Lung Cancer in the West Midlands

West Midlands Cancer Intelligence Unit Lung Cancer in the West Midlands Supporting the fight against cancer through timely, high quality information provision R11/05 November 2011 0 Author: TE Last updated: 19/04/10 Version: 1.1

For any enquires regarding the information in this report please contact: Dr Tim Evans West Midlands Cancer Intelligence Unit Public Health Building The University of Birmingham Birmingham B15 2TT Tel: 0121 414 4274 Fax: 0121 414 7712 E-mail: tim.evans@wmciu.nhs.uk Copyright WMCIU 2011 This report is available to download in pdf form from our website http://www.wmciu.nhs.uk Author: TE/CB/JB/GL/SV Last updated: 20/10/11

TABLE OF CONTENTS EXECUTIVE SUMMARY... 1 1.0 INTRODUCTION... 2 1.1 Lung Cancer... 2 1.2 Risk factors... 2 1.3 Health Geography in the West Midlands... 3 1.4 The West Midlands Cancer Intelligence Unit... 3 2.0 INCIDENCE AND MORTALITY... 4 2.1 Lung Cancer Incidence and Mortality in England and the West Midlands... 4 2.2 Lung Cancer Incidence Trends in the West Midlands... 6 2.3 Variation in Lung Cancer Incidence with Deprivation... 7 2.4 Lung Cancer Incidence in the Top Tier Local Authorities... 7 2.5 Lung Cancer Mortality Trends in the West Midlands... 8 2.6 Variation in Lung Cancer Mortality with Deprivation... 9 2.7 Lung Cancer Mortality in the Top Tier Local Authorities... 9 3.0 SURVIVAL... 11 3.1 Trends in Survival in the West Midlands... 11 3.1.1 Lung cancer survival in the West Midlands by gender... 11 3.1.2 Lung cancer survival trend by morphology... 11 3.1.3 Variation in Lung Cancer Survival with Deprivation... 13 3.2 Lung Cancer survival in the Top Tier Local Authorities... 13 3.3 Variation in Lung Cancer Survival with Trust of Surgery... 14 4.0 STAGE AT DIAGNOSIS... 15 4.1 Histological Confirmation of Lung Cancer... 15 4.2 Variation in Stage Completeness with Trust First Seen... 16 5.0 REFERRAL PATTERNS... 17 5.1 Referral Patterns to Acute Trusts... 17 5.2 Referral Patterns of Trust First Seen to Trusts of Surgery... 17 6.0 TREATMENT... 18 6.1 Types of Treatment... 18 6.2 Lung Cancer Treatment Patterns... 18 6.2.1 Variation in Lung Cancer Treatment with Morphology... 18 6.2.2 Variation in Lung Cancer Treatment with Age... 19 6.2.3 Variation in Lung Cancer Treatment with Deprivation... 19 6.2.4 Variation in Lung Cancer Treatment with Trust Where First Seen... 20 6.2.5 Treatment in Each Top Tier Local Authority... 21 6.3 Clinical Lines of Enquiry Measures... 21 6.3.1 Percentage undergoing surgical resection by Trust where first seen... 22 6.3.2 Small cell lung cancer patients receiving chemotherapy by Trust where first seen 22 6.4 30-day Surgical Mortality... 23 7.0 SURGICAL CASELOAD... 24 7.1 Trust caseload... 24 7.2 Consultant Surgical Caseload... 24 APPENDIX... 25 THE WEST MIDLANDS CANCER INTELLIGENCE UNIT... 27 Author: TE/CB/JB/GL/SV Last updated: 20/10/11

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EXECUTIVE SUMMARY INCIDENCE AND MORTALITY In 2009, 3,380 cases of lung cancer were diagnosed in the West Midlands, and 2,919 people died of the disease. Lung cancer is more common in males than in females and is a disease of the elderly; very few cancers are diagnosed in the under 50s.. Trends in lung cancer incidence and mortality are different for males and females. In males, incidence and mortality are both decreasing, but in females incidence is increasing. Lung cancer incidence and mortality vary with geography, and are highest in areas of high deprivation. Birmingham and Stoke-on-Trent have significantly higher lung cancer incidence and mortality for both males and females. Incidence is lowest in less deprived rural local authorities such as Warwickshire. SURVIVAL Lung cancer survival rates are poor compared with other cancers, with fewer than one in ten patients surviving 5 years after their diagnosis. However, 1-year survival rates have improved significantly with time. A statistically significant survival gap has developed between males and females, with females having better survival. This gender gap has been widening over time. Lung cancer morphology makes a significant difference to survival rates. Survival from non small cell lung cancer is significantly better than that from small cell lung cancer. Surgical treatment is a major predictor of good outcomes for lung cancer, with 1-year survival rates of approximately 70% for surgically treated cancers, compared to 30% for all lung cancers. This is likely to be due to the nature of the cohort selected for surgical treatment as well as the efficacy of the treatment. STAGE AT DIAGNOSIS Staging data were provided to the WMCIU for only 60% of lung cancers, with only one Trust providing a stage for more than 80% of their patients. REFERRAL PATTERNS Most lung cancer patients are diagnosed in Trusts in the cancer network where they live. Lung cancer patients are referred to four main Trusts for surgery in the region; the University Hospitals Coventry & Warwickshire NHS Trust, The Royal Wolverhampton Hospitals NHS Trust, the University Hospital of North Staffordshire NHS Trust and the Heart of England NHS Foundation Trust. TREATMENT The proportion of patients receiving surgical treatment decreases with age. Correspondingly, the proportion of patients recorded as receiving no treatment rises rapidly with age. The Burton Hospitals NHS Trust had a high proportion of patients who had no treatment recorded and a low proportion of patients receiving surgery. This may be due to the incomplete provision of treatment data for patients who are referred on to out of region Trusts. There were no significant differences in 30-day surgical mortality between the four main Trusts performing surgical resections SURGICAL CASELOAD Lung cancer surgery is specialised in the West Midlands, with surgeons in the main Trusts of surgery often performing over 30 operations annually. However, 6 consultants in these Trusts each performed fewer than 10 lung cancer resections in 2009. Author: TE/CB/JB/GL/SV Page 1 of 27 Last updated: 20/10/11

1.0 INTRODUCTION 1.1 Lung Cancer Lung cancer is one of the four most common cancers in England, and it is the cancer responsible for the greatest number of deaths in England annually. This report presents an analysis of lung cancer incidence, mortality and survival in the West Midlands. It also presents data on referral and treatment patterns. Lung cancer is defined for the purposes of this report as an invasive malignant neoplasm of the trachea, bronchus or lung (ICD 10 codes C33 and C34). Figure 1.1 indicates the sites defined as lung cancer in this report. Other definitions of lung cancer could include mesothelioma of the pleura (ICD10 code C45.0), and other malignant neoplasm of the pleura (ICD 10 code C38.4). Neither mesothelioma nor other cancers of the pleura are included in this report, and, as the numbers of these cancers are very small, their exclusion or inclusion makes little difference. Lung cancer can be divided into two main types; non small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Figure 1.1: Lung cancer sites (pleura is included purely for illustrative purposes) 1 Pleura Trachea Lung Upper lobe Middle lobe Bronchus Lower lobe 1.2 Risk factors A number of risk factors can influence the likelihood of an individual developing lung cancer, but the most established cause is smoking. Approximately 90% of lung cancer deaths in males and 83% in females are caused by smoking 2. The risk of developing lung cancer is influenced by the duration of smoking and the level of consumption 3. Passive smoking also increases the risk of 1 Lung diagram adapted from: http://www.patient.co.uk/diagram/lungs.htm (Accessed 29/07/2011) 2 Cancer Research UK Cancer Stats quoting http://www.ctsu.ox.ac.uk/~tobacco/ 3 Cancer Research UK Cancer Stats quoting http://www.ncbi.nlm.nih.gov/pubmed/15668706?dopt=abstract Author: TE/CB/JB/GL/SV Page 2 of 27 Last updated: 20/10/11

developing lung cancer; non-smokers in a smoking household increase their risk of lung cancer by around a quarter 4. There is a suggested genetic link (though no types of inherited lung cancers have been identified); families with a history of lung cancer with cases in younger individuals are at increased risk of developing lung cancer. The naturally occurring gas radon increases lung cancer risk, especially among smokers. Other risk factors include heavy exposure to industrial carcinogens and air pollutants, such as diesel exhaust, asbestos, silica, polycyclic aromatic hydrocarbons and nitrogen oxides 5. 1.3 Health Geography in the West Midlands This report covers cancers diagnosed or treated within the West Midlands. A document containing information about the Cancer Networks, Local Authorities and acute Trusts providing cancer services in the West Midlands is available on the WMCIU s website 6. For easy reference, a table of data containing population characteristics for the top-tier Local Authorities is included below. Table 1.1: Top Tier Local Authority population characteristics, 2009 Local Authority Age profile 2009 Mean Age (Years) Ethnicity profile % Over 70 % White % Asian % Black % Mixed, Chinese or Health profile % Obese % Smoking Other Coventry 38 11 81 12 3 4 28 27 Warwickshire 41 12 94 4 1 2 26 22 Dudley 41 13 92 5 1 2 27 25 Shropshire 43 15 97 1 0 1 27 21 Staffordshire 42 13 96 2 1 1 27 22 Stoke-on-Trent 39 11 93 4 1 2 31 30 Telford & Wrekin 39 10 94 3 1 2 28 25 Wolverhampton 39 12 76 15 5 4 29 25 Birmingham 36 10 67 21 7 5 23 25 Sandwell 39 12 77 15 4 3 28 29 Solihull 41 13 91 5 2 3 24 20 Walsall 40 12 85 11 2 2 28 26 Herefordshire 44 16 98 1 0 1 27 21 Worcestershire 42 13 96 2 1 2 26 21 West Midlands 40 12 89 7 2 2 26 24 This report uses abbreviations for the names of the acute Trusts in the West Midlands in tables and figures; these are defined in Table A.2 in the Appendix. 1.4 The West Midlands Cancer Intelligence Unit The West Midlands Cancer Intelligence Unit (WMCIU) houses the regional cancer registry that serves the West Midlands residents. A document introducing the WMCIU, the data collected by the registry and the typical work of the registry is included at the end of this report. 4 Cancer Research UK, Cancer Stats, Lung cancer risk factors (http://info.cancerresearchuk.org/cancerstats/types/lung/riskfactors/ accessed 29/07/2011) 5 Cancer Research UK, Cancer Stats, Lung cancer risk factors (http://info.cancerresearchuk.org/cancerstats/types/lung/riskfactors/ accessed 29/07/2011) 6 http://www.wmciu.nhs.uk/documents/west_midlands_geographies_la_v_0_5.pdf Author: TE/CB/JB/GL/SV Page 3 of 27 Last updated: 20/10/11

2.0 INCIDENCE AND MORTALITY 2.1 Lung Cancer Incidence and Mortality in England and the West Midlands Table 2.1: Lung cancer incidence and mortality in the West Midlands and England Number of cases/ deaths Crude rate per 100,000 population Gender Males Females Persons Males Females Persons Incidence Mortality West Midlands England West Midlands England 2009 2008 2009 2008 2,001 18,752 1,773 16,021 1,379 14,504 1,146 12,171 3,380 33,256 2,919 28,192 74.9 74.1 66.4 63.3 50.0 55.5 41.5 46.6 62.2 64.6 53.7 54.8 Age-standardised rate Males 56.7 ( 54.2-59.3 ) 58.1 ( 57.3-59.0 ) 49.4 ( 47.1-51.8 ) 49.0 ( 48.3-49.8 ) per 100,000 European Females 33.8 ( 31.9-35.8 ) 37.5 ( 36.9-38.2 ) 26.6 ( 25.0-28.4 ) 30.3 ( 29.7-30.9 ) standard population Persons 45.2 ( 43.7-46.9 ) 47.8 ( 47.3-48.4 ) 38.0 ( 36.6-39.5 ) 39.7 ( 39.2-40.2 ) There were 3,380 cases of lung cancer diagnosed in the West Midlands in 2009, and 2,919 deaths. Lung cancer is more common in males than in females, with a crude incidence rate of 74.9 per 100,000 in males and only 50.0 per 100,000 in females. Lung cancer incidence and mortality rates in the West Midlands are broadly similar to the rates in England as a whole. The 2008 data presented for England are the most recent available, and are suitable for broad comparisons with the 2009 West Midlands data. However as the incidence of lung cancer is changing over time these should be interpreted with care. Table 2.2: Lung cancer incidence by morphology in the West Midlands Number of cases Crude rate per 100,000 population Age-standardised rate per 100,000 European standard population Gender Males Females Persons Males Females Persons Incidence by lung cancer morphology, 2009 Small cell Non small cell 227 1,225 199 758 426 1,983 8.5 45.9 7.2 27.5 Other 549 422 971 20.6 15.3 7.8 36.5 17.9 Males 6.8 ( 6.0-7.8 ) 35.1 ( 33.1-37.2 ) 14.7 ( 13.5-16.0 ) Females 5.4 ( 4.7-6.3 ) 19.9 ( 18.4-21.4 ) 8.5 ( 7.7-9.5 ) Persons 6.1 ( 5.6-6.8 ) 27.5 ( 26.3-28.8 ) 11.6 ( 10.9-12.4 ) Lung cancer can be divided into two main morphological types, non small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC is much more common than SCLC, with a crude incidence rate of 36.5 per 100,000 population compared to a rate of only 7.8 per 100,000 for SCLC. The morphological type of lung cancer is determined by histology or cytology. When these investigations have not taken place (or have not been reported to the WMCIU) the morphological type cannot be determined. This may be because of the late stage of the tumour at presentation, or the co-morbidities of the patient. These cancers are included in the other group. The other group also contains very rare morphologies such as sarcomas and blastomas (see Table A.1 in the Appendix). Table 2.2 gives a breakdown of the incidence of each morphological type in the West Midlands. For all morphologies incidence rates are higher in males than females, although this difference is much greater for NSCLC than for SCLC. The higher incidence of NSCLC in males is likely to be a legacy of historically higher smoking levels in males. There are two common types of NSCLC, squamous cell carcinoma and adenocarcinoma, and a rarer type, large cell lung cancer. When it is known that the patient has NSCLC, but not enough information is available to distinguish the specific morphological type, it is recorded in ICD-O3 as non small cell carcinoma. These cases have been included in other NSC in Table 2.3 which shows the contributions of the different morphology types to the overall incidence of NSCLC. Author: TE/CB/JB/GL/SV Page 4 of 27 Last updated: 20/10/11

Table 2.3: Non small cell lung cancer incidence by morphology in the West Midlands Number of cases Crude rate per 100,000 population Age-standardised rate per 100,000 European standard population Gender Males Females Persons Males Females Persons Incidence of non-small lung cancer morphology, 2009 Squamous cell Adenocarcinoma Large cell Other NSC 514 372 7 332 222 304 11 221 736 676 18 553 19.2 13.9 0.3 12.4 8.0 11.0 0.4 8.0 13.6 12.4 0.3 10.2 Males 14.6 ( 13.3-16.0 ) 10.7 ( 9.6-11.9 ) 0.2 ( 0.1-0.5 ) 9.6 ( 8.6-10.7 ) Females 5.5 ( 4.7-6.3 ) 8.3 ( 7.3-9.3 ) 0.3 ( 0.2-0.6 ) 5.8 ( 5.0-6.7 ) Persons 10.0 ( 9.3-10.8 ) 9.5 ( 8.8-10.3 ) 0.3 ( 0.2-0.4 ) 7.7 ( 7.1-8.4 ) Figure 2.1: Age profile for lung cancer incidence and mortality, West Midlands, 2009 600 400 Crude rates per 100,000 population 450 300 150 300 200 100 Number of cases 0 0 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Males Age group Females No. of tumours No. of deaths Crude incidence rate Crude mortality rate Like the majority of cancers, lung cancer is a disease of the elderly, with incidence rates and mortality rates steadily increasing with age in both males and females (Figure 2.1). Very few cancers are diagnosed in the under 50s. The number of cases and deaths peaks at around age 75 as, although rates are higher in the most elderly groups, the population size is smaller. Figure 2.2: Age profile for lung cancer incidence by morphology, West Midlands, 2009 400 300 Crude rates per 100,000 population 300 200 100 225 150 75 0 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Number of cases 0 Males Females Age group No. of small cell Small cell crude incidence rate No. of non small cell Non small cell crude incidence rate No. of other Other crude incidence rate Figure 2.2 shows the age profile for SCLC, NSCLC and other lung cancers. The age profile of each morphology is similar for both males and females. SCLC has a flatter age profile, with Author: TE/CB/JB/GL/SV Page 5 of 27 Last updated: 20/10/11

relatively more cases in the 55 65 age group. The number of other lung cancers rises steadily with age and is likely to reflect the fact that invasive diagnostics in the most elderly may be clinically inappropriate. 2.2 Lung Cancer Incidence Trends in the West Midlands Figure 2.3: Lung cancer incidence trends, West Midlands Dotted lines indicate 95% confidence intervals Age-standardised incidence rate per 100,000 population 80 70 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 Diagnosis year Males Females 2008 2009 Lung cancer is unusual in that the incidence trend over time is reversed for males and females. Incidence rates for lung cancer have been steadily decreasing in males since 2000. Incidence rates in 2009 are significantly lower than they were 10 years ago. In contrast, incidence rates in females have increased significantly over the same time period. On current trends, incidence rates in males and females are likely to be comparable in the future. Figure 2.4: Lung cancer incidence trends by morphology, West Midlands Dotted lines indicate 95% confidence intervals 45 30 15 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2000 2001 2002 2003 2004 2005 Age-standardised incidence rate per 100,000 population 2006 2007 2008 2009 Males Diagnosis year Small cell Non small cell Other Females The incidence trends in Figure 2.4 are mostly due to changes in the incidence of NSCLC, the most common type of lung cancer, the incidence of which is significantly higher in males. NSCLC has decreased in males but increased in females over the 10 years. This is probably because uptake of smoking in females occurred later than in males, and has been slower to decrease. The incidence of other types of lung cancer in males has decreased over time. This may be due to genuine decreased incidence or to improved diagnostics and data quality. A similar effect is not seen in females. Author: TE/CB/JB/GL/SV Page 6 of 27 Last updated: 20/10/11

2.3 Variation in Lung Cancer Incidence with Deprivation Figure 2.5: Lung cancer incidence by ID2007 deprivation quintile, West Midlands, 2009 Age-standardised incidence rate (per 100,000 population) 100 80 60 40 20 0 Most deprived Average Least deprived Deprivation quintile Males Females Figure 2.5 shows how the incidence of lung cancer in males and females varies with deprivation. Lung cancer is much more common in the most deprived quintile than in the least deprived, with more than twice as many cases diagnosed. 2.4 Lung Cancer Incidence in the Top Tier Local Authorities Figure 2.6: Lung cancer incidence by top tier Local Authority, West Midlands, males, 2009 Age-standardised incidence rate (per 100,000 population) 120 100 80 60 40 20 0 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Top Tier Local Authority Male incidence rate West Midlands, males WM confidence interval In 2009, lung cancer incidence in males was significantly higher in the top tier Local Authorities (TTLA) of Birmingham, Stoke-on-Trent, and Sandwell compared to the West Midlands average; the latter two TTLAs having high levels of smoking prevalence (29-30%). The areas of higher incidence also correspond to areas of higher levels of deprivation. Significantly lower incidence rates were observed in the top tier Local Authorities of Warwickshire and Staffordshire where smoking prevalence rates are amongst the lowest in the region (22%). Author: TE/CB/JB/GL/SV Page 7 of 27 Last updated: 20/10/11

Figure 2.7: Lung cancer incidence by Top Tier Local Authority, West Midlands, females, 2009 Age-standardised incidence rate (per 100,000 population) 120 100 80 60 40 20 0 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Top Tier Local Authority Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Female incidence rate West Midlands, females WM confidence interval As in males, in 2009, lung cancer incidence in females was significantly higher in the top tier Local Authorities of Birmingham, Stoke-on-Trent, and Sandwell compared to the West Midlands average; the latter two TTLAs having high levels of smoking prevalence. Significantly lower incidence rates were observed in Warwickshire and Shropshire where smoking prevalence rates are amongst the lowest in the region. 2.5 Lung Cancer Mortality Trends in the West Midlands Figure 2.8: Lung cancer mortality trends, West Midlands Dotted lines indicate 95% confidence intervals Age-standardised mortality rate per 100,000 population 70 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Mortality rates for lung cancer have been steadily decreasing in males since 2000. Mortality rates in 2009 are significantly lower than they were 10 years ago. This is similar to the trend seen in incidence rates in Section 2.2. In contrast, incidence rates in females have not decreased over the same time period. As discussed previously, this is due primarily to the differing patterns of smoking uptake between the two groups. Death year Males Females Author: TE/CB/JB/GL/SV Page 8 of 27 Last updated: 20/10/11

2.6 Variation in Lung Cancer Mortality with Deprivation Figure 2.9: Lung cancer mortality by ID2007 deprivation quintile, West Midlands, 2009 Age-standardised mortality rate (per 100,000 population) 100 80 60 40 20 0 Most deprived Average Least deprived Deprivation quintile Males Females Figure 2.9 highlights the wide deprivation gap in lung cancer mortality rates; which reflects the incidence rate patterns described in Section 2.3. 2.7 Lung Cancer Mortality in the Top Tier Local Authorities Figure 2.10: Lung cancer mortality by Top Tier Local Authority, West Midlands, males, 2009 100 Age-standardised mortality rate (per 100,000 population) 80 60 40 20 0 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Top Tier Local Authority Male mortality rate West Midlands, males WM confidence interval Figure 2.10 illustrates the variation in lung cancer mortality in males by top tier Local Authority in 2009. Mortality rates were significantly higher in the top tier Local Authorities of Birmingham, Sandwell and Stoke-on-Trent and significantly lower in Herefordshire and Worcestershire. This pattern is similar to lung cancer incidence; due to the poor prognosis of lung cancer patients, incidence rates and mortality rates often mirror each other. Author: TE/CB/JB/GL/SV Page 9 of 27 Last updated: 20/10/11

Figure 2.11: Lung cancer mortality by Top Tier Local Authority, West Midlands, females, 2009 Age-standardised mortality rate (per 100,000 population) 100 80 60 40 20 0 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Top Tier Local Authority Female mortality rate West Midlands, females WM confidence interval Figure 2.11 illustrates the variation in lung cancer mortality in females by top tier Local Authority in 2009. Mortality rates were significantly higher in Stoke-on-Trent, and Birmingham, mirroring incidence rates in Figure 2.7. Wolverhampton also had significantly higher mortality rates compared to the West Midlands average. Incidence rates in Wolverhampton, whilst high, were not significantly greater than the West Midlands average. No top tier Local Authority had mortality rates significantly lower than the West Midlands average. Author: TE/CB/JB/GL/SV Page 10 of 27 Last updated: 20/10/11

3.0 SURVIVAL 3.1 Trends in Survival in the West Midlands 3.1.1 Lung cancer survival in the West Midlands by gender Figure 3.1: Lung cancer survival trends by gender, West Midlands Dotted lines indicate 95% confidence intervals Relative survival rate 40% 30% 20% 10% 0% 2000-2004 2001-2005 2002-2006 2003-2007 Diagnosis year 2004-2008 2005-2009 One-year relative survival, females One-year relative survival, males Five-year relative survival, females Five-year relative survival, males Lung cancer survival rates remain poor for both males and females. Fewer than a third of patients diagnosed with lung cancer survive for a year after their diagnosis, and fewer than 1 in 10 are alive five years after diagnosis. 1-year survival rates have improved significantly with time. For males diagnosed between 2000 and 2004 1-year survival was only 24%. This rose to 27% for males diagnosed between 2005-2009. For females diagnosed between 2000 and 2004 1-year survival was only 26%. This rose to 32% for females diagnosed between 2005-2009. One-year survival rates are significantly better for females than for males. This gender gap has been widening over time. The causes of this gap are not fully understood, but may be due to later presentation in males, increased use of chemotherapy to treat females, which has a proven effect on survival, and the different morphological profile of cancers diagnosed in different genders. The WMCIU is continuing to investigate the drivers for this gap, working with the National Cancer Intelligence Network lead registry for lung cancer. Five-year survival from lung cancer is also very poor, with less than 8% of patients surviving up to five years. As with 1-year survival, survival rates are highest in females. [The data series is truncated for 5-year survival as this cannot be calculated until 5 years after diagnosis.] 3.1.2 Lung cancer survival trend by morphology Survival from NSCLC is significantly better than for SCLC (Figures 3.2 and 3.3). NSCLC survival has improved over time for both males and females. SCLC survival has improved for females, but has not improved for males. Author: TE/CB/JB/GL/SV Page 11 of 27 Last updated: 20/10/11

Figure 3.2: Lung cancer 1-year survival trends by morphology, West Midlands Dotted lines indicate 95% confidence intervals 45% Relative survival 30% 15% 0% 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 2005-2009 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 2005-2009 Males Diagnosis years Females Non small cell Small cell Other The proportion of males who are diagnosed with metastatic SCLC has increased over time (from 33% in 2000-2004 to 43% in 2005-2009), and in 2005-2009 males were more likely to have metastatic disease when they are diagnosed than females (43% compared to 37%). During the same period, the proportion of cases registered through only a death certificate (DCO cases) decreased more rapidly in males than females. DCO cases are excluded from survival analysis due to incomplete diagnostic information. Improved case ascertainment and a reduction in DCO registrations is important for improving registry data quality, but has the incidental effect of including poorer prognosis patients in survival analysis. This is likely to contribute to the overall poorer survival of SCLC in males. This gender-specific trend for SCLC may be partly driving the overall survival gap between males and females, although this gap is seen for all morphological groups. Survival for cancers in the other grouping has also increased significantly over time in females. Figure 3.3: Lung cancer 5-year survival trends by morphology, West Midlands Dotted lines indicate 95% confidence intervals 15% Relative survival 10% 5% 0% 2000-2004 2001-2005 2000-2004 2001-2005 Males Diagnosis years Females Non small cell Small cell Other Five-year survival is poor for all morphological groupings, but is significantly better for NSCLC (8%- 11%) than for SCLC (3%-5%) and other lung cancers (3%-4%). Author: TE/CB/JB/GL/SV Page 12 of 27 Last updated: 20/10/11

3.1.3 Variation in Lung Cancer Survival with Deprivation Figure 3.4 shows how lung cancer survival varies with deprivation in males and females. With the single exception of 5-year survival in the least deprived quintile, 1- and 5-year survival rates were higher for females than for males at all levels of deprivation. Although 1- and 5-year survival rates were higher in males and females in the least deprived quintile, the differences in survival between deprivation quintiles were not significantly different. Figure 3.4: Lung cancer survival by ID2007 deprivation quintile by gender, West Midlands, 1-year diagnosed 2005-2009 and 5-year diagnosed 2001-2005 40% Relative survival rate 30% 20% 10% 0% Most deprived Average Least deprived Most deprived Average Least deprived 1-year survival Male Female 5-year survival 3.2 Lung Cancer survival in the Top Tier Local Authorities Figure 3.5: Lung cancer survival by Top Tier Local Authority, persons, 1-year survival based on cases diagnosed 2005-2009 and 5-year survival based on cases diagnosed 2001-2005. Dotted lines indicate 95% confidence intervals for West Midlands 50% Relative survival rate 40% 30% 20% 10% 0% Coventry Warwickshire Dudley Shropshire Staffordshire Stoke on Trent Telford & Wrekin Wolverhampton Birmingham Top Tier Local Authority 1-year survival West Midlands 1-year survival 5-year survival WM 5-year survival Sandwell Solihull Walsall Herefordshire Worcestershire There were significantly lower 1-year survival rates in Dudley and Telford & Wrekin while significantly higher survival rates were observed in Solihull. Although Herefordshire residents diagnosed with lung cancer in 2001-2005 experienced significantly lower 5-year survival compared to the West Midlands average, lung cancer incidence and mortality rates in Herefordshire are amongst the lowest in the country. Author: TE/CB/JB/GL/SV Page 13 of 27 Last updated: 20/10/11

3.3 Variation in Lung Cancer Survival with Trust of Surgery Figure 3.7: Survival by Trust of surgery, persons, 2001-2009 1-year survival based on cases diagnosed 2005-2009, 2-year survival based on cases diagnosed 2004-2008 and 5-year survival based on cases diagnosed 2001-2005. Relative survival rate 90% 60% 30% 0% UHCW RWH UHNS HEFT UHCW RWH UHNS HEFT UHCW RWH UHNS HEFT 1-year survival 2-year survival 5-year survival Trust of surgery Surgical treatment is usually only appropriate for NSCLC. The vast majority of surgical treatment in the West Midlands takes place in four acute Trusts: the University Hospitals Coventry & Warwickshire NHS Trust, The Royal Wolverhampton Hospitals NHS Trust, the University Hospital of North Staffordshire NHS Trust, and the Heart of England NHS Foundation Trust. Figure 3.7 shows the variation in survival of patients who were treated with surgery in each of the four lung cancer centres. [As the majority of patients are not treated with surgery, these data show only a subset of all lung cancer patients] Survival rates are much higher for this cohort of surgically treated cases than for lung cancers that did not receive surgery. This is partly because of the efficacy of surgical treatment, but also because patients selected for surgery have earlier stage tumours, fewer co-morbidities and a generally better prognosis. One-year survival rates for surgically treated cancers are approximately 70% compared to 30% for all lung cancers. Five-year survival rates for surgically treated cases are approximately 38% compared to 7% for all lung cancers. There is little variation in 1- and 2-year survival between the four lung cancer centres. Five-year survival rates appear lower at The Royal Wolverhampton Hospitals NHS Trust, but this difference is not statistically significant. The Trust has operated on fewer cases than the other Trusts since its Heart and Lung Centre only opened in October 2004, and so the confidence intervals are wider. Author: TE/CB/JB/GL/SV Page 14 of 27 Last updated: 20/10/11

4.0 STAGE AT DIAGNOSIS The stage at which lung cancer is diagnosed is inextricably linked to the expected outcome, with early stage tumours having better outcomes than late stage tumours. A list of abbreviations for acute Trusts used in Figure 4.1 is contained in Table A.2 in the Appendix. 4.1 Histological Confirmation of Lung Cancer Figure 4.1: Histological confirmation by Trust where first seen, cases diagnosed 2009 Solid black line indicates England & Wales average histological confirmation for 2009 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM Trust where first seen 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Histological confirmation No histological confirmation According to the 2010 National Lung Cancer Audit (NLCA) 76% of lung cancers (including mesothelioma) in England and Wales had a histological confirmation. The WMCIU s cancer registration database has population level coverage of lung cancer cases in the West Midlands, including cases only diagnosed at death. The NLCA data which are collected from acute Trusts, include mesothelioma patients (although the numbers are very small) and may include out of region patients. Therefore the two datasets relate to slightly different cohorts of patients, and in general more detailed data will be available on NLCA patients. However, the NLCA data do provide a useful benchmark with which to compare the cancer registration data with. With the exception of six Trusts (the University Hospitals Coventry & Warwickshire NHS Trust, the Mid Staffordshire NHS Foundation Trust, The Royal Wolverhampton Hospitals NHS Trust, the Walsall Healthcare NHS Trust, the University Hospitals Birmingham NHS Foundation Trust and the Worcestershire Acute Hospitals NHS Trust) cancer registration data for Trusts in the West Midlands have histological confirmation rates below the England and Wales NLCA average. In particular, the South Warwickshire NHS Foundation Trust (SW), the Sandwell and West Birmingham Hospitals NHS Trust (SWBH) and the Wye Valley NHS Trust (WV) have rates that are 10 percentage points lower than the England and Wales average. Author: TE/CB/JB/GL/SV Page 15 of 27 Last updated: 20/10/11

4.2 Variation in Stage Completeness with Trust First Seen Figure 4.2: TNM Stage completion by Trust where first seen, cases diagnosed 2009 Dashed black line indicates the West Midlands average for 2009 Solid black line indicates the England & Wales average for 2009 Trust where first seen GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH PH WM 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Staged by mets Staged-other Unstaged In order to make appropriate decisions on treatment, all cancers should be clinically staged at diagnosis. However, not all cancers have a TNM stage recorded on the WMCIU s cancer registration database. This is partially due to the limited flow of clinical stage to the registry. Where staging information is provided to the WMCIU, it is often data on the presence of metastatic lung cancer. This means staged cases are disproportionately likely to be late stage, and cases which are not staged are disproportionately likely to be early stage. Levels of staging are therefore in part a reflection of late diagnosis rather than good provision of data. The data in Figure 4.2 are derived using a combination of overall stage provided by Trusts and internal algorithms derived by the WMCIU which piece together all the information that is received in order to construct a TNM stage at diagnosis. No positive or negative assumptions are made when data are missing. Only the University Hospitals Birmingham NHS Foundation Trust provided complete TNM staging to the WMCIU that was higher than the England & Wales NLCA average. The main reason for the good staging information received from this Trust is the receipt of comprehensive oncology records from their oncology department. The poor staging information received for the Burton Hospitals NHS Foundation Trust may be because the pathology service for this Trust was transferred to a laboratory outside the West Midlands and direct data feeds from this laboratory are not sent to the WMCIU. The NLCA has a TNM stage for over 80% of cancers submitted compared to only 58% of the cancers on the cancer registration database. The WMCIU has, since the analysis of these data, set up local feeds to deliver NLCA staging data to the registry. Direct comparison of cases in the two datasets shows that in many instances, the assumption has been made in the NLCA that a lack of recorded information relating to metastases (Mx) means that metastases are not present (M0). This assumption is not made by the WMCIU, and this accounts for a significant proportion of the staging difference. In addition, the registries do record cases, such as those diagnosed at death or in the community, when a stage may never have been recorded. Author: TE/CB/JB/GL/SV Page 16 of 27 Last updated: 20/10/11

5.0 REFERRAL PATTERNS 5.1 Referral Patterns to Acute Trusts Figure 5.1: Referral patterns from TTLA of residence to Trust where first seen, 2007-2009 Trust where first seen GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH 0 200 400 600 800 1,000 1,200 1,400 1,600 Number of tumours diagnosed Top Tier LA Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire In order to obtain the Trust first seen, all lung cancer patients in the cancer registration cohort were matched to Cancer Waiting Times (CWT) data. Where a match to CWT was not possible a Trust first seen was assigned using the earliest record at an acute Trust or private hospital in the cancer registration data. This methodology may introduce some bias towards the tertiary Trusts if imaging data are not submitted to the WMCIU. However, registration data and CWT data were in agreement in over 97% of cases where both were available. Lung cancer patients were seen at all of the main acute Trusts in the region, though the number of tumours diagnosed varied. The Burton Hospitals NHS Foundation Trust diagnosed the fewest lung cancers in the region (although it also saw out of region patients), while the Heart of England NHS Foundation Trust diagnosed the largest number of lung cancers, over 1,400 in 3 years. The majority of residents were diagnosed in Trusts within the cancer network where they lived. The Trusts with the most diverse referral pattern were The Royal Wolverhampton Hospitals NHS Trust (RWH), the Heart of England NHS Foundation Trust (HEFT) and the University Hospitals NHS Foundation Trust (UHB). These Trusts diagnosed cases from at least 7 of the Top Tier LAs. RWH and HEFT are 2 of the four main surgical centres in the region, while UHB is one of the largest regional centres for non-surgical cancer treatment. 5.2 Referral Patterns of Trust First Seen to Trusts of Surgery Figure 5.2: Referral patterns from Trust where first seen to Trust of surgery, 2007-2009 Trust where first seen GEH SW DGH MSH STH SWBH WH UHB WV WAH Specialist Trust UHCW RWH UHNS HEFT 0 10 20 30 40 50 60 70 80 Number of tumours referred to specialist Trust Author: TE/CB/JB/GL/SV Page 17 of 27 Last updated: 20/10/11

Lung cancer patients are referred to four main Trusts for surgery in the region; UHCW, RWH, UHNS and HEFT. HEFT receives patients from seven Trusts in the region. UHCW and UHNS are referred patients from only two Trusts in the region, perhaps reflecting the fact that unlike HEFT and RWH, they are not located centrally in the region. The Burton Hospitals NHS Foundation Trust is not shown in Figure 5.2, since no cases from this Trust were referred into West Midlands Trusts for surgery. Some cases from Burton were referred to the Derby Hospitals NHS Foundation Trust. 6.0 TREATMENT 6.1 Types of Treatment The treatment of small cell lung cancer (SCLC) and non small cell lung cancer (NSCLC) is very different and therefore accurate histological diagnosis is essential 7. The National Institute For Health and Clinical Excellence (NICE) report The Diagnosis and Treatment of Lung Cancer, outlines the recommended treatments for the different types of lung cancer depending on the stage of the disease. According to the 2010 NLCA, active anti-cancer treatment (surgery, chemotherapy, radiotherapy) was offered to 59% of lung cancer patients in England and Wales in 2009. This is similar to the proportions seen in Figure 6.1 for West Midlands patients. 6.2 Lung Cancer Treatment Patterns 6.2.1 Variation in Lung Cancer Treatment with Morphology Figure 6.1: Treatment patterns for lung cancer cases by morphology, diagnosed 2007-2009 SCLC Morphology NSCLC Other/ Unspecified All 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Surgery Surgery and Chemotherapy Chemotherapy Radiotherapy and Chemotherapy Radiotherapy Other No Treatment Figure 6.1 shows the combinations of treatment offered to patients with different morphological types. For the purpose of this analysis, cases that were death certificate only have been excluded. In line with the 2010 NLCA guidance, very few (n=16) SCLC patients received any surgery to their primary tumour. The first line treatment for these tumours in the West Midlands is mainly chemotherapy, radiotherapy and a combination of both, in agreement with the NLCA. 7 Cancer Research UK website, key facts Author: TE/CB/JB/GL/SV Page 18 of 27 Last updated: 20/10/11

Surgical treatment of NSCLC occurs in around 16% of patients with around 40% of patients receiving some form of radiotherapy. Chemotherapy is given to a smaller proportion of patients. This is also in agreement with treatment patterns described in the NLCA. There is a large proportion (40%) of lung cancers which are not recorded as receiving any treatment. The majority of these are cancers which have not been diagnosed as NSCLC or SCLC and are shown in the other/unspecified group. Over 75% of cancers in this group do not receive any treatment. The poor prognosis cancers in the other group are discussed in Section 2.1. 6.2.2 Variation in Lung Cancer Treatment with Age Figure 6.2: Treatment patterns for all lung cancer cases by age, diagnosed 2007-2009 Age group 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ All 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Surgery Surgery and Chemotherapy Chemotherapy Radiotherapy and Chemotherapy Radiotherapy Other No Treatment The proportion of tumours treated with surgery decreases with age, while the proportion of patients receiving no treatment rises with age. Radiotherapy given as the only treatment (not in conjunction with chemotherapy) is likely to be palliative in intent, and is most common in the 75-85 year age range. These patients may have co-morbid conditions and be unable to withstand aggressive chemotherapy. Note that there are only small numbers of cases in the under 50 age groups (see Figure 2.1). 6.2.3 Variation in Lung Cancer Treatment with Deprivation Figure 6.3 shows how the combinations of treatment given to lung cancer patients vary with deprivation. Treatment patterns are similar for all patients regardless of levels of deprivation, suggesting that the affluence of the patient is not influencing treatment decisions. Although a higher proportion of tumours diagnosed in the least deprived quintile received some surgery, this was not statistically significant. Author: TE/CB/JB/GL/SV Page 19 of 27 Last updated: 20/10/11

Figure 6.3: Treatment patterns for all lung cancer cases by ID2007 deprivation quintile, diagnosed 2007-2009 Most deprived Deprivation quintile Average Least deprived West Midlands 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Surgery Surgery and Chemotherapy Chemotherapy Radiotherapy and Chemotherapy Radiotherapy Other No Treatment 6.2.4 Variation in Lung Cancer Treatment with Trust Where First Seen Lung cancer treatment does show variation based on the Trust where the patient was first seen. Reasons for this are complex. There may be true variation in treatment provided, which may be clinically relevant due to variation in case-mix. There may also be variation in the quality of data sent to the WMCIU by different Trusts as discussed above. Figure 6.4: Treatment patterns for lung cancer cases by Trust where first seen, diagnosed 2007-2009 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM Trust where first seen 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Surgery Surgery and Chemotherapy Chemotherapy Radiotherapy and Chemotherapy Radiotherapy Other No Treatment In Figure 6.4 the proportion of patients receiving surgery appears to be higher in patients first seen in one of the four Trusts in the region which perform cardiothoracic surgery. This may be because these Trusts are more likely to suggest surgery as an option, but it could also be due to the data quality issues already discussed. Author: TE/CB/JB/GL/SV Page 20 of 27 Last updated: 20/10/11

The Burton Hospitals NHS Trust has a high proportion of patients who did not have any treatment recorded and a low proportion of patients receiving surgery. This may be due to the incomplete provision of treatment information for patients who are referred on to out of region Trusts. The University Hospitals Coventry & Warwickshire NHS Trust appears to have provided treatment to over 75% of patients first seen there this is the highest proportion in the region and substantially higher than the regional average of 60%. Further work is needed to ensure that this accurately reflects the true treatment pattern in the Arden Cancer Network Trusts. 6.2.5 Treatment in Each Top Tier Local Authority Figure 6.5: Treatment patterns for all lung cancer cases by TTLA, diagnosed 2007-2009 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire West Midlands Top tier local authority 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Surgery Surgery and Chemotherapy Chemotherapy Radiotherapy and Chemotherapy Radiotherapy Other No Treatment Figure 6.5 shows that higher proportions of residents of Coventry, Warwickshire, Wolverhampton, Walsall and Herefordshire top tier Local Authorities received treatment for their lung cancer compared to the regional average. The above-average proportions of residents receiving radiotherapy in Coventry and Warwickshire top tier Local Authorities (54% and 45% respectively) may be due to the proximity of the Linac machine at UHCW. However, this trend is not repeated in other Local Authorities where Linacs are sited. Variations in treatment will be affected by the composition of cases within each group. It is not necessarily the case that there is an equal distribution and proportion of cases in each group. Therefore further work needs to be undertaken to fully understand the observed differences in treatment patterns. Care should be taken when extrapolating information from the graphs in this section. 6.3 Clinical Lines of Enquiry Measures The Clinical Lines of Enquiry are indicators agreed nationally as quality measures of lung cancer services. Although the eventual aim of the Clinical Lines of Enquiry is to compare outcomes, the indicators are currently mostly process measures, due to limitations of available data. There are five Clinical Lines of Enquiry in the current Peer Review measures (2011/12): proportion of expected cases on whom data is recorded histological confirmation rate Author: TE/CB/JB/GL/SV Page 21 of 27 Last updated: 20/10/11

proportion receiving active treatment proportion undergoing surgical resection proportion of small cell lung cancer cases receiving chemotherapy 8 Three of these (shown in italics) are amenable to analysis using cancer registration data. The histological confirmation rate was discussed in Section 4.1, and the others are reported on here. 6.3.1 Percentage undergoing surgical resection by Trust where first seen Figure 6.6: Percentage receiving a surgical resection by Trust where first seen, 2007-2009 (all confirmed cases except mesothelioma and confirmed SCLC) Solid black line indicates the England & Wales average for 2009 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM Trust where first seen 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of tumours Underwent surgical resection Did not undergo surgical resection According to the 2010 NLCA, 14% of lung cancer tumours received a surgical resection in England and Wales in 2009. The proportion of lung cancers receiving a surgical resection in the West Midlands was calculated using registry data, and the results shown in Figure 6.6. (The possible reasons for differences between the NLCA and the cancer registration data were discussed in section 4.1.) Cases are presented by where the patient was first seen, although their surgery may not have taken place in this Trust. The four Trusts with surgical resection rates greater than the 14% average are the four Trusts that perform the majority of surgical resections in the West Midlands. This could be due to patients who are first seen in these specialist centres being more likely to be recommended for surgery than patients seen in other Trusts. However, it could also be because of issues in identifying the Trust where the patient was first seen, as discussed in Section 5.1 6.3.2 Small cell lung cancer patients receiving chemotherapy by Trust where first seen The data in Figure 6.7 are presented for the Trust where the patient was first seen. For some patients, this will not be the Trust where they received their chemotherapy. It should be noted that these data cover 3 years compared to the single year analysis in the NLCA. According to the 2010 NLCA, 66% of SCLC tumours diagnosed in England and Wales received chemotherapy. Figure 6.7 shows that only six Trusts had this level of chemotherapy recorded at the WMCIU: the South Warwickshire NHS Foundation Trust, the University Hospitals Coventry & 8 National Cancer Peer Review Programme, Lung Clinical Lines of Enquiry Briefing Paper for National Cancer Peer Review, 2011-2012 Author: TE/CB/JB/GL/SV Page 22 of 27 Last updated: 20/10/11