 2006 and 2008, 92.99% were alive at one year, compared to up to 99% in some parts of London. 5 year survival for women diagnosed with breast cancer between shows Tower Hamlets as having the 11 th worst 5 year survival rate in the country. Research has shown that women living in socioeconomically deprived areas have a lower incidence of breast cancer, but a lower survival than those in affluent areas. Variation in survival between areas in England has been partly explained by their differing levels of deprivation. Women from Black Caribbean and Black African ethnic groups have a lower incidence of breast cancer, but a lower survival than White women). 6 Work in North East London has identified that breast cancer survival is a particular issue across the sector, and improvements locally have not kept pace with the rest of the country. Poor one year survival is the cause of the relative poor overall survival compared to the rest of London 7. An audit of the pathways of women who have died within 1 year is being undertaken to better understand and address inequalities in survival. Research into breast awareness amongst 1,500 women in inner north east London in 2010 using the Breast 6 Davies EA, Linklater KM, Coupland VH, Renshaw C, Toy J, Park B, Petit J, Housden C, Møller H Investigation of low 5 year relative survival for breast cancer in a London cancer network British Journal of Cancer (2010) 0, doi: /sj.bjc Housden C, Park B 2009 Breast Cancer Inequalities Project Report of Findings North East London Cancer Network 8 Forbes L, Atkins L, Ramirez A Haste F, Layburn J 2010 Awareness of breast cancer among women living in inner North East London Kings College London and North East London Cancer Network Page 3 of 11

4 Cancer Awareness Measure(Breast CAM) found that just 18% of women were breast aware and that there were differences between women of different ages and from different ethnic groups in both awareness of breast symptoms and perceived barriers seeing their doctor if they suspected symptoms of breast cancer; 8 18% of black and 13% Asian women regularly checked their breasts compared with 28% white women. Older women were less confident about noticing a change in their breasts. White women were more likely to mention physical barriers to making an appointment with their doctor if they were worried (too busy, too many other things to worry about) and to worry about wasting their doctor s time. Asian women were more likely to be embarrassed, find it difficult to talk to their doctor or to be anxious about what the doctor might find. 3. What are the effective interventions? The UK Advisory Committee on Breast Cancer Screening found that the scientific evidence demonstrates clearly that regular mammographic screening between the ages of 50 and 70 years reduces mortality from the malignancy. Screening for breast cancer has successfully reduced mortality and improved survival. Women whose breast cancer is detected through screening have a significantly better one year survival (95%) than those diagnosed outside the screening programme (77%). 9 In 2000, the DH produced the NHS Cancer Plan: A plan for investment and plan for reform. This was the equivalent to a national service framework, and set out several key actions to be taken on the organization of cancer services. Building on this, the Cancer Reform strategy 2007 (CRS) has among other things focused on prevention and early detection. Furthermore the CRS made a commitment to extend the breast screening programme to women aged and by The Improving outcomes: A strategy for cancer 2011 also acknowledged that cancer screening remains an important way to detect cancer early with over 5% of all cancers being currently diagnosed via screening and this is considered to rise as the extensions to the breast screening programme progresses. Around a third of breast cancers are now diagnosed through screening, but the improving outcomes paper recognises that some groups and communities are not accessing breast screening services. Earlier detection of cancer Survival from cancer is improved when it is detected and diagnosed early through screening or through early symptomatic presentation and rapid referral for diagnosis. Evidence suggests that key actions in improving cancer survival are to increase the uptake of breast screening increase public awareness of breast cancer and the importance of seeking medical help early if symptoms are suspected identify and reduce delays in referral to specialist assessment so that treatment can start early use cancer intelligence to evaluate the effectiveness of initiatives which are known to improve survival and to treat cancer effectively 9 Screening for Breast Cancer in England past and future, February 2006 Page 4 of 11

5 A review of literature undertaken in Tower Hamlets looked at the effectiveness of various types of interventions to increase uptake the of breast screening 10. The review made the following recommendations: GP recommendations including letters, phone calls and brief verbal advice have been shown to increase uptake. Follow up by other member of the primary care team can also be effective. Reminders and second appointments for non attenders have been shown to increase uptake. Simple GP letters have been shown to be as effective as more intensive educational interventions. There is some evidence that making information about the benefits of breast screening more widely available could help to increase uptake. There is some evidence that targeted educational programmes addressing misconceptions about the causes and treatments for breast cancer and the benefits of breast screening can increase uptake in some BME groups NHS Tower Hamlets commissioned Forster (2008/9) to look at ways breast screening coverage could be improved. Forster used qualitative techniques to investigate what local women thought would encourage attendance to breast screening. Findings suggested that there was a clear distinction between the types of messages perceived to be effective among different groups of women; White women felt that peers and family members had a major influence on screening attendance whereas Bangladeshi women felt that GP endorsement was perceived as a major influence on screening attendance. The National Awareness and Early Diagnosis Initiative (NAEDI) commissioned Audience, a social marketing company to conduct qualitative research to look at the awareness and perception of breast cancer. Findings suggest that women need support in breast checking behavior through various channels such as; network of survivors and ambassadors to spread the word in a variety of ways. Also raising positivity about early diagnosis, better treatments and survival rates, pointing to success stories which were considered as more effective than statistics. 10 Legerton P, Trenchard Mabere E (2006). Breast screening uptake: a review of the determinants of breast screening uptake and the effectiveness of interventions to increase uptake. Directorate of Public Health, Tower Hamlets PCT Page 5 of 11

6 4. What are we doing locally to address this issue? 1. Raising public awareness To date, evidence of effectiveness in increasing early diagnosis of cancer is limited, and interventions that aim to increase population awareness and remove delays in referral are being tested and evaluated. In 2010, a successful joint application by the 3 inner north east London PCTs with Waltham Forest PCT resulted in a 400,000 Department of Health NAEDI grant; working with Barts and the London NHS Trust communications department, the project is taking a social marketing approach to increasing early diagnosis of lung and breast cancer, as are likely to have the greatest impact on overall cancer survival and mortality. It will run from the spring of 2011 for a year, alongside a similar project in outer NE London targeting colorectal cancer; findings and resources will be shared across the whole sector. The local project targets groups where there is a highest risk of breast cancer and of late presentation. Interventions will aim to increase breast awareness in white and black women over 40, amongst whom the incidence of breast cancer is highest. This will be through practice nurses, radiographers within the breast screening service and through community organisations, ensuring inclusion of women over 70, where survival is low. 2. Breast cancer screening Breast screening is offered to all women aged 50 to 70 every 3 years and this will begin to increase to 47 to 73 years from Breast screening coverage rates in Tower Hamlets (the proportion of eligible women in the population screened in the last 3 years) has been consistently lower than both London and national rates. However there was a 10% increase in coverage (to 63.5% in March 2009) following investment in a range of evidence based interventions and based on the findings of social marketing research. Local data indicates that the PCT target of 67% for was achieved in December 2010 when reported coverage reached 67.1%. The longer term target is to achieve the national minimum standard coverage for women aged 53 to 70 years of 70% by March 2012 and 75% by March High impact interventions to improve screening coverage are: systematic evaluation of the impact of different interventions which have contributed to improving coverage of breast cancer screening to inform future investment. Continued stronger commissioning and performance management of the screening service with contractual arrangements based on a tariff (i.e. cost per screening) in order to incentivise the service to increase uptake. The specification includes providing second appointments for people who have not attended, and increased accessibility and flexibility, for example through evening and weekend appointments. Contractual obligations include the provision of accurate and timely data. use of a locally designed invitation letter and contact by trained community phone callers, the bi lingual advocacy service and text message reminders. Development of an online booking facility. increased engagement with GP practices through the GP Cancer Screening Lead and a team of four cancer locality facilitators who also co ordinate health promotional activities and wider awareness raising initiatives, working with commissioned community groups. follow up of women who do not attend through effective phone calling by bi lingual health advocates and commissioned community providers working in GP practices and where it is helpful, using transport from GP surgeries. In 2009 a Local Enhanced Service (LES) for breast screening was introduced as an incentive for GP practices to improve their breast screening coverage. a new Network Improved Service (NIS)to replace Page the 6 of LES 11 is to be introduced by April 2011; this will provide additional incentives to GP Networks (groups of practices based on the Tower Hamlets Local Area

7 Partnership (LAP) boundaries) to increase their coverage for breast, cervical screening and bowel screening by ensuring that specified evidence based interventions are undertaken e.g. list cleaning, endorsing screening and following up invited people who have not attended; maximum payments will be made for achieving target coverage rates for breast screening. 3. Early Diagnosis A one stop assessment clinic for breast symptoms commenced at Barts and the London NHS Trust in January 2010, and 100% of Tower Hamlets women with breast symptoms referred by their GP are now assessed within 14 days of referral. The JSNA fact sheet on Cancer contains further information on cancer treatment and care. 5. What evidence is there that we are making a difference? Over a 4 year period in Tower Hamlets there has been more than a 14% increase in breast screening coverage from 53.4% in 2007 to 67.6% in 2011 (figure 2). The most recent data for shows that 1 year survival from breast cancer is improving from being the lowest to the 6 th lowest in the country. 6. What is the perspective of the public on services? The National Cancer Patient Experience Survey carried out in 2010 compared cancer patient s experience along the whole pathway from referral from the GP to treatment and care at the Bart s and The London compared to national responses for the most common cancers. For Breast cancer the most striking difference in terms of lower patients satisfaction at Bart s and The London compared to experiences nationally were relating to the communication about the diagnostic tests that were carried out, deciding treatment choice, support for people with cancer, confidence and relationship with hospital doctors and hospital care as a day patient/outpatient. 7. What are the priorities for improvement over the next 5 years? Reduce mortality from breast cancer, and reduce the inequalities in breast cancer survival and mortality between Tower Hamlets and the rest of the country through the following actions: Increase public awareness of breast cancer and the importance of seeking medical help early if symptoms are suspected Identify and reduce delays in referral to specialist assessment so treatment can start early Increase coverage of breast screening Ensuring that the Central East London Breast Screening Service (CELBSS) is operating to a quality standard for all eligible residents of Tower Hamlets. 8. What more do we need to know? We need to collate more information regarding the characteristics of the women that are not attending for breast screening. The slope indicator analysis will contribute to more targeted work to increase attendance for breast screening. 9. Key Contacts & Links to Further Information Sukhjit Sanghera Public Health Strategist, breast screening lead, NHS Tower Hamlets. sukhjit.sanghera@thpct.nhs.uk Page 7 of 11

8 Date updated: Updated by: Next Update Due: Page 8 of 11

9 Figure 1 Breast cancer incidence, all ages ( to ) Source: NCHOD Figure 2: Mortality trend data for breast cancer, All ages (Source: NCHOD) Page 9 of 11

10 Figure 3 Figure 4 NHS Tower Hamlets Target Trajectory Year Current 09/10 10/11 11/12 12/13 13/14 14/15 Target 56% 64% 67% 70% 72% 74% 75% Result 63.5% 65.9% 67.6% Page 10 of 11

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