Cancers

Cancers

Overview

Overall, cancer is the second most common cause of death in Barnet and across the country. However, unlike CHD and stroke which are organ specific, there are many types of cancers which impact differently on organs.1

Overall, cancer is the second most common cause of death in Barnet and across the country. However, unlike CHD (which only affects the heart) and stroke (which only affects the brain) there are many types of cancer and different ones affect different organs and their causes and effects are different.2 For example, in 2004-2007, the total numbers of people in Barnet dying from some of the more common cancers were as shown in Table 1.

Table 1 The number of people dying from the more common cancers over the four-year period 2004-2007

Organ Total number of deaths over 4-year period 2004-2007

Average number of deaths/year (rounded)

Lung 575 144

Colon or rectum 293 73

Breast 234 59

Prostate 169 42

Bladder 49 12

Cervix 16 4

Source: Office for National Statistics Annual District Mortality Data

The risk we face

As death rates from CVD drop so more people live long enough to develop a cancer: cancer is thus becoming more common. However, like CVD, death rates from cancer are also dropping. This is predominantly due to earlier diagnosis, in part because of screening, and because many (but not all) cancer treatments are now much more effective than they used to be.

There are different risk factors for different cancers which independently or in combination, can increase an individual’s risk of developing a specific cancer.i,ii Tobacco use, for example, increases the risk for pancreatic, kidney and urinary bladder cancers, as well as for the more familiar lung, colorectal, head and neck and cervical cancers. Higher-than moderate alcohol intake can increase the risk of breast, oesophageal and head and neck cancer. High dietary fat and being obese can increase the risk for colon and breast cancer. There is also an increased risk for colorectal, breast, prostate, ovarian, thyroid and melanoma cancers for people in whom a first-degree relative has had one of these types of cancer.

The relationship between diversity and deprivation and cancer

1 Most cancers have similar characteristics, i.e. they are abnormalities of cell growth causing the affected tissue to grow in a relatively uncontrolled way. The majority of cancers spread locally by infiltrating adjacent tissues and spread distantly by ‘metastatic spread’ through the blood and lymphatic systems. The rate of growth, the degree of spread and the effect on other parts of the body differs with each type of cancer

2 Most cancers have similar characteristics, i.e. they are abnormalities of cell growth causing the affected tissue to grow in a relatively uncontrolled way. The majority of cancers spread locally by infiltrating adjacent tissues and spread distantly by ‘metastatic spread’ through the blood and lymphatic systems. The rate of growth, the degree of spread and the effect on other parts of the body differs with each type of cancer

Cancers 1

There is little reliable data in this country to draw any firm conclusions about differences in cancer incidence or survival rates amongst people in Black and minority ethnic groups. However, there is some evidence from studies in the United States of America that some Asian American subgroups are more likely to develop and to die from some cancers than people in other ethnic groups.iii And, for example, whilst large bowel cancer is common in developed countries its incidence in India is low,iv yet the incidence and spread of breast cancer has been shown to be different in people from different ethnic groups in New Zealand.v In terms of deprivation, there is evidence that women who live in more deprived communities tend to have poorer outcomes if they develop breast cancer.vi,vii There is also evidence to suggest that differences in breast cancer diagnosis, treatment and survival may be more related to economic differences than to ethnicity.viii,ix

Various factors have been reported that increase the risk of developing breast cancer. Some like gender (being female), age (being older), genes (having the BRCA 1 and 2 genes), ethnicity (being White), and having a family history of breast cancer all increase the risk but cannot be changed.x However, lifestyle factors like never given birth, having the first child after the age of 30 years, which are commoner features amongst women living in more affluent areas, obesity, high fat diets and inactivity, also increase the risk of breast cancer but can be changed in many instances.xi,xii

Research shows that cervical cancer and death from the disease is commoner amongst women living in more deprived areas.xiii There is also evidence that women from deprived backgrounds are less likely to attend for cervical screening, and this may be connected with reduced self-esteem, lower educational attainment and poorer literacy skills.xiv Women who smoke (smoking is also more prevalent amongst people in lower socio-economic groups) are less likely to attend for cervical screening.xv

There do not seem to be any specific associations between cervical cancer and women from Black and minority ethnic groups. However, there is some evidence that some women from these groups are likely to be screened more often than others and that others are likely to be screened less often. Error: Reference source not found The reasons for this are unclear.

There is also an association between cervical cancer and early age of first sexual intercourse, having many different sexual partners, having a large number of pregnancies and with smoking. Error: Reference source not found

Thus, the picture with cancer in terms of deprivation, ethnicity and other factors is complex and not easy to unravel. It is further complicated when examined at a local level because the numbers of people with different cancers (even the common ones) are relatively small. This means that year-to-year variations in the number of people developing cancer are not necessarily significant: it is the overall trend over several years that is more important.

Figure 1, and figure 21 show the trends in deaths from lung cancer, breast cancer and colorectal cancer (respectively) in relation to deprivation. This has been done by ranking all the census superoutput areas in Barnet by deprivation score and then dividing them into three groups (tertiles) of low, medium and high deprivation, and correlating the deaths occurring in each of these groupings.

Cancers 2

Figure 1: The trend in deaths from lung cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas)


Figure 2: The trend in deaths from breast cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas)


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Figure 3: The trend in deaths from colorectal cancer in people aged under 75 years in Barnet in areas with different deprivation scores (derived from census superoutput areas)


In Figure 1, there is a relatively clear trend: people living in the more deprived areas are more likely to die from lung cancer.

In the pattern is less clear and the numbers are smaller, which can exaggerate year-to-year differences. However, women in higher socio-economic groups are more likely to develop breast cancer and this is reflected in these data to some extent.

In Figure 21 it is not possible to discern an obvious trend other than the fact that overall the Barnet average death rate from colorectal cancer is relatively unchanged over the four years shown but there seems to be a trend of a decreasing rate amongst those living in the most affluent areas.

Local targets

In common with other London PCTs, Barnet has agreed to reduce deaths from cancer by 2010/2011 and our trajectory for this is shown in Figure 22.

Like other targets, cancer deaths cannot continue to drop to zero, but, it is reasonable to expect the NHS to further reduce cancer deaths. This can be achieved through (i) encouraging and enabling more people to be screened so that some cancers to be diagnosed sooner (when treatment is likely to be more effective), and (ii) supporting, within the resources available, the use of more aggressive and effective treatments.3

3 It is important to recognise that many of the new drugs developed to treat cancer do not cure but can, in some instances, prolong survival times. However, not all prolong survival by much, and many are very expensive. A balance has to be struck between the wants of individual patients and their relatives and the needs of the wider population: sometimes the needs of the wider population conflict with the needs of individuals, and the NHS has a duty to use public money to the maximum advantage of the maximum number of patients

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Figure 4: The trajectory for cancer deaths in Barnet

Source: Barnet PCT Operating Plan

Key things that need to be done

The key activities required are:

improving the uptake of screening (see section ) for breast and colorectal cancer screening – the two biggest cancer killers for which population screening is available;

work with local providers to improve access to services to ensure that people who may have cancer are investigated and, as necessary, treated, as soon as possible;

work with local providers to try to improve the availability of clinically and cost-effective treatments for cancer; and

continue to encourage people to avoid starting smoking and, for those who do, to encourage and enable them to quit – whilst stopping smoking will take many years before there is a detectable drop in deaths from cancers caused by smoking, stopping smoking improves the effectiveness of many treatments and reduces potential complications of surgery and, by increasing health generally, contributes to prolonging life.

Screening

Breast cancer screening

Nearly all breast cancers can be treated successfully if detected early, and regular breast screening with mammography, an x-ray examination of the breast, is reported as the single most effective way to detect breast cancer at an early, curable stage.xvi There has been a dramatic reduction in mortality since the late 1980s when over 15,000 women were dying each yearxvii and the data in figure 44 show that this has occurred in Barnet as well.

However, the latest available figures show that breast screening for Barnet PCT residents has fallen over recent years from 65% in 2005/06 (which was better than the pan-London rate of 62%). This is shown in Figure 5.

Figure 5: The proportion of women invited for breast screening who attended for mammography

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Source: North London Breast Screening Service performance report

The breast screening unit serving Barnet developed significant operational difficulties and was closed for a while in 2007. Whilst the service is running again and many of the problems have been dealt with, there is still some degree of backlog to overcome.

i Bal D.G., Nixon D. W.. Foerster S, B,. Brownson RC Cancer Prevention. In GP Murphy, W. Lawrence, and R E Lenhard Jr (Eds). American Cancer Society Textbook of Clinical Oncology (2nd ed) Atlanta, GA The American Cancer Society, Inc, 1995

ii Greenwald, P., Kramer B,S. Weed DL (eds) Cancer prevention and control. New York, NY: Marcel Dekker, Inciii McCracken M, Olsen M, Chen MS, Jemal A, Thun M et al. Cancer incidence, mortality, and associated risk

factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. Cancer Journal for Clinicians. 2007; 57(4):190-205

iv Mohandas KM. Desai DC. Epidemiology of digestive tract cancers in India Large and small bowel. Indian J Gastroenterology. 1999; 18(3):118-21

v Weston M K, Hill A. G, Moss DP. Differences in breast cancer biology between ethnic groups in New Zealand. Abstract number: BS015. The Royal Australasian College of Surgeons Annual Scientific Congress. 2006

vi Macleod U, Ross S, Twelves C, George D, Gillis C, Watt GMC. Primary and secondary management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records. Br Med J 2000; 321: 1442-5

vii Bradley C.J., Given C W, Roberts C.Disparities in cancer diagnosis and survival. Cancer 2001; 91: 178 – 88viii McGinnis LS, Menck HR, Eyre HJ, Bland KI Scott – Conner CE et al. National Cancer Data Base survey of

breast cancer management for patients form low income zip codes. Cancer 2000; 88 933 - 45ix Bradley C, Given CW, Roberts C. Race, Socioeconomic Status, and Breast Cancer Treatment and Survival.

Journal of the National Cancer Institute 94; 7: 490 - 496x Yood MU, Johnson CC, Blount A, Abrams J, Wolman E, McCarthy BD, et al. Race and differences in breast

cancer survival in a managed care population. Journal of the National Cancer Institute 1999; 91:1487-91xi McPherson K, Steel CM, Dixon JM. Breast cancer – epidemiology, risk factors and genetics. Br Med J 2000;

321: 624-8xii Hunter DJ and Willett WC: Diet, body size, and breast cancer. Epidemiol Rev 15:110-132, 1993.xiii Barnet Health Authority. Cervical Screening Coverage in Barnet: An action plan to improve the coverage rate.

Barnet Health Authority. London 1999.xiv Zelenyanszki, C. Psychosocial variables in women attending or non-attending for their cervical screening test:

systemic literature review. September: 2002. PR: 1901 4805 xv Chiu F. inequalities of access to cancer screening: a literature review: Cancer Screening Series No 1: NHS

Cancer Screening Programmes: December 2003xvi Bal D.G., Nixon D. W.. Foerster S, B,. Brownson RC (1995) Cancer Prevention. In GP Murphy, W. Lawrence,

and R E Lenhard Jr(Eds). American Cancer Society Textbook of Clinical Oncology (2nd ed) Atlanta, GA The American Cancer Society, Inc, p. 42

xvii Office for National Statistics Twentieth Century Mortality - 95 years of mortality data in England and Wales by age, sex, year and underlying cause. Office for National Statistics. London. 1997

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This is not the only issue: the data in Figure 5 show the proportion of women who are invited to attend for screening and who subsequently do so. The service needs to become more accessible and there is an important need to enable people to understand the importance and benefit of breast screening and thus why they should attend. Put simply, breast screening increases the likelihood of a woman who has breast cancer being diagnosed at an earlier stage and thus being more likely to overcome the disease: earlier treatment is more likely to be successful.

Colorectal cancer screening

Bowel cancer is the second most common cause of cancer deaths in the UK, and has the fourth highest incidence of cancer in Barnet PCT.xviii It is predicted that deaths from bowel cancer could drop by as much as 15% as a result of screening.xix Overall, deaths from bowel cancer in Barnet are declining (see also Figure 21) and this is likely to be due to early diagnoses being made and to treatment being more effective. Full implementation of the bowel screening programme in Barnet began in October 2007 and, as a consequence, bowel cancer’s contribution to the overall cancer mortality rate should start to reduce further.

The bowel cancer screening programme invites men and women aged 60-69 (people aged 70 or over are provided with a testing kit on request) to be screened for bowel cancer every two years. Testing kits are sent direct to individuals to be used in their homes.

xviii Thames Cancer Registry – Cancer in Barnet 1994-2004xix Cochrane Database of Systematic Reviews, 2006. Screening for colorectal cancer using the faecal occult blood

test: An update

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Documents

Cancers