Early Detection of Cancer in Greater Manchester Report on data and intelligence

Jo Farrington, Quality Improvement Programme Lead (Cancer), Nov 2014

Table of Contents

Executive Summary ................................................................................ 3 Introduction ........................................................................................................................... 4 Sources of Data and Information .......................................................................................... 4 National Strategy and Outcomes .......................................................................................... 4 Supporting Outcomes Frameworks....................................................................................... 4

Putting Information on Early Detection in Context .................. 5 The population of Greater Manchester ................................................... 5 Populations per Clinical Commissioning Group (CCG) 2013-14 .......................................... 5 Deprivation in LSOAs within Greater Manchester ................................................................ 5

Cancer mortality ....................................................................................... 6 Differences in Mortality by Geographical area ..................................................................... 6 Difference in Mortality for different types of cancer .............................................................. 7 Differences in Mortality by Age ............................................................................................ 7 Gender ................................................................................................................................ 8 Deprivation .......................................................................................................................... 8 Difference in Mortality for Ethnic groups .............................................................................. 9

Cancer incidence .................................................................................... 10 Cancers caused by Modifiable Risk Factors ...................................................................... 12

Early Detection Indicators ........................................................ 14 Cancer survival ....................................................................................... 14 Difference between survival in England and other countries.............................................. 14 Trends in 1 year Survival in Greater Manchester ............................................................... 15 Cancer Survival and Deprivation ....................................................................................... 16 Differences in cancer survival by ethnic group...................... Error! Bookmark not defined.

Route to Diagnosis ................................................................................. 18 Two week wait referrals ..................................................................................................... 18 Stage at Diagnosis ............................................................................................................ 21

Screening ................................................................................................ 28 Breast Cancer Screening programme ............................................................................... 28 Cervical Cancer Screening programme ............................................................................. 29 Bowel Cancer Screening programme ................................................................................ 29

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Executive Summary The early detection of cancer leads to less aggressive treatments, better survival rates and a longer life expectancy. This report summarises the data and information available, describing the picture of early detection of cancer in Greater Manchester. This is set in the context of the demography of this city region, the incidence of cancer and mortality. Greater Manchester (GM) is more deprived than the average for England as a whole and has a higher proportion of its residents from a Black and minority ethnic (BME) background. These factors impact on cancer risk, access to services and capacity to benefit from therapies and so we might expect outcomes to be poorer in GM than in England. Cancer mortality (2009-11) was significantly higher in GM at 187 (European age standardised rate (EAS)) than in England where the EAS rate was172 and this difference persists in the mortality of people under 75 years of age. 6 out of the 10 local authorities (LA) in GM are in the worst 20% nationally for the rate of premature mortality (Under 75 years). Cancer incidence is also higher in Greater Manchester compared to England being 431 compared to 391 (EAS rate). There has been a decline in mortality from cancer alongside a rising incidence over the same timescale and this decline is accounted for by an improvement in survival. 1 year survival from Cancer (the proportion of the population surviving 1 year after diagnosis) is an indicator of the stage of cancer at the time of diagnosis. Remarkably the 1 year survival from all cancers was higher in GM, in people diagnosed in 2011 than it was in England in the same year. This is not expected from what we know of the differences in the characteristics of the population. 1 year survival in GM has improved from 55% in 1996 to 69% for people diagnosed in 2011, and it has improved from 59% to 68% for the population of England as a whole. This is testament (at least in part) to the combined efforts of public health, health promoters, clinicians and the community. Over 15 years the 1 year survival of people diagnosed with cancer improved by 25% in GM compared to 15% in England. There is no difference in the number of cases referred that lead to a diagnosis of cancer (the conversion rate) between GM and England. There are more cancers diagnosed as a result of emergency presentation in GM (25%) than in England (23%) in 2006-10 and this factor is associated with poorer outcomes. The uptake and coverage of screening programmes is lower in GM than England. There is evidence from the data on stage of cancer at diagnosis recorded in 2012 that cancers are being diagnosed at an earlier stage in GM compared to England and this is likely to account for the improved 1 year survival. In England, in 2012, 42% of cancers were diagnosed at stage 1 or 2 and this was exceeded in all of the GM Clinical Commissioning Group (CCG) areas with the proportion diagnosed at stage 1 and 2 ranging from 43 to 50%. So we have cause for celebration but there is also a concern that there is a significant difference in the 1 year survival between each category of socioeconomic status in the population (categorised by quintile of Index of Multiple Deprivation score). In Greater Manchester, 1 year survival is 23 % better in the least deprived compared to the most deprived category of patients, for people diagnosed between 2008 and 2010. This difference in 1 year survival between the socioeconomic groups is of the same order of the change in survival for the whole population in Greater Manchester over the last 15 years;  1 year survival has improved from 55 % to 69% for people diagnosed in 1995 and 2011 respectively.  1 survival was 64% in the most deprived group (quintile) and 79% in the least deprived group (quintile) for people diagnosed between 2008 and 2010. It is not just those in the most deprived circumstances that experience poorer outcomes. Addressing this health inequality will be fundamental for our strategy and our interventions need to be tailored and adapted to ensure that these disparities do not persist or increase in the future.

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Early Detection of Cancer Introduction Different approaches are used to improve the number of cancers that are diagnosed and treated at an earlier stage of their development, they include:      

Raising awareness of the signs and symptoms of cancer Encouraging earlier presentation and advice seeking Training and education for professionals, in particular those working in primary care - in awareness of signs and symptoms, in routes to diagnosis and in building confidence in what can be a difficult conversation with those at risk Improving access to diagnostic services Improving uptake and coverage of screening programmes for breast (women) bowel and cervical cancers-in particular disadvantaged groups Supporting the development and implementation of tests to rule out cancer as a prelude to diagnostic testing

To plan interventions and monitor our progress in achieving earlier diagnosis we use available data, in particular we can use the information to see if there are areas of GM or particular populations who are at risk that we need to target.

Sources of Data and Information Every new case of cancer is logged with a cancer registry, such as the National Cancer Registration Service (NCRS) North West office, which is one of eight regional cancer registration offices in England. The cancer intelligence team are a part of the Knowledge and Intelligence Team (KIT) North West. They have provided us with reliable statistics on cancer mortality (i.e. death rates), incidence (the rate at which new cases are diagnosed), and survival (the percentage of people who are still alive one, five or more years after a cancer diagnosis). To allow comparison with old Primary Care Trust (PCT) boundaries they mapped the Lower Super Output Area (LSOAs) level data to the Clinical Commissioning Group (CCGs) boundaries in GM. This is the most up to date data available for mortality, incidence and survival. Information has also been accessed from the Office for National Statistics (ONS), National Cancer Intelligence Network (NCIN), Health and Social Care Indicator Centre (HSCIC), Cancer Research UK (CRUK) and NHS England screening dashboard. This report will provide information about all cancers including the four cancers that account for about half of all new cases which are lung, bowel (or colorectal), breast (female), and prostate cancer. These four cancers accounted for 53% of the 283,087 new cases of cancer in England and caused 45% of all cancer related deaths in that year.

National Strategy and Outcomes In January 2011 Improving Outcomes: A Strategy for Cancer set out the Government’s plans to save an additional 5,000 lives per year by 2014/15. The major priorities were:    

Prevention and earlier diagnosis Quality of life and patient experience Better treatment Reducing inequalities

Supporting Outcomes Frameworks  Department of Health’s NHS Outcomes Framework  Public Health Outcomes Framework  Clinical Commissioning Group Outcomes Indicator Set

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Putting Information on Early Detection in Context

The population of Greater Manchester The 2011 census recorded 2,682,528 people living in GM city region, which is made up of 10 local authorities and 12 NHS CCGs. There are 3 CCGs in Manchester city: North, South and Central Populations per Clinical Commissioning Group (CCG) 2013-14 CCG Number of Practices Bolton 51 Bury 35 Central Manchester 42 Heywood Middleton and Rochdale (HMR) 39 North Manchester 40 Oldham 49 Salford 56 South Manchester 26 Stockport 53 Tameside and Glossop 43 Trafford 39 Wigan 65

Registered Population 294600 195000 211800 223200 183200 239600 247600 165100 299000 240300 233100 320300

GM is more deprived than the average for England but there is great variation in socioeconomic conditions across this city region. As socioeconomic status and lifestyle factors associated with it impact on cancer incidence mortality and survival it is important to understand this variation. The map below uses the Index of Multiple deprivation 2010 as a measure of deprivation for each Lower Super Output Area (LSOA) that houses about 1500 people. Those areas colour coded with dark red being the most deprived and dark blue being the least deprived LSOAs, as classified nationally. Whilst there are some deprived rural areas much of the population living in a deprived area is urban and based in inner city environments.

Deprivation in LSOAs within Greater Manchester

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When comparing the Local authority areas of GM; Bolton, Manchester, Oldham, Rochdale, Salford, Tameside and Wigan have higher levels of deprivation than for England as a whole and Bury and Trafford have better than average levels of deprivation (IMD 2010). GM is ethnically diverse with 80% defining themselves as White British (ONS NW ethnicity census Table CT0010, 2011 census data). There were 218,151 people who were Pakistani, Indian or Bangladeshi (8% population) and the population was concentrated in particular areas being greater than 10% of the population in Bolton, Oldham, Rochdale, Manchester with the greatest proportion in Oldham (18%). 2% of the population are Black, African or Caribbean and they predominantly live in Trafford, Salford, Manchester and Bolton. From 2001 to 2011 the non-white population grew by 80%. The proportion of BME residents in Manchester is expected to continue to increase.

Cancer mortality In 2013, cancer caused nearly half a million deaths (145,344) representing 29% of all deaths in England

Differences in mortality by geographical area Mortality data for Breast Cancer and major cancers was aggregated over 3 years and mapped to current CCG boundaries to enable an evaluation of whether there are significant differences in cancer mortality across Greater Manchester.

All cancer mortality 2009-2011 Mortality from cancer is significantly higher in GM than in England. All CCGs in GM have a mortality rate significantly higher than for England with the exception of Bolton, Bury, Trafford and Stockport. Manchester (North Central and South CCGs) and Salford all have a significantly higher mortality from cancer compared to the mortality rate for the whole of GM. The chart below indicates in red and green those areas with a significantly different mortality rate from that of GM as a whole and confidence Intervals are shown.

Mortality (All cancers) European age-standardised rate 250

200

Rate

150

100

50

0 England

GMSCN

NHS Bolton

NHS Bury

NHS Central NHS NHS North NHS Oldham NHS Salford NHS South NHS NHS NHS Trafford NHS Wigan Manchester Heywood, Manchester Manchester Stockport Tameside Borough Middleton & and Glossop Rochdale

CCG/Region

Source D Purkayastha, NWKIT

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Mortality (DSR) in the 12 CCG areas of GM ranges from 113 to 166.8 but most of the differences between CCGs are not significant. However 6 CCGs have a significantly higher mortality rate than Trafford where it is lowest and in North Manchester it is significantly higher than in Bolton, Trafford and Stockport.

Difference in Mortality for different types of cancer Aggregating mortality data over a three year period from 2009 to 2011, we find that there are no significant difference in mortality from breast cancer colorectal and prostate cancers between Greater Manchester and the constituent CCGs. The only observed significant difference is that Bury CCG has a significantly lower mortality from breast cancer than North Manchester CCG. It is also the only CCG with a significant lower mortality from breast cancer compared to the rate for England. For lung cancer we find that there are some differences in mortality across GM. Mortality is significantly higher in North and South Manchester and Salford compared to GM and significantly lower in Bolton, Stockport and Trafford.

Lung Cancer mortality in Greater Manchester 2009-2011 (with confidence intervals)

Lung Cancer Mortality -European age standardised rate 90.0

European age-standardised rate

80.0

70.0

60.0

50.0

Rate

40.0

30.0

20.0

10.0

0.0 GMSCN

NHS Bolton

NHS Bury

NHS Central Manchester

NHS NHS North NHS Oldham NHS Salford Heywood, Manchester Middleton & Rochdale

NHS South Manchester

NHS Stockport

NHS NHS Trafford NHS Wigan Borough Tameside and Glossop

CCG/Region Source D Purkayastha, NWKIT

Differences in Mortality by Age We are particularly concerned about premature mortality from cancer and this is defined as being in those under 75 years of age. Reduction in premature mortality is a target for NHS and other organisations. In 2012 in England, 62,358 people died from cancer under 75 years old; of these 3,325 were in Greater Manchester (GM). Earlier detection of cancer will contribute to reducing the numbers of premature deaths alongside improvements in treatment, care and management. The directly standardised mortality rate (DSR) in those under 75 is significantly higher in GM (135.76) than it is in England (123.26) as a whole.

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Premature Death from Cancer –National Ranking of Local Authorities Public Health England (Fingertips tool) have ranked the premature death from cancer for each of the 150 local authorities in England. 6 of the 10 local authorities in GM are ranked in the worst 20% nationally (highlighted in bold) and most notably, Manchester has the worst premature death rate from cancer in the England.

Local Authority Bolton Bury Manchester Oldham Rochdale Salford Stockport Tameside & Glossop Trafford Wigan

Rank 78 112 150 135 132 139 89 133 52 123

Premature death/100,000 population 148.1 162.2 207.3 179.1 177.2 182.3 152.4 177.2 138.8 168.4

Population 278,984 186,199 510,772 225875 212020 237,085 283,897 220241 228,466 318,670

The under 75 mortality considered to be preventable (men and women) (2012)

Cancer mortality is higher amongst people who are over 75, which may be partly explained by older people being less likely to receive intensive cancer treatments. This is justifiable if they are too frail or otherwise ill to withstand them, but evidence suggests that such treatment decisions are too often based on chronological age alone. Gender Nationally, the numbers of cases and deaths in males and females are not very different, but given that women live longer, this means that men shoulder more than their ‘fair share’ of the cancer burden. After standardising for age, men have a 15% higher incidence rate and 38% higher mortality rate than women. There is limited evidence for men delaying seeking advice for possible cancer symptoms for longer than women. Deprivation The National Cancer Intelligence Network (NCIN) estimates that there could be as many as 14,000 fewer cases of cancer each year in England if everybody was as healthy as the least deprived. Overall, the most disadvantaged have higher cancer incidence and mortality and lower cancer awareness, screening uptake and survival rates.

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The relationship between deprivation and cancer mortality is believed to be attributable to a number of factors; lifestyle, particularly smoking, later presentation and diagnosis, difference in access to services and treatments and differences in capacity to benefit from the treatments given. Difference in Mortality for Ethnic groups The risk of poorer cancer outcomes in BME communities is recognised. This risk is interrelated with the impact of deprivation as overall BME communities are more likely to be living in socially and economically disadvantaged circumstances. Lower uptake of screening programmes and later presentation are understood to be factors affecting the difference in mortality between ethnic groups. Local evidence from a study of quality of mammograms showed an association between fluency in English and quality of mammograms and recall rate (Jain A et al poster) It is interesting to note that the patterns of cancer mortality and under 75 mortality to not completely follow the pattern expected if deprivation and ethnicity were the only influences involved as areas, for example, Bolton has a lower than expected mortality rate.

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Cancer incidence Between 1977-79 and 2006-08, the incidence rate of new cases of cancer in Great Britain rose by 16% in males and 34% in females, although most of this rise was before the late 1990s. The number of new cases each year is predicted to continue to rise as the population grows and ages further. New research predicts that although the rate will hardly change at all, the number of new cases in the UK will rise from 298,000 in 2007, to 374,000 in 2020, and 432,000 in 2030. The incidence of cancer in GM is higher than the rate for England in all CCGs except Bolton. The Chart below compares the incidence of all cancers in each CCG area with GM, with those shaded red having a significantly higher incidence and those shaded green having a significantly lower incidence. The differences in incidence follow the pattern seen in differences in mortality suggesting that at least in part the higher mortality from cancer in North and South Manchester and Salford can be attributed to the higher incidence rate in these areas.

Cancer Incidence in Greater Manchester and CCG populations 2008-2010 Incidence (All cancers) European age-standardised rate 600

500

Rate

400

300

200

100

0 England

GMSCN

NHS Bolton

NHS Bury NHS Central NHS NHS North NHS Oldham NHS Salford NHS South NHS NHS Manchester Heywood, Manchester Manchester Stockport Tameside Middleton & and Glossop Rochdale

NHS Trafford

NHS Wigan Borough

CCG/Region

Deprivation Risk Factors for the development of cancer are distributed variably amongst the population with those who are socially and economically deprived being more likely to be exposed to factors such as smoking tobacco, poor diet (including lower intakes of protective fruit and vegetables) and physical inactivity.

Breast, Prostate, Colorectal and Lung Cancer Incidence Incidence of breast and colorectal cancers did not differ significantly between individual CCG areas and for GM as a whole from 2008-2010 (D Purkayastha, NWKIT 2014). For prostate cancer however there was greater variation across GM (see chart below). Central and South Manchester have significantly lower incidence rates of prostate cancer alongside Bolton. Bury, HMR and Oldham have significantly higher rates.

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Prostate Cancer Incidence in Greater Manchester and CCG populations 2008-2010 Incidence (Prostate Cancer) European age-standardised rate 160.0 European age-standardised rate 140.0

120.0

Rate

100.0

80.0

60.0

40.0

20.0

0.0 GMSCN

NHS Bolton

NHS Bury

NHS Central Manchester

NHS NHS North NHS Oldham NHS Salford NHS South Heywood, Manchester Manchester Middleton & Rochdale

NHS Stockport

NHS NHS Trafford NHS Wigan Tameside Borough and Glossop

CCG/Region

Lung Cancer Incidence in Greater Manchester and CCG populations 2008-2010  

Bolton Stockport and Trafford- significantly lower incidence compared to GM North Manchester, Salford and S Manchester significantly higher

Incidence (Lung Cancer) European age-standardised rate 120.0 European age-standardised rate

100.0

Rate

80.0

60.0

40.0

20.0

0.0 GMSCN

NHS Bolton

NHS Bury

NHS Central Manchester

NHS NHS North NHS Oldham NHS Salford NHS South Heywood, Manchester Manchester Middleton & Rochdale

NHS Stockport

NHS NHS Trafford NHS Wigan Tameside Borough and Glossop

CCG/Region

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Cancers caused by Modifiable Risk Factors The chart of smoking prevalence (2012, PHE) varies across GM and its association with the development of lung cancer is well established. Lung incidence in this year is expected to be associated with smoking behaviour in years past. Prevalence in 2012 provides information on the risk of future disease.

Smoking Prevalence 2012 30 25 20 15 10 5 0

Cancer Research UK represent the proportion of cancer deaths due to modifiable risk factors in men and women in the diagram overleaf. These deaths could be prevented.

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Ethnicity Research by the National Cancer Intelligence Network (NCIN) found that most BME groups, including Asian males and females, had a lower risk of getting cancer than the white population. The only cancer posing a higher risk to South Asian people than to the white population, across both sexes and all age groups, was liver cancer (between 1.5 and 3 times more likely in Asians than in Whites). Older Asian women (over 65 years) were found to have an increased risk of mouth and cervical cancers. South Asians were at significantly lower risk of getting any of the four major cancers (breast, prostate, lung and colorectal), plus several other less common cancer sites (including cancers of the bladder, brain and CNS, kidney, oesophagus, ovary, pancreas and malignant melanoma of the skin).

Trends in incidence and mortality The England cancer mortality rate for people aged 0 to 74 has declined steadily over the years for both males and females. During the same time frame there has been an increase in cancer incidence. The improvement in survival accounts for this phenomena.

Early Detection Indicators Cancer survival Survival rates depend on both the rate of incidence of new cases of cancer and on mortality rates once cancer has been diagnosed. The survival rate tells us the proportion of patients who are still alive 1 year after diagnosis. However, it is usually adjusted to allow for the fact that some of these people would have died anyway, for reasons other than cancer. The adjusted version is known as the relative survival rate. Survival rates are a reflection of the quality of care provided once cancer has been diagnosed. However, they will also be influenced by how advanced the cancer was when diagnosed, and 1-year survival rates in particular are considered to be a good proxy for early detection.

Difference between survival in England and other countries The Public Accounts Committee in 2011 heard that 10,000 of the annual 130,000 cancer deaths in England could be avoided if survival rates matched the best in Europe. Just reaching the European average survival rate would save 5,000 lives per year. On average, a PCT or CCG serving a population of 200,000 people would save 40 lives per year if survival rates in England matched those in Australia, Sweden or Canada. The Committee also learned that it was mainly on one-year survival rates that England compared poorly. Those who survived twelve months in England had as good a chance of reaching five years as anywhere else. This means that it is important to tackle late presentation and diagnosis.

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5 year survival by stage for colorectal, breast, lung and prostate cancer

Source: The King’s Fund (2011)

Survival rates are dated according to the year(s) when the patients concerned were diagnosed with cancer, so they will appear to lag behind the corresponding mortality statistics.

Trends in 1 year Survival in Greater Manchester Survival from Cancer has been steadily improving and most recently the adjusted survival rates for all cancers in GM has exceeded the national rate. This is noteworthy as the population are at increased risk from cancer in GM due to a combination of factors including those associated with deprivation and ethnicity.

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Cancer Survival and Deprivation Analysis of 3 years of survival data for patients diagnosed between 2008 and 2010 show that all of the differences in survival rates between each quintile of deprivation are statistically significant. These significant differences persist in for 5 year survival.

I year survival for all cancers diagnosed in GM from 2008-2010

In GM, the differences in 1 year survival between each quintile of deprivation are all statistically significant. People’s social and economic circumstances are associated with survival rate across the whole of society; it is not just people in the most deprived circumstances who are disadvantaged. The 1 year survival in GM was significantly better than in England for people in the least deprived quintiles 1 th and 2 and in the 4 quintile (more deprived) in people diagnosed from 2008-2010. During this time period there was no overall significant difference between 1 year survival in GM and England although in the most recently available data (reported on previous page) 1 year survival is now better in GM than in England as a whole. A similar gradient is observed in the study of the data for the differences in survival for lung, prostate and colorectal cancers. The differences are significant when comparing the survival of the least and most deprived quintiles.

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Further analysis of survival from breast cancer was undertaken by age group to investigate differences in survival between women of screening age and those who were older or younger. BREAST (Age-specific relative survival) - 1 year Relative survival (%)- diagnosed 2008-10 100 Relative survival (%) 90 80 70 60 50 40 Relative Survival (%)

30 20 10 0 1 - least deprived

2

3

4

5 - most deprived

1 - least deprived

2

3

4

5 - most deprived

1 - least deprived

2

3

4

5 - most deprived

Deprivation Score Age 20-49

Age >70

Age 50-70

1 year Cancer Survival in Greater Manchester and CCG areas diagnosed from 1996 to 2011 The last 15 years has seen a tremendous improvement in cancer survival across GM however we have not succeeded in addressing the inequalities and differences in survival between the areas of the city region.

CCG Bolton Bury HMR North Manchester Central Manchester South Manchester Oldham Salford Stockport Tameside and Glossop Trafford Wigan Greater Manchester

2011 68 68.5 68.5 65.6 70.5 68.6 66.2 67.8 70.8 67.6 71.0 67.6 68.9

1996 55 55.2 54.1 50.4 52.8 52.3 54.2 53.8 57.5 53.2 57.1 54.4 55.1

Source-HSCIC Indicator Portal.

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Route to Diagnosis Information on referrals can give a guide on the numbers and proportions of people who have been referred as an urgent referral, as a suspected case of cancer (two week wait -2WW), through usual referral routes and as an emergency case. In general survival rates are best for cases referred via the 2WW route.

Two week wait referrals The NHS Cancer Plan of 2000 introduced a maximum Two Week Wait (2WW) for an outpatient appointment for suspected cancer following urgent referral by a GP. The number of such referrals can be expressed as a rate per head of practice population, which reveals wide variation between practices and between PCTs. There is concern that low referrals combined with low use of diagnostic tests might mean that cases were being missed, and high referrals combined with high use of diagnostic tests might mean that money was being wasted.

Conversion rate The proportion of Two Week Wait referrals which result in a diagnosis of cancer is known as the ‘conversion rate’. The chart below illustrates the conversion rate for 2WW referrals in 2013/14 for each of the GM CCGs and GM as a whole. Most of the differences in conversion rate are not significantly different from the GM average but notably Central Manchester CCG is significantly lower. There is no significant difference in the conversion rate for GM (9.1%) and England where it is 9.0%.

2013/14 Proportion of urgent 2WW referrals that are diagnosed cancer cases 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00%

Source –Cancer commissioning toolkit CCG profiles Further analysis of data from the Cancer Commissioning Toolkit (NCIN) provides information on the proportion of all the cases diagnosed that are not 2WW referrals. A value below 50% means that less than half are not 2 WW ie more than half of all cases diagnosed are via the 2WW route. As 2 WW as a route to diagnosis is associated with improved survival then a lower value is a more positive indicator. Most of the differences between CCGs are not significant however. Oldham CCG performs best in terms of this indicator and the proportion on cases that are not 2WW is significantly less than in Bolton and Trafford who are also both significantly above the GM proportion.

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A national study of routes to diagnosis from 2006 to 2010 provided important evidence of the association between survival and route to diagnosis (NCIN). The route by which that diagnosis had been reached was recorded as via screening, Two Week Wait, other GP referral, or emergency admission. For almost all cancers, they found that 1-year relative survival following diagnosis through the emergency admission route was significantly lower than average. In GM 25% of cancers were diagnosed via emergency presentation and 23% in England as a whole. Of the emergency presenting cancers; 61% were via A and E, 28% from GP referral and 3% via inpatient emergency and 7% outpatient emergency.

Proportion of cases of cancer diagnosed in 2014/14 that are not via the 2WW referral route 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

Source –Cancer commissioning toolkit CCG profiles

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All Malignant Neoplasms (excl. NMSC) Bladder Bladder (in situ) Female breast cancer Female Breast (insitu) Colorectal Kidney and unspecified urinary organs Lung Prostate

5%

Death Certificate Only

Emergency presentation

Inpatient Elective

Other Outpatient

GP referral

Two Week Wait

Screen detected

Routes to Diagnosis by cancer site in GMLSC SCN footprint 2006-2010 (source PHE)

Unknown

Number of cases

110,547

25%

28%

12%

3%

25%

1%

3%

27%

32%

15%

4%

19%

0%

2%

28%

42%

14%

6%

8%

27%

43%

16%

5%

0%

6%

58%

13%

16%

8%

0%

1%

4%

24%

27%

12%

4%

27%

1%

2%

17%

31%

19%

2%

29%

1%

2%

23%

21%

12%

2%

40%

1%

2%

27%

44%

12%

3%

11%

0%

2%

0%

4,254

2%

1,656

3%

15,495

4%

1,610 13,062

2,898 16,362 13,187

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Stage at Diagnosis The Stage of a cancers development at diagnosis is important as we know that people with cancers diagnosed at an earlier stage have better prognosis. Cancers at stage 1 and 2 have not spread to a secondary site (have not metastasised). The Public Health Outcomes Framework indicator on the proportion of cases diagnosed in 2012 who were diagnosed at stage 1 or 2 does provide us with some insight into the variation across GM. • •

NHS Trafford CCG has the highest (49.6%) and NHS Central Manchester has the lowest (42.9%) proportion of cancers diagnosed at an earlier stage. All GM CCGs have a higher proportion of cancers detected at stage 1 or 2 compared to England (42%) supporting the observation made on the 1 year survival data- that this was at least in part due to improved earlier detection.

Source: CCT

Stage of cancer at diagnosis by cancer site in Greater Manchester, 2012 The data available on stage of diagnosis in 2012 provides further insight into early detection for different cancer sites and for different areas of Greater Manchester. Of particular concern are the large numbers of people being diagnosed at stage 3 or 4 with lung and colorectal cancers. Nearly three quarters of women are diagnosed with breast cancer at stage 1 or 2. Although proportionately fewer women are diagnosed with breast cancer at a later stage compared to other types of a cancer, early detection remains a concern as so many women are affected. 350 women in GM were diagnosed at stage 3 or 4 during 2012 which is nearly as many as the total numbers diagnosed with bladder or kidney cancer.

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Stage at Diagnosis for 6 Cancers in Greater Manchester in 2012 Cancer Type

Stage 1 Stage 2 No of % of all No of % of all cases cases cases cases Bladder 120 31.1% 85 22.0% Breast 799 40.1% 688 34.5% Colorectal 298 17.0% 399 22.7% Kidney 136 35.2% 27 7.0% Lung 347 15.2% 184 8.0% Prostate 698 42.4% 151 9.2% Source Sabrina Sandhu NW KIT

Stage 3 No of % of all cases cases 26 6.7% 221 11.1% 487 27.7% 53 13.7% 450 19.7% 245 14.9%

Stage 4 No of % of all cases cases 62 16.1% 129 6.5% 386 22.0% 83 21.5% 1082 47.3% 271 16.4%

Known No of cases 293 1837 1570 299 2063 1365

unknown No of % of all cases cases 93 24.1% 155 7.8% 186 10.6% 87 22.5% 223 9.8% 283 17.2%

The recording of data collected in 2012 on stage of diagnosis has improved, enabling more meaningful conclusions to be drawn. There is some variation in the proportion of cases where the stage has been recorded and this needs to be considered in any interpretation of the data, in particular caution is needed when the proportion of cases with stage unknown is high.

Stage of Diagnosis of cancer in each CCG in 2012 Lung Cancer In GM 45% of cases of lung cancer are diagnosed at stage 4 and only 16% at stage 1. There is some variation between the CCG areas of GM in the proportion of cases diagnosed at each stage. For either stage 4 alone or stage 3 and 4 combined, none of the differences between CCGs are significant. For cancers diagnosed at stage 1 it is only Trafford CCG where patients are more significantly likely to be diagnosed at an earlier stage compared to Bury, HMR and Tameside and Glossop. Most of the variation in proportions of patients diagnosed at each stage of lung cancer at diagnosis between different CCG areas is not significant.

Proportion of patients diagnosed with lung cancer at each stage in 2012 1

2

3

4

Unknown

60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

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Number and proportion of cases of lung cancer in 2012 by stage of diagnosis CCG Area

Stage 1 No of cases

Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Gtr Manchester

Stage 2 No of cases

28 17 16 14 28 32 36 23 36 22

% of all cases 14.2% 10.1% 18.4% 9.2% 17.7% 15.2% 16.1% 15.3% 15.7% 9.5%

44 51 363

23.4% 17.5% 15.9%

Stage 3 No of cases

17 14 6 9 15 22 19 17 16 13

% of all cases 8.6% 8.3% 6.9% 5.9% 9.5% 10.4% 8.5% 11.3% 7.0% 5.6%

13 23 193

6.9% 7.9% 8.4%

Stage 4 No of cases

30 36 21 41 32 50 33 27 39 49

% of all cases 15.2% 21.4% 24.1% 27.0% 20.3% 23.7% 14.7% 18.0% 17.0% 21.2%

% of all cases

96 81 39 71 69 88 116 69 120 109

48.7% 48.2% 44.8% 46.7% 43.7% 41.7% 51.8% 46.0% 52.4% 47.2%

36 56 414

19.1% 19.2% 18.1%

79 145 1022

42.0% 49.8% 44.7%

Stage unknown No of % of cases all cases 26 13.2% 20 11.9% 5 5.7% 17 11.2% 14 8.9% 19 9.0% 20 8.9% 14 9.3% 18 7.9% 38 16.5% 16 16 294

8.5% 5.5% 12.9%

Breast Cancer Nearly three quarters of all cases of breast cancer are diagnosed at stage 1 and 2. In all but 2 CCGs (Stockport and Tameside and Glossop) it is at stage 1 when most cases are diagnosed. Most noteworthy is that in North Manchester over 50% of cases were diagnosed at stage 1 in 2012; significantly more than in Stockport. It is important to note that in North Manchester uptake of the breast screening programme was lower than in other areas (see screening section for further information). North Manchester also had a significantly lower proportion of women diagnosed at stage 3 and 4 combined. A study of the database of breast cancer patients at the Nightingale showed Asian and Caucasian women presenting via the screening programme had a similar prognosis at diagnosis. The prognosis was poorer for South Asian women diagnosed via the symptomatic mammography service compared to their Caucasian counterparts. This is a concern also because the uptake of the screening programme is lower amongst South Asian women and that South Asian women are more likely to develop breast cancer before the age at which the screening programme starts.

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Total of cases 197 168 87 152 158 211 224 150 229 231 188 291 2286

Proportion of cases of breast cancer diagnosed from stage 1-4 in 2012 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

1

2

3

4

Unknown

Number and proportion of women diagnosed with breast cancer at each stage in 2012 CCG Area

Stage 1 No of cases

Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Gtr Manchester

Stage 2 No of cases

85 57 41 53 46 76 89 41 74 63

% of all cases 40.1% 40.1% 42.7% 40.2% 50.5% 43.9% 48.1% 39.8% 28.9% 32.0%

79 95 799

43.9% 42.2% 40.1%

Stage 3 No of cases

82 46 30 40 31 60 54 32 101 76

% of all cases 38.7% 32.4% 31.3% 30.3% 34.1% 34.7% 29.2% 31.1% 39.5% 38.6%

54 82 688

30.0% 36.4% 34.5%

Stage 4 No of cases

31 22 10 15 6 19 25 8 26 22

% of all cases 14.6% 15.5% 10.4% 11.4% 6.6% 11.0% 13.5% 7.8% 10.2% 11.2%

12 ≤5 9 13 ≤5 ≤5 11 7 17 19

% of all cases 5.7% 3.5% 9.4% 9.8% 2.2% 2.3% 5.9% 6.8% 6.6% 9.6%

16 21 221

8.9% 9.3% 11.1%

14 16 129

7.8% 7.1% 6.5%

Stage unknown No of % of cases all cases ≤5 0.9% 12 8.5% 6 6.3% 11 8.3% 6 6.6% 14 8.1% 6 3.2% 15 14.6% 38 14.8% 17 8.6% 17 11 155

9.4% 4.9% 7.8%

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Total of cases 212 142 96 132 91 173 185 103 256 197 180 225 1992

Colorectal Cancer There is a less marked difference in the proportions of people diagnosed with colorectal cancer at each stage compared to breast and lung cancer. It is at stage 3 where the greatest proportion (28%) of cases are diagnosed in GM and it is greatest in 9 of the 12 CCG areas. Combining stage 1 and 2 data there are no significant differences between the CCG areas in the proportion diagnosed at these earlier stages. Similarly for stage 3 and 4 combined there are no significant differences between the 12 CCG areas in the proportion diagnosed.

Proportion of cases of colorectal cancer diagnosed at each stage in 2012 in Greater Manchester CCGs 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

1

2

3

4

Unknown

Numbers and proportions of cases of colorectal cancer diagnosed at each stage in 2012 in Greater Manchester CCGs CCG Area

Stage 1 No of cases

Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Gtr Manchester

Stage 2 No of cases

43 23 12 17 18 25 16 13 32 34

% of all cases 22.3% 19.7% 15.6% 15.3% 21.4% 16.0% 10.7% 14.9% 15.5% 17.5%

25 40 298

17.5% 16.8% 17.0%

Stage 3 No of cases

43 23 17 29 15 31 41 19 42 57

% of all cases 22.3% 19.7% 22.1% 26.1% 17.9% 19.9% 27.3% 21.8% 20.4% 29.4%

24 58 399

16.8% 24.4% 22.7%

Stage 4 No of cases

51 36 21 29 26 46 41 26 62 39

% of all cases 26.4% 30.8% 27.3% 26.1% 31.0% 29.5% 27.3% 29.9% 30.1% 20.1%

40 23 22 25 12 34 28 22 52 45

% of all cases 20.7% 19.7% 28.6% 22.5% 14.3% 21.8% 18.7% 25.3% 25.2% 23.2%

42 68 487

29.4% 28.6% 27.7%

30 53 386

21.0% 22.3% 22.0%

Stage unknown No of % of cases all cases 16 8.3% 12 10.3% ≤5 6.5% 11 9.9% 13 15.5% 20 12.8% 24 16.0% 7 8.0% 18 8.7% 19 9.8%

Total of cases 193 117 77 111 84 156 150 87 206 194

22 19 186

143 238 1756

15.4% 8.0% 10.6%

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Prostate Cancer In GM, in 2012, 42% of prostate cancers were diagnosed at stage 1. A significantly greater proportion were diagnosed at stage 1 in Trafford (52 %), South Manchester (58.7%) and NS 43.4 % compared to Central Manchester (26%) and Tameside and Glossop (31%). However the level of recording of stage of diagnosis in Central Manchester was suboptimal (stage unknown in 47% of cases) and in Tameside and Glossop (stage unknown in 34 % cases), which makes any conclusions drawn about these areas unreliable. In GM 21% of cases of prostate cancer were diagnosed at stage 3 or 4. There were no significant differences in the proportion of cases diagnosed at these stages between any of the CCG areas.

Proportion of cases of prostate cancer diagnosed at each stage in 2012 in Greater Manchester CCGs 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

1

2

3

4

Unknown

Numbers and proportions of cases of prostate cancer diagnosed at each stage in 2012 in Greater Manchester CCGs CCG Area

Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Gtr Manchester

Stage 3

Stage 4

Stage 1 No of % of cases all cases 74 38.7% 59 43.4% 18 25.7% 60 44.1% 22 36.7% 62 49.2% 46 39.0% 44 58.7% 91 45.0% 52 30.1%

Stage 2 No of % of cases all cases 17 8.9% 18 13.2% 7 10.0% 9 6.6% ≤5 3.3% ≤5 1.6% 20 16.9% ≤5 4.0% 12 5.9% 15 8.7%

No of % of cases all cases 44 23.0% 15 11.0% ≤5 4.3% 24 17.6% 7 11.7% 22 17.5% 21 17.8% 7 9.3% 31 15.3% 22 12.7%

No of cases

70 100 698

12 34 151

10 39 245

52.2% 44.1% 42.4%

9.0% 15.0% 9.2%

7.5% 17.2% 14.9%

Stage unknown

No of % of all cases cases

Total of cases

42 22 9 25 15 26 18 14 25 25

% of all cases 22.0% 16.2% 12.9% 18.4% 25.0% 20.6% 15.3% 18.7% 12.4% 14.5%

14 22 33 18 14 14 13 7 43 59

7.3% 16.2% 47.1% 13.2% 23.3% 11.1% 11.0% 9.3% 21.3% 34.1%

191 136 70 136 60 126 118 75 202 173

19 31 271

14.2% 13.7% 16.4%

23 23 283

17.2% 10.1% 17.2%

134 227 1648

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Bladder and Kidney Cancer The small numbers of people diagnosed with Bladder and Kidney Cancer in each CCG area mean that it is difficult to draw any meaningful conclusions about the proportion of cases diagnosed at each stage of cancer and so these results are not included in this section of the report.

Number of cases of bladder cancer diagnosed at each stage in 2012 in Greater Manchester CCGs CCG 1 Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Greater Manchester

11 9 ≤5 12 ≤5 11 12 6 14 11 10 17 120

Stage at Diagnosis 2 3

8 14 ≤5 8 6 6 7 ≤5 10 6 8 7 85

≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 26

4

≤5 ≤5 ≤5 ≤5 ≤5 7 ≤5 2 6 ≤5 ≤5 13 62

Unknown

Total number of cases

13 5 7 8 ≤5 9 ≤5 ≤5 10 14 ≤5 13 93

42 35 16 36 19 35 27 18 43 37 25 53 386

Number of cases of kidney cancer diagnosed at each stage in 2012 in Greater Manchester CCGs CCG 1 Bolton Bury C Manchester HMR N Manchester Oldham Salford S Manchester Stockport Tameside and Glossop Trafford Wigan Greater Manchester

15 9 ≤5 16 6 12 10 9 14 14 14 16 136

Stage at Diagnosis 2 3

0 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 6 27

9 ≤5 ≤5 6 ≤5 ≤5 ≤5 ≤5 ≤5 ≤5 6 9 53

4

11 7 ≤5 ≤5 6 ≤5 6 ≤5 11 7 ≤5 15 83

Unknown

Total Number of cases

7 10 6 ≤5 ≤5 13 7 ≤5 7 7 10 9 87

42 31 16 32 23 36 27 17 38 32 37 55 386

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Screening What is coverage? The proportion of people in the eligible group of the population who actually undergo the screening. What is uptake? The proportion of people who when offered a test take it up, in effect those invited for screening for whom a test result is recorded. Uptake for all of the cancer screening programmes is lower in GM than that achieved nationally.

Breast Cancer Screening programme Breast cancer is the most common cancer in England and around a third of cases are diagnosed through the breast cancer screening programme. The age range for women to be invited to attend breast screening has extended from 50-70 years to 47-73 years. Breast screening is a method of detecting breast cancer at an early stage. The first step involves an x-ray of each breast - a mammogram, which is taken while carefully compressing the breast. Most women find it uncomfortable and some find it painful. The mammogram can detect small changes in breast tissue which may indicate cancers which are too small to be felt either by the woman herself or by a doctor.

Coverage by PCT (age range: 53-70) 2010- March 2013 Operating Standard: 70% Breast screening coverage women 53 to 70 PCT ALW Bolton Bury HMR Manchester Oldham Salford Stockport T&G% Trafford Greater Manchester

eligible 33421 27885 19395 20931 35121 22305 20628 30807 23651 22196 256340

2010/11 attended missed 25362 8059 21211 6674 15092 4303 15018 5913 23109 12012 16327 5978 14586 6042 23060 7747 17755 5896 16725 5471 188245 68095

coverage 75.9 76.1 77.8 71.8 65.8 73.2 70.7 74.9 75.1 75.4 73.4

eligible 33867 28360 19656 21277 35827 22529 20934 31162 24071 22695 260378

2011/12 attended missed 25357 8510 21396 6964 15245 4411 15360 5917 23050 12777 16450 6079 14811 6123 23300 7862 18013 6058 17124 5571 190106 70272

coverage 74.9 75.4 77.6 72.2 64.3 73 70.8 74.8 74.8 75.8 73

eligible 34553 28840 19919 21754 37353 22845 21458 31743 24525 23036 266026

2012/13 attended missed 25746 8807 21530 7310 15479 4440 15730 6024 24077 13276 16522 6323 14768 6690 23293 8450 18316 6209 17348 5688 192809 73217

coverage 74.5 74.7 77.7 72.3 64.5 72.3 68.8 73.4 74.7 75.3 72.5

Source: HSCIC Uptake and Coverage of breast cancer screening in GM, April-October 2013, Area National Greater Manchester Bolton CCG Bury CCG Central Manchester CCG Heywood, Middleton + Rochdale CCG North Manchester CCG Oldham CCG Salford CCG South Manchester CCG Stockport CCG Tameside And Glossop CCG Trafford CCG Wigan Borough CCG Source: NHS England

Uptake 50-70 years 73.2% 67.8%

Coverage 50-70 years 72.0% 68.4%

70.5% 71.1% 58.9% 65.6% 57.5% 70.2% 62.4% 58.0% 67.7% 71.0% 73.6% 72.3%

72.2% 74.1% 60.5% 67.6% 57.6% 66.8% 65.9% 62.4% 69.4% 69.3% 70.8% 71.0%

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The NHS England data for the North 50-70 years indicate that both the coverage and uptake are below the minimum standard of 70% for GM as a whole and in Manchester and Salford uptake is especially low. It is below the minimum standard in Heywood Middleton and Rochdale and Stockport. Coverage and uptake for the age range 50-70 years in GM is lower than for the age range 53-70. This discrepancy may be accounted for by the staggered recruitment into the programme across the GM geography. As the breast screening is a rolling programme this should be taken into consideration in

interpretation of the data and further analysis is warranted.

Cervical Cancer Screening programme Cervical screening is a method of preventing cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer in a woman's cervix (the neck of the womb). The first stage in cervical screening is taking a sample using liquid based cytology (LBC). A sample of cells is taken from the cervix for analysis. Women are invited for a smear test every three years between the ages of 25 and 49, and every five years between the ages of 50 to64 years. Of note is the particularly low coverage in Salford and Manchester areas (see table below) in the 25-49 year age range.

Coverage by CCG (age range: 25-49 and 50-64 years) - April 2013-Jan 2014 Area National Greater Manchester Bolton Bury HMR Oldham North Manchester CCG Central Manchester South Manchester Salford Stockport Tameside and Glossop Trafford Wigan

Age 25-49

71.6 70.7 70.6 73.6 71.0 71.3 66.1 63.8 68.0 68.0 74.6 72.6 71.9 74.7

Cervical screening coverage /% Age 50-64

79.4 78.3 79.6 79.7 79.4 78.4 74.2 75.6 73.5 77.2 80.6 78.4 78.7 78.5

Bowel Cancer Screening programme Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), and this is when treatment is more likely to be effective. Bowel cancer screening can also detect polyps that may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing. People aged 60-74 years are included in the bowel screening programme and are able to opt in over the age of 74years. The coverage of the bowel cancer screening programme has been steadily improving over the period recorded by the NHS England North region dashboard; April 2011-October 2013 to a peak on October 2013 of 50.5% for GM. Coverage is poorest in Manchester (see table below).

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Uptake by CCG (age range: 60-74) January – December 2013 - % CCG Bolton Bury Central Manchester Heywood, Midd & Roch North Manchester Oldham Salford South Manchester Stockport Tameside & Glossop Trafford Wigan Borough North West England

Jan-Mar 13 52.63% 55.24% 35.78% 52.83% 39.58% 51.92% 51.04% 43.52% 53.10% 50.60% 54.68% 54.15% 55.01% 58.70%

Uptake rates Apr-Jun 13 Jul-Sept 13 13 52.46% 50.71% 57.37% 53.58% 38.96% 35.94% 55.06% 50.49% 43.96% 40.11% 54.67% 51.64% 51.56% 48.41% 42.26% 42.80% 53.74% 56.02% 51.15% 50.83% 54.23% 56.85% 53.90% 51.54% 55.46% 50.21% 58.16% 52.80%

Oct-Dec 13 49.02% 49.89% 39.38% 46.27% 35.68% 46.17% 45.23% 41.34% 53.55% 49.81% 54.19% 48.44% 48.65% 51.65%

Jan-Dec 13 (cumulative rate) 51.42 54.14 37.44 51.22 40.05 51.33 49.42 42.50 54.10 50.61 54.99 52.33 52.44 55.30

Source: OBIEE dashboard In Greater Manchester the uptake of the screening programme for age 60-74 years was over 50% in 2013 as it was for the NW and England. Of particular concern is the low uptake in Manchester and Salford. Manchester has a greater proportion of its population from BME backgrounds who are understood to have a lower uptake of the bowel screening programme but this factor alone is not likely to account for the discrepancy as other areas, for example, Oldham also have a significant BME community. This requires further analysis of the demography of the population in the screening age group to further understand this. Age, gender, and deprivation are also known to be associated with bowel screening uptake.

Acknowledgement With thanks to Jason Gladwin, Analyst, GMLSC SCN, for assistance in preparing this report.

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