Introduction

This paper provides information on cancer, including local incidence, mortality and survival. It outlines the current position in relation to cancer across Nottinghamshire and in reference to the national position for England. The information presented seeks to highlight any key differences between the six CCGs where sufficient information is available, and differences within the overall population in terms of such characteristics as age, sex, ethnicity and socio-economic status. 

Cancer is a disease caused by normal cells changing so that they grow in an uncontrolled way. There are more than 200 different types of cancer. Cancer is a complex disease.

Cancer is one of the biggest health challenges in the UK with one in three people expected to develop some form of cancer in their lifetime. There were 299,923 new cancers diagnosed in 2015 with the most common cancers being breast (46,083), lung (37,637), bowel (colorectal) (34,729) and prostate cancers (40,331). Medical developments along with an ageing population overall in the UK is resulting in an increasing number of cancer diagnoses. The National Strategy estimates this increase is in the region of 2% per annum.

Mortality for all cancers and all ages in England was 135,166 (2013). This compares to coronary heart disease which is one of the other biggest disease groups, accounting for 56,363 (2014) in England. In Nottinghamshire 5,867 new cancers were diagnosed in 2013, and 2,299 people’s deaths were attributed to cancer.

Mortality and Incidence under 75 years of age

Cancer is largely a disease related to ageing, but when a cancer is identified or causes a death in someone under the age of 75 year it is considered ‘premature’ in the context of the nation’s health overall. In England 189,217 (2014) cancers are diagnosed in the under 75s annually; representing two-thirds of all cancers diagnosed (PHOF under 75 mortality rate for cancer). Premature death from cancer is an important marker of health inequality within and between communities.

Cancer Survivorship

Cancer has been considered a life-limiting disease characterised by treatment provision that cannot heal. Due to this, an approach used to understanding how cancer is affecting a population is through one and five year survival information following a diagnosis. Survival rates from recent years are showing a steady increase. In England the one and five year overall survival rates for all cancers were 70% and 54% respectively (Macmillan, 2014). In terms of the number of people in England who have had a diagnosis of cancer in their lifetime, it was almost 1.8m in 2012. These figures show a developing picture of extending periods of ‘survival’ subsequent to a cancer diagnosis for many people.

The health situation of people living after cancer treatments is a health need too. Most cancers are treated through a combination of surgery, chemotherapy and radiotherapy. The medical, technological and pharmaceutical advances in treatments are a main reason for the improvements seen in the survivorship. These treatments can themselves cause illness, however, whilst healing the cancer disease. Common illnesses, or late effects, can be chronic pain, crippling fatigue, incontinence and sexual difficulties. There can be mental health illness too, including the psychological distress relating to fears of a reoccurrence. Some of these health needs are now being approached from the consideration of cancer as a long term health condition. Within this approach the role of ‘self-care’ is explored as a potential best health care intervention for supporting people to live a full life following their treatment.

Cancer, Public Health and Social Care

The cost of treating cancer in England by the NHS is £6.7bn (2012/13), (NAO, 2015). The projection is for this to increase by 9% a year bringing it to an estimated costs of £13bn by 2020/21. Social care support is also anticipated to increase, especially in light of the predicted increase in the number of people living after cancer treatment and potentially suffering ‘late effects’. By 2030 the prediction is that three million people in the UK population will have had a cancer diagnosis. 

In addition to Public Health’s (PH) role in identifying need and health inequality, supporting the development of population wide health and social care systems to bring improvements in health outcomes for people with a diagnosis of cancer, PH has a key role in preventing people from ‘contracting’ cancer. Cancer Research UK (CRUK) estimates that four in every ten cancers can be prevented by lifestyle change. PH endeavours to reduce the number of new cancers through a range of initiatives. These include health protection approaches such as tobacco control, workplace health, health promotion initiatives through to the provision of ‘healthy’ lifestyle service support to individuals. 

Cancer in Nottinghamshire

This paper is presented to provide information on cancer in Nottinghamshire. It is written with reference to the National Strategy, ‘Achieving World-Class Cancer Outcomes (AWCCO) 2015 – 2020 (Independent Cancer Taskforce, 2015). This paper first summarises the national literature on the risk of cancer in the UK, before considering the Nottinghamshire risks in light of this. The cancer health need is then examined in terms of cancers diagnosed and mortality due to cancers. The paper will then look at local service provision, cancer resources, the evidence-based recommendations for improving cancer outcomes and efficiencies, and a consideration of important developments coming up. The views of local cancer service users and people affected by cancer (PAC) are drawn on and links for further information are made. The paper concludes with a number of recommendations directed at the key cancer commissioning stakeholders. A summary of these is presented below.

Unmet needs and service gaps

In Nottinghamshire there remain areas of the National Strategy which need to be achieved prior to its completion in 2020. The introduction of the new 28 day referral to diagnosis is one of these critical areas. In addition, with the prediction of a rapid increase in the number of cancer diagnoses over the coming decade, there is the need to ensure the local cancer assets are systematically enhanced enabling them to deliver services as effectively as possible.

Recommendations for consideration

Cancer is a chronic disease that remains a challenge to diagnose and treat. The treatment and care of cancer is complicated, traumatic and expensive. The impact of a diagnosis of the disease for an individual and those close to them remains an overwhelming experience. 

Notwithstanding this understanding though, through the information presented in this paper it is clear that Nottinghamshire has a great wealth of resource to deliver cancer services and to continue to improve on the immense achievements that have been realised over the past decade. These include the improvements in the cancer survivorship ‘stories’ for many residents, and the critical changes in environmental and lifestyle choices which can reduce people’s risk of exposure to cancer overall, with exposure to tobacco smoke being the most notable of factors here.

The overarching recommendation for Nottinghamshire now is to complete the implementation of the ninety-six recommendations in AWCCO (Independent Cancer Taskforce, 2015). Many of these will be implemented at the national and regional level and they are mostly NHS service specific. Successful local implementation, however, will require local engagement including the participation in pilot schemes. In addition, for Nottinghamshire to make the most of its current assets and prepare for the anticipated large increase in cancer diagnosis over the coming years (especially due to the ageing population), the information and issues highlighted through this report suggests there are other key recommendations to be considered as a priority for public health, cancer service and related commissioners overall. These are outlined below:-

• Addressing the health inequalities that feed into the risk factors for cancer, and prevent certain population groups from realising the cancer outcomes that other groups achieve. Core within this is the delivery of the LA PH commissioned services in the areas of tobacco control, alcohol abuse, weight management, and physical activity. 
• Addressing the underlying social determinants that are at the core of the relationship to the health inequalities highlighted above.
• Develop a local strategic vision for the cancer service workforce across health, social and third sector / voluntary provision in response to increasing demand and changing requirements of cancer survivors. This will include implementation of the recommendations set out in the Health Education England (HEE) (2017) Cancer Workforce Plan. This is included with the National Strategy, but the acuteness of the mounting pressures particularly with reference to NHS provision due to increases in demand, as well as changing requirements, suggests the need for this to be included as a specific recommendation too.
• Continue to develop local cancer systems and structures that are well led and coordinated; that will deliver improved cancer and the cancer related health outcomes aligned with the Nottingham and Nottinghamshire Sustainability and Transformation Partnership (STP) and the East Midlands Cancer Alliance.
• Provide a supportive environment for the third/voluntary sector to flourish, covering national organisations and local organisations. This includes ensuring financial resources are sourced from the STP Cancer Programme Board partners to support the local patient groups so that they continue to have an active remit that will ensure the ‘currency’ of their voice.
• Full implementation of the Equality Act 2010 throughout cancer prevention and treatment provision. The delivery of cancer services in its widest sense will need to engage with this Act if the subtleties of discrimination of poverty, age, race and disabilities within service delivery are to be addressed, especially in-light of the rising demands on services due to increasing cancer incidence rates. Implementing equality is reliant on knowing and understanding the breadth of people’s views, and especially requires the inclusion of views from people of socio-economic disadvantage as well as other vulnerable and minority groups including the views of people for who cancer outcomes are poor; the socially isolated elderly, prisoners and particular ethnic groups.
• The provision of a supplementary report for Bassetlaw. This cancer JSNA is endorsed by Nottinghamshire Cancer STP Programme Board, which in essence is comprised of cancer stakeholders covering the NHS cancer service providers of Nottingham University Hospitals NHS Trust (NUH), Sherwood Forest Hospitals NHS Foundation Trust (SFHT), and the Circle Nottingham NHS Treatment Centre, and so a group without the authority to ‘speak to’ Bassetlaw cancer service provision. Bassetlaw cancer risk and need are covered in this paper. Beyond this in terms of cancer services, Bassetlaw details will need to be addressed in an additional supplementary paper. 

Sue Coleman, Public Health and Commissioning Manager

sue.coleman@nottscc.gov.uk

Geoff Hamilton, Senior Public Health and Commissioning Manager

geoff.hamilton@nottscc.gov.uk