ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

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ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

    Report of the Independent Cancer Taskforce
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

EXECUTIVE SUMMARY                                                         4

1.   THE CURRENT LANDSCAPE OF CANCER IN ENGLAND                           7

2.   AMBITIONS AND PERFORMANCE METRICS                                   12
     2.1   CANCER INCIDENCE                                              12
     2.2   CANCER SURVIVAL                                               12
     2.3   PATIENT EXPERIENCE AND QUALITY OF LIFE                        13
     2.4   UNDERPINNING METRICS                                          13

3.   PRINCIPLES                                                          16

     4.1  LIFESTYLE AND AWARENESS                                        17
     4.2  SMOKING                                                        18
     4.3  OBESITY AND OVERWEIGHT                                         19
     4.4  ALCOHOL                                                        20
     4.5  UV RADIATION EXPOSURE                                          20
     4.6  HPV INFECTION                                                  21
     4.7  DRUGS TO PREVENT CANCER                                        21
     4.8  LIFESTYLE-BASED SECONDARY PREVENTION                           22
     4.9  OCCUPATIONAL EXPOSURES                                         22

5.   HOW SHOULD WE IMPROVE SURVIVAL?                                     23
     5.1  SCREENING                                                      23
     5.2  EARLY DIAGNOSIS                                                26
     5.3  TREATMENT                                                      34
     5.4  MOLECULAR DIAGNOSTICS                                          39
     5.5  ENHANCING TREATMENT SERVICE DELIVERY                           41
     5.6  SPOTLIGHT ON TARGET GROUPS                                     42
     5.8  RESEARCH AND INNOVATION                                        45

     6.1  MEASURING PATIENT EXPERIENCE                                   48
     6.3  STAFF EXPERIENCE                                               50
     6.4  SHARED DECISION-MAKING                                         50
     6.5  DIGITAL COMMUNICATION                                          51
     6.6  WORKFORCE COMMUNICATION SKILLS                                 52
     6.7  ROLE OF CLINICAL NURSE SPECIALISTS                             52
     6.8  CANCER SUPPORT GROUPS                                          53
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

         AND AT THE END OF LIFE?                                                  54
         7.1   LIVING WITH AND BEYOND CANCER                                      54
         7.2   MEASURING QUALITY OF LIFE                                          55
         7.4   FOLLOW-UP PATHWAYS                                                 57
         7.5   CANCER REHABILITATION                                              58
         7.6   DEPRESSION                                                         58
         7.7   PROVISION OF CARE IN THE COMMUNITY                                 59
         7.8   SUPPORTING PEOPLE WITH CANCER TO RETURN TO WORK                    59
         7.9   END OF LIFE AND PALLIATIVE CARE                                    60

         DRIVE IMPLEMENTATION?							                           		              62
         8.1       COMMISSIONING                                                  63
         8.2       LOCAL IMPROVEMENT ARCHITECTURE                                 65
         8.3       NATIONAL QUALITY STANDARDS                                     66
         8.4       QUALITY ASSESSMENT                                             67
         8.5       WORKFORCE                                                      68
         8.6       CANCER DATA AND INTELLIGENCE                                   72
         8.7       RESPONSIBILITY FOR IMPLEMENTING THE STRATEGY                   73
         8.8       NATIONAL ACCOUNTABILITY                                        74
         8.9       VALUE FOR MONEY                                                74
         8.10      BEYOND 2020                                                    74

    9.   HOW MUCH WILL IT COST?                                                   75

    ANNEX A: METHODOLOGY AND ACKNOWLEDGEMENTS                                     79

    ANNEX B: GLOSSARY AND ABBREVIATIONS                                           81

    ANNEX C: REFERENCES                                                           87
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

Over the next five years, we can improve           Over the last ten years, we have been able
radically the outcomes that the NHS delivers       to fill critical gaps in our knowledge about
for people affected by cancer. This report         cancer. We have begun to understand its
proposes a strategy for achieving this.            intricacies better as well as the short and
                                                   long term impacts it can have on patients.
It includes a series of initiatives across the     This has enhanced our ability to address
patient pathway. These emphasise the               these impacts and deliver improved
importance of earlier diagnosis and of living      outcomes for patients, their carers and their
with and beyond cancer in delivering               families, as well as limit the burden that
outcomes that matter to patients. The report       cancer places on society.
recognises that no two patients are the
same, either in their cancer or their health       However, the number of people diagnosed
and care needs. At its heart, it sets out a        and living with cancer each year will
vision for what cancer patients should             continue to grow rapidly, even with major
expect from the health service: effective          improvements in prevention. The primary
prevention (so that people do not get              reasons for this are our ageing population
cancer at all if possible); prompt and             and our success in increasing survival. This
accurate diagnosis; informed choice and            will place significant additional demand on
convenient care; access to the best effective      health and social care services. Cancer
treatments with minimal side effects; always       survival in England has improved
knowing what is going on and why; holistic         significantly over the last 15 years. More than
support; and the best possible quality of life,    half of people receiving a cancer diagnosis
including at the end of life. It is crucial that   will now live ten years or more. But our
patients are treated as individuals, with          mortality rates are higher than they could
compassion, dignity and respect                    be. In addition, unacceptable variability
throughout. The strategy seeks also to             exists in access to and experience of care
harness the energy of patients and                 across different areas, sub-groups of the
communities and encompass their                    population and cancer types. There is much
responsibilities to the health service. This       we could do to improve patient experience
means taking personal ownership for                and long-term quality of life, and to make
preventing illness and managing health;            our care more patient-centred.
getting involved in the design and
optimisation of services; and providing            The Independent Cancer Taskforce has
knowledge as experts through experience.           consulted widely to determine how the NHS
                                                   can deliver a step-change in outcomes. It
For the NHS, there is the opportunity to           has identified where opportunities exist for
deliver the vision set out in the Five Year        improvement, and how resources can be
Forward View (FYFV). Because of the strong         used differently and in a more targeted way.
evidence base that exists, cancer is uniquely      Realising the potential will require a broad
placed to be an early exemplar. Success in         set of approaches, including more
delivering the aspirations of this strategy will   integrated pathways of care and increased
depend on devolved decision-making,                investment. It will need the active
agility, and new models of care, within a          involvement of a range of individuals and
framework of national standards and                organisations beyond the NHS. Many of
ambitions. In turn, this will be reliant on        these approaches will deliver benefits not
research and intelligent use of data to drive      just for cancer patients, but for people with a
continuous improvement, as well as a “test         range of other conditions. They will also
and learn” approach in areas where the             deliver financial savings in the medium to
evidence of what works is immature. It will        long term.
also be reliant on the culture and attitude of
health care professionals in embracing             This report encompasses a large number of
partnership working with patients, seeing          recommendations. However, we propose
them as equals in decisions about their            that the six strategic priorities over the next
treatment and care.                                five years should be:
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

    • Spearhead a radical upgrade in                                   follow-up care will be in place for the
      prevention and public health: The NHS                            common cancers. A national quality of
      should work with Government to drive                             life measure should be developed by 2017
      improvements in public health, including                         to ensure that we monitor and learn
      a new tobacco control strategy within the                        lessons to support people better in living
      next 12 months, and a national action                            well after treatment has ended. We also
      plan on obesity. We should aim to reduce                         recommend that CCGs should
      adult smoking prevalence to less than                            commission appropriate End of Life care,
      13% by 2020 and less than 5% by 2035;                            in accordance with the NICE quality
                                                                       standard, and taking into account the
    • Drive a national ambition to achieve                             independent Choice Review and
      earlier diagnosis: This will require a shift                     forthcoming Ambitions;
      towards faster and less restrictive
      investigative testing, quickly responding to                  • Make the necessary investments
      patients who present with symptoms, by                          required to deliver a modern high-
      ruling out cancer or other serious disease.                     quality service, including:
      We recommend setting an ambition that
      by 2020, 95% of patients referred for testing                    o Implementing a rolling plan to replace
      by a GP are definitively diagnosed with                            linear accelerators (linacs) as they
      cancer, or cancer is excluded, and the                             reach 10-year life and to upgrade
      result communicated to the patient, within                         existing linacs when they reach 5-6
      four weeks. Delivering this will require a                         years;
      significant increase in diagnostic                               o Working to define and implement a
      capacity, giving GPs direct access to key                          sustainable solution for access to new
      investigative tests, and the testing of new                        cancer treatments, building from the
                                                                         Cancer Drugs Fund;
      models which could reduce the burden
                                                                       o Rolling out a molecular diagnostics
      and expectation on GPs;                                            service which is nationally-
                                                                         commissioned and regionally
    • Establish patient experience as being                              delivered, enabling more personalised
      on a par with clinical effectiveness and                           prevention, screening and treatment;
      safety: We have the opportunity to                               o Implementing plans to address critical
      revolutionise the way we communicate                               workforce deficits and undertaking a
      with and the information we provide to                             strategic review of future workforce
      cancer patients, using digital                                     needs and skills mix for cancer. The
      technologies. From the point of cancer                             priority deficit areas to address should
      diagnosis onwards, we recommend                                    be radiology, radiography and
      giving all consenting patients online                              endoscopy for diagnosis; and clinical
                                                                         oncology, medical oncology and
      access to all test results and other
                                                                         clinical nurse specialists for treatment
      communications involving secondary or                              and care;
      tertiary care providers by 2020. We should                       o Supporting a broad portfolio of cancer
      also systematise patients having access                            research.
      to a Clinical Nurse Specialist (CNS) or
      other key worker to help coordinate their                     • Overhaul processes for commissioning,
      care. We should continue to drive                               accountability and provision. We
      improvement through meaningful patient                          recommend setting clearer expectations,
      experience metrics, including the annual                        by the end of 2015, for how cancer
      Cancer Patient Experience Survey, which                         services should be commissioned. For
      should be embedded in accountability                            example, most treatment would be
      mechanisms;                                                     commissioned at population sizes above
                                                                      CCG level. By 2016, we should establish
    • Transform our approach to support                               Cancer Alliances across the country,
      people living with and beyond cancer:                           bringing together key partners at a sub-
      We recommend accelerating the roll-out                          regional level, including commissioners,
      of stratified follow up pathways and the                        providers and patients. These Alliances
      “Recovery Package”. The aim should be                           should drive and support improvement
      that by 2020 every person with cancer will                      and integrate care pathways, using a
      have access to elements of the Recovery                         dashboard of key metrics to understand
      Package, and stratified pathways of
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

  variation and support service redesign.
  We should also pilot new models of care
  and commissioning. For example, the
  entire cancer pathway in at least one
  area should have a fully devolved budget
  over multiple years, based on achieving a
  pre-specified set of outcomes.

The National Audit Office has estimated
cancer services cost the NHS approximately
£6.7bn per annum in 2012/13. The Five Year
Forward View projections indicate that this
will grow by about 9% a year, implying a
total of £13bn by 2020/21. The
recommendations set out in this report will
cost an estimated £400m per annum, of
which approximately £300m per annum
may already be included within the FYFV
baseline projections. However, in the
medium term, implementation of these
recommendations should contribute
substantially in excess of £400m per annum
to the projected £22bn funding gap.

If the NHS is successful in implementing the
initiatives and ambitions outlined in this
strategy, we expect that the most significant
benefits will be:

• An additional 30,000 patients per year
  surviving cancer for ten years or more by
  2020, of which almost 11,000 will be
  through earlier diagnosis;
• A closing of the gap in survival rates
  between England and the best countries
  in Europe and elsewhere;
• Better integration of health and social
  care such that all aspects of patients’ care
  are addressed, particularly at key
  transition points;
• Cancer patients feeling better informed,
  and more involved and empowered in
  decisions around their care;
• A radical improvement in experience and
  quality of life for the majority of patients,
  including at the end of life;
• A reduction of the growth in the number of
  people being diagnosed with cancer;
• A reduction in the variability of access to
  optimal diagnosis and treatment and the
  resulting inequalities in outcomes;
• Significant savings which can be re-
  invested to cope with increases in
  demand and to achieve further
  improvements in outcomes.
ACHIEVING WORLD-CLASS CANCER OUTCOMES - A STRATEGY FOR ENGLAND 2015-2020 - Report of the Independent Cancer Taskforce - Cancer Research UK

    Every two minutes someone in England will                                  are increasing our age-standardised risk.
    be told they have cancer. Half of people                                   These changes place increasing demands
    born since 1960 will be diagnosed with                                     on the health system, alongside demands
    cancer in their lifetime1 (see Figure 1), with                             resulting from the changing nature of other
    that proportion continuing to rise. The good                               conditions. As noted in the FYFV, long-term
    news is that cancer survival is at its highest                             health conditions – rather than illnesses
    ever2, with significant improvements made                                  amenable to a one-off cure – now consume
    over the last 15 years. More than half of                                  70% of the health service budget.
    people receiving a cancer diagnosis will
    now live ten years or morei2. This progress
    has been driven by improvements in our                                     New cancer patients diagnosed
    knowledge of how to treat and control                                      400,000
    cancer, combined with the commitment of                                                                               new
    NHS staff to deliver transformative care.                                                                   o je cted
                                                                               300,000                        Pr
                                                                                           New ca
          Lifetime risk of cancer
         55%                                                                   200,000


         45%                                                                             2000          2010          2020                2030
                                                                                         Year of diagnosis

         40%                                                                              Figure 2: Incidence projection4

                                                                               Cancer is the biggest cause of death from
         35%                                                                   illness or disease in every age group, from
                                                                               the very youngest children through to old
                 1930             1940             1950            1960        age, with mortality significantly higher in
                 Year of birth
                                                                               men than in women. Death rates in England
                 Figure 1: Lifetime risk of cancer1                            have fallen by more than a fifth over the last
                                                                               30 years and by 10 per cent over the last
    A total of 280,000 individuals are now                                     decade5. They are expected to continue to
    diagnosed with cancer in a year, a number                                  fall, with a drop of around 17% by 20306 (see
    which has been growing by around 2% per                                    Figure 3). But 130,000 people still die from
    annum3 (see Figure 2). Around half of these                                cancer each year – a number that has
    diagnoses will be of the most common                                       remained relatively constant as incidence
    cancers – breast, lung, prostate, and                                      has increased. There also remain groups of
    colorectal – and the other half will be of rare                            patients for whom outcomes and quality of
    or less common types. Incidence is                                         life are particularly poor. Survival has
    expected to reach over 300,000 diagnoses in                                improved significantly in some types of
    2020, and more than 360,000 in 20304. The                                  cancer, notably malignant melanoma,
    rise is due partly to the ageing and growth of                             breast, testicular and prostate cancers.
    the population, a result of the overall success                            However, in lung, pancreas and
    of the healthcare system, such that people                                 oesophageal cancers and most brain
    are less likely to die early from other                                    tumours, survival has remained stubbornly
    conditions, such as cardiovascular disease.                                low to date.
    But the rise in cancer diagnoses is also in
    part driven by shifts in our lifestyles, which

        Age-standardised ten-year survival from all cancers is now above 50%
                                                                            Fig 4 - Deprivation.pdf   1   16/07/2015   10:14

  Actual and Projected Number of Deaths, UK                                     Avoidable
                                                                                                                                         Cancer of
                   300                                                               Lung                                                unknown


                   250                                                                                                                           1,600            650
Rate per 100,000

                                       Per                                                                                               Stomach         Others
                                           ale                                                                                                   1,400
                         1970   1980   1990    2000   2010   2020   2030
                                              Year                                                                             11,700              730

            Figure 3: Cancer mortality projections –
            actual and projected number of deaths,
                         persons, UK6
                                                                                                                                         Cancer of
We see significant variation in survival                                               Lung                                              unknown                  520
outcomes for patients across England. For                                                                                                                  Others
example, one year survival in some CCGs is                                                                                                         1,700
more than 10% higher than in others7. This                                                                                               Oesophagus
variability cannot be explained solely by
correlation with deprivation levels. It can be                                                                                                 1,100
quantified across a number of indicators. For                                                                                            Stomach
example, there is around a two-fold
difference in the proportion of cancers
diagnosed at an early stage8.
Health inequalities across England mean                                                                                        9,900     Liver
there is potentially avoidable variation in
survival outcomes9 (see Figure 4). There
would be around 15,300 fewer cases and                                       Figure 4: Yearly excess cancer cases and
19,200 fewer deaths per year across all                                           deaths attributed to deprivation9
cancers combined9 if socio-economically
deprived groups had the same incidence
rates as the least deprived . More than half                                People in the UK with a cancer diagnosis
of the inequity in overall life expectancy
between social classes is linked to higher
smoking rates among poorer people.
                                                                                                                               2                                   3.4
The combination of improvements in survival                                                                            million                                     million
and detection, and a growing and ageing                                                                                                                          (projected)
population has resulted in an estimated 2
million people living in England who have
had a cancer diagnosis. This represents an
                                                                                     2010                                 2015          2020         2025               2030
increase of 0.3 million in the last five years10
and the number is projected to rise to 3.4
million in 203010 (see Figure 5). Of people                                Figure 5: Projections of cancer prevalence in
living with cancer, prostate is the most                                               England, 2010 – 203010
prevalent type in men and breast in women.
                                                                           Patient experience of hospital treatment has
                                                                           been measured systematically for the last
                                                                           four years and been positive overall.
                                                                           However, this masks considerable variability,
                                                                           with older and younger patients, those from
                                                                           BME groups, those with less common

    cancers and those in some parts of the
    country such as London all reporting lower                                     With no other
    levels of satisfaction11. Furthermore, patients                                long-term
    across the country report that poor                                            conditions (LTCs)
    communication is the aspect of care most in
    need of improvement, both in terms of the                                                     30%
    information they are given about their                                         With 1 other LTC
    diagnosis and treatment options, and in the
    level of compassion and empathy they
                                                                                   With 2 other LTCs
    Historically, there has been less focus on the
    care received by patients after their initial
    treatment. We know that patients who have                                      With 3+ other LTCs
    been diagnosed with cancer have a greater
    risk of being diagnosed with cancer again in
    the future. Many of the treatments we use
    can have long-term physical and mental
    health consequences, which result in a high
    proportion of individuals requiring                               Figure 6: Proportion of people with cancer in
    subsequent health and social care support,                       the UK living with other long-term conditions12
    and there are also practical impacts for
    patients such as loss of income. Our lack of                    Many patients have inadequate care
    attention to these issues may result in poorer                  support or may be carers themselves.
    quality of life for patients and increased                      Therefore, it is imperative to take a holistic
    pressure on their carers, as well as inefficient                and individual perspective in considering
    use of scarce resources.                                        the after-treatment care and support that
                                                                    patients need. Not doing so can have
    Many patients treated for a primary cancer                      multiple adverse consequences, not least
    will also develop secondary or metastatic                       exacerbating the “bed-blocking” problem
    cancer, which can often be incurable.                           which bedevils NHS secondary care services.
    Nevertheless, these patients may live for
    many years with the disease, and they                           For too many people, cancer remains a
    should be given the treatment and support                       disease from which they will die. Evidence
    they need to live for as long and as well as                    shows that many of these people are not
    possible, managing their cancer effectively                     experiencing the care they would like at the
    as a chronic condition.                                         end of their lives. Around three in four people
    The experience and quality of life that                         with cancer would prefer to die at home with
    patients have through and beyond                                the right support and with their friends and
    diagnosis and treatment is equally as                           family around them, rather than in a hospital
    important as clinical effectiveness and                         or hospice13. However, less than a third are
    safety. Because the majority of cancer                          able to exercise that choice at present. We
    patients are over the age of 65, it is also the                 also know that just one in five people with
    case that many have multiple morbidities. It                    cancer who die at home have complete
    is estimated that 70% of cancer patients                        pain relief all the time in the last three
    have at least one other long-term condition                     months of life, compared with just under two-
    that needs managing and over a quarter                          thirds of those with cancer who die in a
    have at least three other such conditions12                     hospice14.
    (see Figure 6).
                                                                    Despite international surveys15 ranking the
                                                                    NHS highly on the basis of overall
                                                                    performance in health and efficiency, this is
                                                                    not true of cancer outcomes, in which we
                                                                    lag considerably behind countries of similar
                                                                    wealth. Some aspects of our delivery – such
                                                                    as screening and vaccine uptake, and
                                                                    smoking cessation services – are admired
                                                                    across the world, but this is not reflected in

our survival rates. We have amongst the                                                effective treatments. Neither do we have the
lowest levels of cancer incidence of rich                                              optimal capacity and configuration of
countries, but amongst the highest levels of                                           resources to support patients beyond their
mortality16. This situation has persisted since                                        initial treatment.
researchers began collating these data
systematically in the 1990s. There is now                                                  Lung cancer
                                                                                           5-year survival changes, 1995-1999 to 2005-2007
strong evidence that late diagnosis and sub-
optimal access to treatment – particularly for                                                              0%       5%         10%     15%       20%

patients with more advanced disease - are                                                   Canada
the key drivers for these poorer clinical                                                   Australia
The most up-to-date published international                                                 Norway
comparisonsii show that relative survival
during 1995-2007 improved for breast,                                                       Denmark
colorectal, lung and ovarian cancer patients                                               UK* cancer
   Lung cancer 22                                                                         Breast
in all jurisdictions
   5-year               . However,
           survival changes, 1995-1999the   gap in
                                        to 2005-2007                                      5-year survival changes, 1995-1999 to 2005-2007
survival   between
   Lung cancer         the   highest   performing                                         Breast cancer
                  0%      5%       10%       15%     20%                                             70%                  75%     80%     85%      90%
   5-year    (Australia,
           survival changes,Canada
                             1995-1999and    Sweden)
                                        to 2005-2007                                      5-year survival changes, 1995-1999 to 2005-2007
    Canada                                                                                  Sweden
and the lowest (England, Northern Ireland,                                                 Bowel cancer
    Australia                                                                                Australia
                  0%      5%       10%       15%     20%                                             70%                  75%     80%     85%      90%
Wales    and Denmark) remains largely
    Canada                                                                                 5-year survival changes, 1995-1999 to 2005-2007
    Sweden except for breast             cancer, where                                       Canada       45%      50%      55%      60%              65%
the UK   is narrowing the gap22 (see Figure 7).                                              Australia
        recently, the survival gap has also                                                  Norway
    Sweden                                                                                   Canada
started   to close in stomach and rectal                                                     Canada
    Denmark                                                                                  Denmark
    Norwayaccording to as yet unpublished
cancers,                                                                                     Norway
    UK*                                                                                      Sweden
data.   But it remains significant in lung and
    Denmark                                                                                  Denmark
colon cancers. Here there is also evidence
                                                                                           Lung   cancer
                                                                                           5-year survival changes, 1995-1999 to 2005-2007
of aUK*
     worse stage distribution at diagnosis                                                   UK*
                                                                                            Denmark 0%               5%         10%     15%     20%
than comparator countries, i.e. cancers are
more         cancer on average at the time of
        advanced                                                                           Ovarian
                                                                                            UK*    cancer
   5-year survival changes, 1995-1999 to 2005-2007                                         5-year survival changes, 1995-1999 to 2005-2007
diagnosis.                                                                                   Australia
        Bowel cancer
                 45%                  50%         55%         60%         65%              Ovarian cancer
                                                                                                     25%             30%      35%       40%        45%
        5-year survival changes, 1995-1999 to 2005-2007                                    *5-year
                                                                                              UK includes
                                                                                                            changes,Northern Ireland
                                                                                                                      1995-1999       and Wales
                                                                                                                                 to 2005-2007
Treatment differences play a more                                                             Canada
signifi cant role45%than anticipated
                            50%      55%
                                           at the
                                                   time65%                                  Norway
                                                                                                             25%          30%     35%     40%      45%
      Australia                                                                              Canada
these international comparisons were                                                        Denmark
      Sweden                                                                                Australia
      Canadawith survival within stage being
initiated,                                                                                   Norway
          in England too (particularly for more                                             UK*
      Sweden                                                                                 Australia
      Denmarkbreast and ovarian cancers).                                                   Denmark
          Europe, cancer survival for older                                                  UK*
peopleUK*  (75 and above) tails off markedly
      Denmark                                                                               Denmark
                                                                                           Bowel cancer
compared with survival for younger age
      UK* (e.g. 55-64) 23. In 2012, one year                                               5-year survival changes, 1995-1999 to 2005-2007
    * UK includes England, Northern Ireland and Wales
survival was 57% and 77% in these groups                                                                     45%      50%         55%     60%      65%

respectively    23
                   .                                                                         Australia
    * UK includes England, Northern Ireland and Wales
Over the last several years, the growth in
demand for cancer services has not been                                                      Sweden
met by an associated growth in capacity.                                                     Norway
There are significant workforce deficits,
particularly in diagnostic services, oncology,
and in specialist nursing support. These                                                     UK*
shortfalls result in severe bottlenecks in the
diagnostic process, suboptimal care in                                                     * UK includes England, Northern Ireland and Wales
certain parts of the country, and an inability
to deliver newer, evidence-based and cost-                                              Figure 7: Age standardised five-year survival
                                                                                        trends, 1995 – 2007, by cancer and country22
     Comparisons are with countries that also have universal health coverage and comprehensive cancer registration

     Finally, commissioning of cancer services
     has become highly fragmented and, partly
     as a result, insufficiently accountable. CCGs
     consistently report that they have neither the
     expertise nor the time adequately to
     commission complex cancer services, many
     of which are changing rapidly as research
     drives progress. Until recently, CCGs had little
     role in the commissioning of diagnostic
     services, and some still do not. Pathways are
     neither optimised for patients nor for use of
     resources. Furthermore, there is a lack of
     hard accountability when providers or
     commissioners fail to meet national targets,
     as demonstrated by hospitals missing the 62-
     day wait standard for over a year24.

     In conclusion, there may be much to
     celebrate since the first NHS Cancer Plan was
     published in 2000, but there remains much
     more to do.

This strategy focuses on the outcomes which      some less common cancers or those with the
matter most to patients and society. This is     poorest outlook, will offer greater scope for
not only about improving survival. We also       gains than others. This strategy focuses on
need to ensure that we reduce the incidence      three ambitions related to survival:
of cancer and improve patients’ experience
and quality of life.                             • Increase in 5 and 10-year survival.
                                                   Surviving for ten years following a cancer
2.1 CANCER INCIDENCE                               diagnosis is far more meaningful for
                                                   patients than one or five years. Many
Much could be done to slow the rise in the         experts believe it should be possible that,
numbers of patients being diagnosed with           by 2034, 3 in 4 patients in England
cancer each year. Increasing incidence             diagnosed with cancer will survive at least
places a considerable burden on the NHS.           10 years following their diagnosis,
But it also places a huge burden on patients       compared with 50% now, benefitting
and their families, as they undergo intensive      around 150,000 patients per year. By 2020,
and sometimes debilitating treatment. We           57% of patients should be surviving ten
recommend focusing attention on two key            years or more.
ambitions in this area:
                                                 • Increase in one-year survival, with a
• We will start to see a discernible fall in       reduction in CCG variation. Surviving
  age-standardised incidence and a                 one year after diagnosis is clearly a pre-
  reduction in the number of cases linked          requisite for long term survival and data is
  to deprivation. As noted above, overall          available much sooner, which enables
  incidence has been rising, and we have           commissioners and providers to track
  also seen an increase (5%) in age-               progress. Furthermore, one-year survival
  standardised incidence rates over the last       trends, alongside staging data, will
  ten years. Prevention efforts take time to       specifically enable us to assess progress
  feed through in to incidence, beyond a           on earlier diagnosis. We propose that
  five-year timeframe, but setting an              one-year survival should reach 75% by
  ambition that is measured and reported           2020 for all cancers combined, compared
  on will keep the focus on these efforts, so      with 69% now. Reducing variability will be
  that we see the benefits in the longer term.     a key driver of overall improvement at a
                                                   population level. Whilst it is implausible
• By 2020, adult smoking rates will have           that variability can be eliminated entirely,
  fallen much further. Smoking remains by          raising survival across CCGs towards the
  far the largest modifiable risk factor for       highest levels being delivered today
  cancer, responsible for around 60,000            should be possible.
  new cases per year in England25.This
  strategy sets a specific ambition that adult   • Reduction in survival deficit for older
  smoking rates should fall to 13% by 2020,        people. Recent international comparison
  and that rates in routine and manual             data suggests that the deficit in survival is
  workers should fall to 21%.                      even greater for older people than it is for
                                                   younger age groups for some types of
                                                   cancer. Moreover, if we are to narrow the
                                                   gap with other countries overall, we will
2.2 CANCER SURVIVAL                                also need to do so with older patients.
Achieving improvements in survival will
require a combination of earlier detection
and diagnosis, better treatment and access
to treatment, improved access to data and
intelligence and reductions in variability
around the country. Some cancer types, e.g.

     2.3 PATIENT EXPERIENCE AND                                      2.4 UNDERPINNING METRICS
     QUALITY OF LIFE                                                 Many of the metrics proposed above are
     The NHS needs to move to a more patient-                        only available after a considerable time lag.
     centred service in line with the aspirations set                Therefore it is essential that we also have a
     out in the FYFV, with a change in the                           series of supporting metrics, which will
     relationship between patients and                               enable commissioners and providers to
     professionals. It is therefore appropriate to                   have more rapid feedback on the impact of
     have ambitions that reflect this shift. In                      interventions and more timely intelligence
     addition, we need to transform our                              on the likely trajectory against the ambitions
     approach towards supporting people to live                      set out above. These metrics should also be
     well outside hospital and to return to their                    a key focus for Cancer Alliances, as the
     lives as far as possible after treatment has                    main vehicles for local service improvement
     ended. To achieve this requires a significant                   (see section 8.2).
     focus on measuring and improving people’s
     quality of life. For some areas, we do not yet                  Recommendation 1: NHS England, working
     have reliable measures, so these will need to                   with the other Arms Length Bodies, should
     be developed over the coming years:                             develop a cancer dashboard of metrics at
                                                                     the CCG and provider level, to be
     • Continuous improvement in patient                             reported and reviewed regularly by
       experience with a reduction in                                Cancer Alliances. The following metrics
       variation. In the latest Cancer Patient                       should be included as a minimum:
       Experience Survey (CPES), 89% of patients
       said overall their care was excellent or                      CCG Dashboard:
       very good11. It is quite likely that patient
       expectations will increase in coming                           • Proportion of patients referred by a GP
       years, so that maintaining or improving on                       with symptoms receiving a definitive
       this level of satisfaction will require                          cancer diagnosis or cancer excluded
       considerable effort. Some patient groups,                        within 2 and 4 weeks, with a target of
       such as those with rare and less common                          50% at 2 weeks and 95% at 4 weeks by
       cancers, report less satisfactory                                2020
       experience. In addition, some areas of
       the country score poorly on patient                            • Proportion of diagnoses through
       satisfaction measures and we should                              emergency presentation
       expect these areas to deliver significant
       improvement in the coming years. CPES                          • Proportion of cancers diagnosed at
       should continue to evolve and should be                          stage 1 or 2, with a target of 62% by
       repeated every year, with patient                                2020 for cancers staged, and an
       satisfaction measured for every hospital                         increase in the proportion of cancers
       and CCG.                                                         staged

     • Continuous improvement in long-term                            • Screening uptake, with an ambition of
       quality of life. We want people with                             75% for FIT in the bowel screening
       cancer to lead healthy, fulfilled and                            programme by 2020
       productive lives, as far as is possible,
       whether they have completed treatment                          • One-year survival
       or are living with an advanced and
       incurable form of the disease. To this end                     • Proportion of patients meeting cancer
       the strategy proposes the development of                         waiting times targets: target of 96%
       a national metric of quality of life,                            meeting 31 day target and 85% meeting
       underpinned by a robust approach to                              62 day target
       measurement, which will incentivise the
       provision of better aftercare interventions,                   • CPES data
       as well as more informed choice at the
       point of diagnosis.                                            • Proportion of patients with patient-
                                                                        agreed written after-treatment plan,
                                                                        with a target of 95% by 2020

• Under-75 mortality

• Over-75 indicator (to be developed)

• Further patient experience and quality
  of life measures as they are developed,
  e.g. Patient Reported Outcome
  Measures (PROMs)

• Proportion of people who die who had
  a personalised end of life care plan

Provider Dashboard:

• Proportion of patients meeting cancer
  waiting times targets: target of 96%
  meeting 31 day target and 85% meeting
  62 day target

• CPES data

• Data from clinical audits

• Further patient experience and quality
  of life measures as they are developed,
  e.g. PROMs

• Proportion of cancer patients
  participating in research

Figure 8 is an illustration of how the ‘cancer
dashboard’ for a CCG might be presented,
including many of the metrics above. Where
data are available we would expect them to
be broken down across different cancer
types and equality groups on request. The
dashboard would be generated by the
National Cancer Intelligence Network in
conjunction with NHS England.

For people who die from cancer, we need to
incentivise the system to ensure these
individuals experience a “good” death, with
their preferences taken in to account. A
good deal of end of life care is provided
outside the NHS and suitable metrics have
been proposed in the Choice Review.

                                Figure 8: Example ‘dashboard’ of metrics

                                Figure 8: Example 'dashboard' of metrics

Certain principles are central to the context      quality standards and appropriate
and successful implementation of this              population sizes.
                                                 • Systems of external accountability:
• One-size fits no-one: No two patients are        Many different organisations at local and
  the same, either in their cancer or in their     national level deliver services to prevent
  needs. We must strive towards greater            cancer and to treat and support cancer
  stratification and personalisation of            patients. Individual care pathways can
  approaches. Critical to this will be systems     span several of these organisations. A
  and processes which capture the needs            system of external accountability is
  and circumstances of individual patients         therefore necessary, both at local and
  and their carers, and the recognition and        national levels, to ensure cross-
  acceptance by doctors and other health           organisational issues are appropriately
  care professionals of the patient as an          considered and resolved.
  equal partner in their care.
                                                 • Research and data as drivers of
• Co-design: It is clear that fragmentation        continuous improvement: Substantial
  of care is a reality for patients across         opportunities exist to reduce variation and
  many health and social care pathways.            to drive progress through intelligence and
  Putting the patient at the heart of the re-      innovation. All parts of the health service
  design of services for cancer (and other         must embed a culture in which data and
  long-term conditions) will require a will        intelligence are seen as drivers of
  and determination that must be realised.         improvement and that research and
  This principle should be embedded in             controlled data access are viewed as a
  every aspect of the cancer journey, to           core responsibility.
  ensure that services are responsive to
  patients’ needs.                               • Agility: The pace of progress in all
                                                   aspects of cancer means that we need
• Pre- and post- treatment are as                  processes and systems that are agile and
  important as treatment: This strategy            adaptable. Agility will enable the rapid
  places considerable emphasis on the              spread of cost-effective innovations.
  prevention and earlier diagnosis of              Furthermore, this strategy takes a “test and
  cancer, as well as on living with and            learn” approach in many areas,
  beyond cancer, and end-of-life care.             recognising that we don’t know all the
                                                   answers to the many different challenges
• Individual responsibility and self-              we face, and we need to try different
  management: We need to facilitate and            solutions and evaluate them carefully
  empower people to take their share of            before national roll-out.
  responsibility for staying healthy and
  where appropriate enable them to               • Cancer as an exemplar for other
  manage their health and care needs.              conditions: Many aspects of cancer
                                                   services are relevant for other conditions.
• Devolved decision-making, within                 Equally, a large proportion of cancer
  national standards and ambitions:                patients have one or more other long-
  Cancer services (and the NHS more                term conditions. Cancer is uniquely
  broadly) are too extensive for all decisions     placed to drive forward the vision set out
  to be made nationally. Local or regional         in the FYFV. We should learn what works for
  decision-making unlocks creativity and           cancer, and ensure we apply lessons as
  innovation, provides a vehicle for               quickly as possible to other areas. Cancer
  clinicians and patients to drive service         care should also take opportunities to
  development, and enables appropriate             learn from other conditions.
  consideration of local circumstances (e.g.
  rural geographies). However, local
  decision-making must be within a
  national framework of agreed service

                                                                     supported in making appropriate lifestyle
     Chapter Summary                                                 choices. This is important not only for cancer
                                                                     but a variety of other potentially avoidable
     • More than 4 in 10 cases of cancer are                         conditions such as cardiovascular disease,
       caused by aspects of our lifestyles which                     diabetes and dementia.
       we have the ability to change. Tobacco
       remains the main risk factor, followed by                     The figures for England are stark. Despite
       obesity                                                       being widely acknowledged as having the
                                                                     best smoking cessation services in the world,
     • We need to continue to raise awareness                        nearly one in five adults still smokes. A third
       of the impact risk factors have on our                        of people drink too much alcohol. A third of
       health, especially in selected populations,                   men and half of women don’t get enough
       and support people to make changes                            exercise. Almost two thirds of adults are
                                                                     overweight or obese. Our young people
     • Efforts to tackle smoking rates should                        have the highest consumption of sugary soft
       continue at pace, with the ultimate aim of                    drinks in Europe26.
       reaching 5% in adults by 2035

     • Vaccination and chemo-prevention will                         4.1 LIFESTYLE AND AWARENESS
       play an increasing role
                                                                     An estimated 4 in 10 cases of cancer could
     • With increasing numbers of people                             be prevented, largely through modifying
       surviving their primary cancer, we need a                     aspects of our lifestyles which we have the
       stronger focus on preventing secondary                        ability to change27. The main risk factors
       cancers                                                       include tobacco, weight, diet, alcohol
                                                                     consumption, UV exposure and lack of
                                                                     sufficient physical activity (see Figure 9).
     There is much more we could do to ensure                        These are supplemented by other exposures,
     that people are engaging with health and                        such as air pollution, occupational risks,
     community services early enough to shift                        infections (including Human Papilloma Virus
     focus onto preventing rather than treating                      and viral hepatitis B and C) and radiation.
     disease. The ability of our National Health
     Service to deliver the care required now and                    Awareness needs to start early. The
     in the future is entirely dependent on the                      progression of children through school
     health of our nation. We will not be able to                    presents an opportunity to influence lifestyle
     sustain comprehensive health and social                         behaviours, including through children
     care coverage unless we take more                               being able to influence their families.
     concerted action on prevention. Rising                          Information on healthy lifestyles could be
     numbers of cancer cases that could be                           packaged with more tailored content
     prevented should be seen as unacceptable.                       relating to common signs and symptoms of
     It is within our control to prevent many cases                  cancer and other conditions. Early
     of cancer and we should seize this                              awareness would also provide young
     opportunity. This will require fundamentally                    people with the confidence to make best
     resetting the social contract within society,                   use of primary care services in later life, for
     such that individuals take more responsibility                  example in how to have constructive
     for their own health. It will also require                      conversations about their health.
     stronger leadership from Government,
     healthcare providers, and local
     organisations, so that individuals are

                                                                                                                                                                                   and diseases. Increased risk of cancer can
 Lifestyle factors                                                                                                                                                                 be a powerful driver of change for many
                                                                                                                                                                                   individuals, but there are low levels of
                                                  KEEP                                                                                                                             awareness of the links between many risk
                                           A                                                                                                                                       factors and cancer.
                                        HEALTHY                                                  BE SMOKE FREE
                                                                                                                                                                                   Health and Wellbeing Boards (HWBs) can
                    EAT FRUIT
                                                                                                                                                                                   continue to play a valuable role as
                      & VEG                                                                                                                                                        facilitators to encourage local government,
                                                                                                                                                                                   local health services, communities and
                                                                                                                                                                                   charities to work together to develop local
                           LESS                                                                                                                                                    strategies, taking a cross-disease approach,
                      ALCOHOL                                                                                                                                                      to address major social and environmental
                                                                                                                                                       T LESS
                                                                                                                                                                                   determinants of ill health. An important part

                                                                                                                  T A HIGH
                                             BE                               EAT LESS
                                                                                                               EABRE DIET
                                                                                                                FI                                                                 of local strategies will be health promotion
                                                                                                                                                                                   initiatives to raise awareness and help


                                    NS                        R              PROCESSED

                                                                             & RED MEAT                                                                 I
                                                                                                                                             BE ACT
                                                                                                                                                                                   individuals make healthier choices around
                                                                                                                                                                                   risk factors including smoking, alcohol, diet
                                                                                                                                                                                   and physical activity. Partners should work
 Other factors                                                                                                                                                                     together to ensure that local approaches
                                                                                                                                                                                   are tailored to the local community, and
                                                                                                                                                                                   appropriately target specific groups in which
                                                                                                                                                                 M IN I
                                                                                                                                                                                   certain cancer types are particularly




                                                                                                                                                                  E S M IS E A H
                                                                                                                                                                     PENT O N
  MINIMISE                                          MINIMISE
                                                                                                                                                                                   prominent (e.g. prostate cancer, triple-
                                                                                                                                                                                   negative breast cancer for BME groups).
                                                                                                such a

                                                                                                                                             IF E A S T F E EE
                                                                                                  M I N ra


                                                                                                                                                P O S SIB L


                                                                                                               IS E          A


                                                                                                                      R A DI

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                                         H                                                                         n d un nece


                                             .P                                        ti
                                                  ylo                             pa
                                                                                                                                                                                   Each time a person interacts with the health
                                                        r i, E B
                                                                   V, HIV,

                                                                                                                                                                                   service is an opportunity to encourage a
 Figure 9: Preventable cancer risk factors                                                                                                                                         conversation about healthy lifestyles.
                                                                                                                                                                                   Making ‘every contact count’ is an essential
Subject to evaluation of pilots being                                                                                                                                              culture shift that needs to be embraced by
undertaken by Teenage Cancer Trust and                                                                                                                                             everyone in the NHS who has contact with
others, NHS England and Public Health                                                                                                                                              the public and has the opportunity to have a
England should consider the evidence base                                                                                                                                          conversation to improve health.
for rolling out a cancer education
programme to all secondary schools to raise
awareness of healthy lifestyles and cancer                                                                                                                                         4.2 SMOKING
                                                                                                                                                                                   Smoking rates have halved in Great Britain
The health of the nation is not solely the                                                                                                                                         over the last 35 years, declining steadily
responsibility of NHS organisations; we need                                                                                                                                       since the 1970s (see Figure 10). Current rates
to harness efforts across local government,                                                                                                                                        for all adults in England are at 18.4%28
employers and the wider community to                                                                                                                                               although rates vary by age. This remarkable
tackle prevention. Many local approaches                                                                                                                                           change is principally down to governments
are already in place or are being                                                                                                                                                  adopting a comprehensive and consistent
developed. However, there is now a need for                                                                                                                                        approach, both in supporting smokers to
greater urgency, with concerted action to                                                                                                                                          quit and in discouraging and denormalising
focus on cancer. Local organisations are                                                                                                                                           smoking in society as a whole. Indeed, we
best-placed to determine which                                                                                                                                                     have not yet seen the benefit of measures
combination of initiatives across education,                                                                                                                                       introduced in the last Parliament, some of
housing, planning and healthcare would                                                                                                                                             which are still to be implemented.
deliver the most impact, and which should
be led through workplace health and
wellbeing initiatives. A local approach also
enables occupational risk factors in specific
geographies to be taken into account. It is
important to note that most risk factors are
relevant to a number of different illnesses

     Cigarette smoking prevalence (%)                                It is imperative that we maintain a focus to
      100%                                                           drive down smoking rates further and target
                                                                     those groups with the worst outcomes to
                                                                     reduce health inequalities. For hard to reach
       80%                                                           groups, evidence suggests that smoking
                                                                     cessation services and taxation are the
       60%                                                           interventions which make the biggest
                                                                     difference. High quality smoking cessation
                                                                     services, coupled with Government action
       40%                   male
                                  s                                  on marketing and taxation, mean that we
                            female                                   should be optimistic that further declines are
       20%                                                           possible in the years ahead. New
                                                                     technologies such as e-cigarettes offer
                                                                     additional means to help people quit. Public
             1974   1980      1990        2000       2010            Health England and Government should
                                 Year                                carefully monitor the research programme
                                                                     initiated by Cancer Research UK, in
      Figure 10: Cigarette smoking prevalence                        conjunction with PHE, to understand better
                 (%), Great Britain29                                the use and safety of e-cigarettes in
                                                                     reducing tobacco consumption.
     But smoking still kills. 18.4% of the population
     equates to more than 8m adults; up to two-                      Adult smoking rates have been declining by
     thirds of long term smokers will die as a result                around 0.7% per year over the last 10 years29.
     of their smoking if they do not quit30. Smoking                 If we maintain the current trajectory, we
     remains the leading cause of preventable                        would therefore be at 15% by 2020. We
     death and disease in England, responsible                       recommend being more ambitious than this.
     for around one in six deaths of adults aged                     The Government’s existing tobacco control
     35 and over in 201331. It remains the largest                   plan comes to an end in 2015. A recent
     preventable cause of cancer, with an                            report by ASH sets out some of the steps we
     estimated 19% of cancer cases and more                          should consider next36.
     than a quarter of cancer deaths in the UK
     linked to exposure to tobacco smoke25, 32.                      Recommendation 2: Government should
     Around 60,000 cases per year could be                           work with Public Health England and NHS
     prevented if tobacco smoke exposure was                         England to publish a new tobacco control
     eliminated25. There is growing evidence that                    plan within the next 12 months. The
     smoking not only impacts cancer risk but                        ambition should be to reduce adult
     also response to treatment. There is also a                     smoking prevalence to less than 13% by
     strong financial rationale to continue to                       2020 and less than 5% by 2035, and
     tackle smoking. The estimated total cost of                     reduce smoking among routine and
     tobacco use to society in England is £13.8                      manual workers to 21% by 2020. The plan
     billion per year33, compared with revenue                       should include a full range of actions,
     from tobacco in 2013/14 of £7.6 billion34.                      such as a tobacco industry levy, a tax
                                                                     escalator, payment based incentives to
     Smoking throws into sharp focus the                             ensure smoking cessation services are
     challenge we face in England to tackle                          strengthened and a focus on groups
     health inequalities. Smoking prevalence is                      where smoking rates remain high,
     higher amongst people with lower incomes                        including social marketing campaigns
     (23% of individuals in the lowest income                        where appropriate. It should highlight the
     band, compared to just 11% amongst those                        importance of NHS action in primary and
     who earn £40,000 or more29). In addition,                       secondary care, in particular among
     smoking is relatively widespread amongst                        those with long-term conditions.
     people with mental health problems; an
     estimated 42% of tobacco in England is used
     by people with mental health issues35.                          4.3 OBESITY AND OVERWEIGHT
     Smoking related inequalities also exist by
     gender, sexual orientation, and level of                        Obesity represents a critical challenge to the
     education.                                                      NHS, and its impact on the health of our
                                                                     nation is growing in significance. England is

amongst the worst performers on obesity in
Western Europe. The proportion of the                 Recommendation 3: Public Health
population that is overweight increased from          England should work with the Government
58 per cent to 67 per cent in men and from            and a wide range of other stakeholders to
49 per cent to 57 per cent in women between           develop and deliver a national action
1993 and 201337 (see Figure 11). Sixteen per          plan to address obesity, including a focus
cent of boys and 15% of girls aged 2 to 15            on sugar reduction, food marketing, fiscal
are obese37. The proportion of children who           measures and local weight management
are obese doubles while they are at primary           services. Within this there should be a
school. Less than one in ten are obese when           strong focus on children. Implementation
they enter reception class, but by the time           of the programme should be supported by
they reach year six, nearly one in five are           PHE, aligned with the physical activity
obese. A programme of work should be                  strategy ‘Everybody active, every day’.
undertaken to evaluate the curriculum in
primary schools and how lifestyle factors
and behavioural changes are                           4.4 ALCOHOL
                                                      Alcohol consumption has more than
 Overweight and obesity prevalence (%)                doubled in the UK since the 1950s39, 40.
                                                      Excessive alcohol consumption leads to
                                                      around 12,800 UK cases of cancer each year
                     le                               and is linked to several different types of

                                                      cancer41. As little as one standard drink a
                       ns                             day can increase the risk of a number of
                                                      cancers. Consumption clearly has wide-

                                    Fe males
                                                      reaching impacts beyond cancer, including
                                                      increasing the risk of other health conditions,
                                                      and to date much of the focus has been on
 50%                                                  these wider societal issues. Awareness
                                                      amongst the public of the links between
                                                      alcohol and cancer specifically is low, with
                                                      only a third identifying it as a risk factor.
 40%                                                  Therefore there is an opportunity for a
                                                      comprehensive alcohol strategy to
           1995     2000           2005        2010   acknowledge the risk of cancer to help drive
                                                      behaviour change. PHE has undertaken a
                                                      rapid evidence review of alcohol harm and
       Figure 11: Obesity and overweight              prevention and is writing a report to
            prevalence (%), England                   Government which will outline possible
                                                      policy solutions.
These statistics presage significant problems
for the future in the form of cancer and other        Recommendation 4: The PHE report should
illnesses. An estimated 5% of cancer cases in         form the basis for the development of a
the UK each year are linked to excess                 national strategy to address alcohol
bodyweight - 17,000 cases a year across               consumption, possibly including measures
bowel, womb, oesophageal, pancreatic,                 to tackle price, marketing, availability,
kidney, liver, gallbladder and post-                  information on products and social
menopausal breast cancers38 – as well as              marketing campaigns to raise awareness.
being linked to other conditions such as
diabetes. Obesity can also have an impact
on survival once a person has developed
cancer because certain ‘life-saving’
                                                      4.5 UV RADIATION EXPOSURE
treatments, including surgery, may not be             UV exposure is linked to one frequently lethal
available to patients. Unlike tobacco, there          cancer, malignant melanoma, which is
has to date not been coordinated and                  increasing in incidence. It is now the fifth
concerted action taken to address obesity,            most common cancer type in England,
and it is essential that this now becomes a           responsible for 1,900 deaths per year42.
priority.                                             Continued action on UV exposure therefore

     remains important to prevent more cases of                                          Recommendation 5: By December 2016,
     this cancer. There are a number of simple                                           PHE should determine the level at which
     actions that individuals can take to reduce                                         HPV vaccination for boys would be cost-
     their exposure to UV radiation, but where                                           effective. JCVI should make a final
     certain populations continue to need                                                decision by 2017. Assuming a cost-
     support is in making healthy choices related                                        effective price can be achieved, national
     to sunbeds. In those areas where sunbed use                                         roll-out should take place by 2020.
     remains high, local strategies can helpfully
     include measures to limit over-exposure to
     UV radiation. Health and Wellbeing Boards                                           4.7 DRUGS TO PREVENT CANCER
     provide a forum to bring together local
     partners to ensure, through the joint Strategic                                     The use of drugs to prevent cancer
     Needs Assessment (JSNA) process, that                                               (including secondary cancers) is
     strategies are tailored to the needs of the                                         increasingly likely to play a key role,
     local community and are appropriately                                               particularly to prevent breast cancers in
     targeted to high-risk groups.                                                       specific groups of women. Tamoxifen is
                                                                                         indicated for five years for pre-menopausal
                                                                                         women at high risk and either tamoxifen or
     4.6 HPV INFECTION                                                                   aromatase inhibitors, e.g. anastrazole, for
                                                                                         post-menopausal women at high risk, e.g.
     HPV is one of the most common sexually                                              those who have a strong family historyiii44.
     transmitted infections. Persistent infection                                        However, there is currently considerable
     with high-risk HPV types can lead to the                                            variability in uptake and adherence of these
     development of cervical, other rare ano-                                            medicines, given the long period over which
     genital cancers and some cancers of the                                             they are taken. A more systematic approach
     head and neck.                                                                      to making these drugs available could
                                                                                         significantly improve outcomes.
     The HPV vaccine is currently offered routinely
     to females aged 12 to 13 years and the                                              Recommendation 6: NHS England should
     programme’s primary aim is to reduce the                                            work through CCGs to ensure that GPs are
     incidence of cervical cancer in women. The                                          appropriately prescribing chemo-
     HPV vaccination programme in England has                                            preventive agents to reduce the risk of
     been one of the most successful in the world,                                       invasive breast cancer where their use is
     with more than 86% of year 8 girls receiving                                        established through NICE guidelines.
     all three doses43 and early indications of a
     reduction in HPV 16/18 infections43. Since                                          Approximately 5% of colorectal cancers
     September 2014, the programme has                                                   have a genetic hereditary basis45. Some
     switched to a two-dose schedule. The                                                patients with these cancers have hereditary
     success of this programme needs to be                                               non-polyposis colorectal cancer (HNPCC) or
     sustained and built upon. Men who have sex                                          Lynch Syndrome. A randomised controlled
     with men are a group at high risk for HPV                                           trial has shown that the long term use of
     infection, and will benefit much less from the                                      daily aspirin by individuals known to harbour
     herd protection effects of the adolescent                                           these genetic mutations can substantially
     female programme. Expanding the                                                     reduce the incidence of subsequent
     vaccination programme to include this                                               colorectal cancer46.
     group of men is under consideration
     currently by the Joint Committee of                                                 Recommendation 7: NHS England should
     Vaccination and Immunisation (JCVI).                                                commission NICE to develop updated
     Assessment of the extension of HPV                                                  guidelines for the use of drugs for the
     vaccination to adolescent boys is ongoing                                           prevention of breast and colorectal
     and as the benefits of HPV vaccination                                              cancers. Updated guidelines should
     become better known, there is good reason                                           consider the use of aromatase inhibitors
     to consider the effectiveness and cost-                                             for untreated post-menopausal women at
     effectiveness of gender-neutral vaccination.                                        high risk and the use of aspirin for
                                                                                         individuals with HNPCC. Once these
                                                                                         guidelines are published, CCGs should

      Use of tamoxifen or an aromatase inhibitor for five years in post-menopausal women at high risk has been shown to reduce the risk of invasive breast cancer by

     50% or more, with the benefit extending to 20 years or more
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