What is the London cancer landscape? Report on London cancer intelligence Prepared by Katherine Henson, National Cancer Intelligence Network, QA by Ruth Swan, NCIN and Stephen Scott, LCA

10.9% of England10.4% of England 2London Cancer Intelligence London ,224 deaths 94,453 cases Cancers in London Note: London had a population of 8.3 million at mid-2012, 13% of the total UK population (ONS)

3London Cancer Intelligence London Cancer Alliance Cases diagnosed = 60,398 Age-standardised incidence rate = ( ) Deaths = 26,035 Age-standardised mortality rate = ( ) London Cancer Cases diagnosed = 38,914 Age-standardised incidence rate = ( ) Deaths = 17,288 Age-standardised mortality rate = ( ) England Cases diagnosed = 861,437 Age-standardised incidence rate = ( ) Deaths = 395,353 Age-standardised mortality rate = ( ) Comparison to benchmarks: Cancers in London

4London Cancer Intelligence LC and LCA both have significantly lower age- standardised incidence and mortality rates compared to England. The proportion of deaths and cases is lower than the population size of London in proportion to England. This is not explained by the younger population in London. Cancers in London

How does the risk vary by gender? 5London Cancer Intelligence

6 Number of Cases Diagnosed Incidence & Mortality by Gender Equal number of cases diagnosed for men and women, but more males died from cancer

7London Cancer Intelligence Significant difference in incidence and mortality rate by gender Male incidence rate is 1.3-fold the female rate, and mortality is 1.5-fold higher than female Incidence & Mortality by Gender

Is there substantial variation in incidence and mortality by cancer type? 8London Cancer Intelligence

9 There were 14,966 cases of breast cancer diagnosed in , and deaths were 3,223, but the highest number of deaths was for lung cancer (3,901). Incidence & Mortality by Cancer Females,

10London Cancer Intelligence There were 12,529 cases of prostate cancer diagnosed in , and deaths were 2,649 but the highest number of deaths was for lung cancer (5,071). Incidence & Mortality by Cancer Males,

11London Cancer Intelligence Breast cancer has the highest incidence rate. The highest cause of death for an individual tumour type is lung cancer. Incidence & Mortality by Cancer Females,

12London Cancer Intelligence Three cancer sites have almost equal mortality & incidence rates : pancreatic, liver and brain (as with females). The highest cause of death for an individual tumour type is lung cancer. Incidence & Mortality by Cancer Males,

13 B & D = Barking & Dagenham, C & H = City & Hackney, H & F = Hammersmith & Fulham, H = Hillingdon, I = Islington, K & C = West London (Kensington & Chelsea), K = Kingston, L = Lambeth, R = Richmond, S = Southwark, TH = Tower Hamlets, W = Central London (Westminster), WF = Waltham Forest London Cancer London Cancer Alliance London Cancer Intelligence Incidence by CCGs for All Malignant Neoplasms

14 B & D = Barking & Dagenham, C & H = City & Hackney, H & F = Hammersmith & Fulham, H = Hillingdon, I = Islington, K & C = West London (Kensington & Chelsea), K = Kingston, L = Lambeth, R = Richmond, S = Southwark, TH = Tower Hamlets, W = Central London (Westminster), WF = Waltham Forest London Cancer London Cancer Alliance London Cancer Intelligence Mortality by CCGs for All Malignant Neoplasms

15London Cancer Intelligence Prostate and breast cancer had highest age- standardised incidence rates and lung cancer had highest age-standardised mortality rate for 2011 – 2013 in London. Pancreatic, liver and brain cancer are of particular concern in London as the survival rates are poor (this is reflective of patterns seen nationally). Incidence & Mortality by Cancer Note that ‘All other sites’ is C00-C97 excluding: C44, C00-C14,C31-C32, C69, C73, C15, C16, C18-C20, C22, C25, C33-C34, C43, C64, C67, C71, C82-C85, C61, C50, C53, C54-C55, C56-C57

16London Cancer Intelligence Ranking of number of cases in London: 1)Breast (16%) 2)All other sites (14%) 3)Prostate (13%) 4)Lung (12%) 5)Colorectal (11%) 6)Head and neck (5%) 7)Non-Hodgkin lymphoma (4%) 8)Melanoma of skin (3%) 9)Bladder (3%) 10)Pancreas (3%) Incidence by Cancer

17London Cancer Intelligence Ranking of number of deaths in London: 1)Lung (22%) 2)All other sites (19%) 3)Colorectal (9%) 4)Breast (8%) 5)Prostate (6%) 6)Pancreas (6%) 7)Oesophagus (4%) 8)Liver & intrahepatic bile ducts (3%) 9)Stomach (3%) 10)Bladder (3%) Mortality by Cancer

18London Cancer Intelligence Cancers with significantly higher incidence than England: Corpus uteri in LC Head and neck cancer in LCA Cancers with significantly higher mortality than England: Liver & intrahepatic bile ducts in LC and LCA Corpus uteri in LC and LCA Head and neck in LCA Incidence & Mortality by Cancer

19London Cancer Intelligence Cancers with significantly lower incidence than England: Bladder cancer in LC Brain cancer in LC Breast cancer in LC and LCA Cervix uteri cancer in LCA Colorectal cancer in LC and LCA Kidney cancer in LC and LCA Melanoma of skin in LC and LCA Oesophageal cancer in LC and LCA Ovarian cancer in LC and LCA Incidence & Mortality by Cancer

20London Cancer Intelligence Cancers with significantly lower mortality than England: Bladder cancer in LCA Brain cancer in LC Colorectal cancer in LCA Kidney cancer in LC and LCA Lung cancer in LCA Melanoma of skin in LC Oesophageal cancer in LC and LCA Ovarian cancer in LC and LCA Prostate cancer in LC and LCA Incidence & Mortality by Cancer

21 Cancer Prevalence at 31/12/13 London Cancer, Diagnosed Malignant cancer with the highest prevalence rate are breast cancer in woman, and prostate in men, which is in line with the incidence and mortality (as expected) London Cancer Intelligence

22 Highest prevalence cancers same as for London Cancer, and second most common (other than all other sites) is colorectal cancer London Cancer Intelligence Cancer Prevalence at 31/12/13 London Cancer Alliance, Diagnosed

23London Cancer Intelligence Prevalence rates are highest in the sites with the biggest gap between incidence and mortality. Therefore, as expected from the incidence & mortality rates, breast cancer and prostate cancer have the highest prevalence rate. However, colorectal cancers also have a high prevalence rate. Cancer Prevalence at 31/12/13 Diagnosed

Does the incidence and mortality rate vary over time? 24London Cancer Intelligence

25London Cancer Intelligence Since 2001, incidence rate has steadily increased in London for all cancers, yet mortality rate has steadily decreased. Incidence & Mortality in London by Year of Diagnosis Source: CancerStats

26London Cancer Intelligence Trend is a positive message, and likely reflects improvements in diagnosis, screening and treatment, among other factors. These include public health factors, e.g. decreased prevalence of smoking in men. Continual improvements necessary to keep reducing the mortality rate. Incidence and mortality rates are significantly lower than England in recent years, where the two trends start to diverge. Incidence & Mortality in London by Year of Diagnosis

What is the stage distribution of all cancers? 27London Cancer Intelligence

28 Lung cancer has the highest proportion of stages 3 and 4 cancer, and melanoma of skin (followed by breast cancer) have the highest proportion of stages 1 and 2 Cancers Diagnosed by Stage 2013 London Cancer Intelligence

29London Cancer Intelligence 11 cancer groups had met the expectation of 70% of staged cancers (Melanoma of skin, Corpus uteri, Kidney, except renal pelvis, Cervix uteri, Bladder, Breast, Prostate, Colorectal, Lung (incl. trachea & bronchus), Stomach, Oesophagus) Cancers Diagnosed by Stage 2013

30London Cancer Intelligence Variation or differences in mortality can partially be explained by differences in stage. For example, lung cancer has the highest mortality rate and also has the highest proportion of patients diagnosed at late stage. However, we need to include information on exposure, lifestyle and environmental factors to fully understand the variation in mortality and incidence risk. Cancers Diagnosed by Stage 2013

Are there more cancers diagnosed in London than expected from the general population? 31London Cancer Intelligence

32London Cancer Intelligence Excess Cancer Cases in London GenderICD10 CodeICD10 Description Expected Cancer Cases Actual Cancer Cases Excess Cancer Cases MaleC00-C97 (exc. C44)All malignant neoplasms , FemaleC00-C97 (exc. C44)All malignant neoplasms , Fewer cancers diagnosed in London than expected from the general population

33London Cancer Intelligence The majority of cancers had fewer cases diagnosed than expected from the general population. A number of cancers had more cases diagnosed than expected. Of note: prostate cancer in LCA (319.7), lung cancer in males in LC (165) and NHL in females in LCA (112) Excess Cancer Cases London Cancer & London Cancer Alliance,

34London Cancer Intelligence In general, London is performing better than expected from deaths in the general population. Of note where London has performed poorly: liver cancer in LCA males (126.2) and lung cancer in LC males (106.3) Excess Cancer Deaths London Cancer & London Cancer Alliance,

35London Cancer Intelligence Out of 18 cancer groups, 10 had more cancers diagnosed than expected from the general population (for either gender or ICS). 8 cancer groups had more deaths than expected. Of concern is lung and liver cancer in males. Corpus uteri in females is also of concern. Excess Cancer Cases and Deaths London Cancer & London Cancer Alliance,

How many patients are surviving from the common cancers in London? 36London Cancer Intelligence

37London Cancer Intelligence Lung cancer survival is the poorest, but for both lung cancer and colorectal the survival rate increased over time. Prostate cancer and breast cancer have remained stable at around 95% 1-year Survival in London Source: CancerStats

38London Cancer Intelligence In the most recent time period ( ) the 1-year survival rates were: -Breast cancer = 97% -Prostate cancer = 96% -Colorectal (M) = 79% -Colorectal (F) = 75% -Lung (F) = 37% -Lung (M) = 33%

39London Cancer Intelligence For further information on cancer survival, please refer to: -International comparisons: Report entitiled ‘How to improve cancer survival’. The King’s Fund, June survival-Explaining-England-poor-rates-Kings-Fund-June-2011.pdf - PHAST 1 year survival reports for CCGs: This report considers cancer survival and other measures related to cancer from a variety of statistics, for all cancers and for three main cancers breast, lung and colorectal, and for different age groups. The results give an indication of how well residents in the CCG are being screened, diagnosed and treated for cancer in comparison with those in the rest of London and West Essex and in comparison with England averages. The findings indicate where the CCG may want to examine further or take action in their commissioning processes.

What are the screening uptake trends in London? 40London Cancer Intelligence

41London Cancer Intelligence Breast Screening Coverage in LC Source: FingerTips Range of % coverage in 2014/2015: 49% - 74%

42London Cancer Intelligence Breast Screening Coverage in LCA Source: FingerTips Range of % coverage in 2014/2015: 55% - 74%

43London Cancer Intelligence Colorectal Coverage in LC Source: FingerTips Range of % coverage in 2014/2015: 40% - 58%

44London Cancer Intelligence Colorectal Coverage in LCA Source: FingerTips Range of % coverage in 2014/2015: 40% - 58%

45London Cancer Intelligence Cervical Screening Coverage in LC Source: FingerTips Range of % coverage in 2014/2015: 59% - 76%

46London Cancer Intelligence Cervical Screening Coverage in LCA Source: FingerTips Range of % coverage in 2014/2015: 57% - 76%

47London Cancer Intelligence Most CCGs do not meet the national average. Camden had a sharp decrease in breast screening in the most recent time period, as did Islington. Havering, Bromley and Bexley had a substantially slower uptake of bowel screening. Camden has a noticeably worse uptake of cervical screening over the entire time period. Overall, bowel screening has a worse uptake over all regions and time periods. Screening Coverage

Are there any outlying CCGs in the cancer specific results? 48London Cancer Intelligence

Lung cancer ( ) ~50% of cases are diagnosed as stage 4 throughout London (2013) CCGs with the highest age-standardised rates: Mortality: Barking & Dagenham (M) and Islington (F) Incidence: Tower Hamlets 9 CCGs have significantly higher mortality and incidence than England Colorectal Cancer ( ) In Tower Hamlets, Sutton, Brent, West London, Lambeth and Hillingdon the number of cases diagnosed is lower among females than males, but the number of deaths is substantially higher among females  what is occurring with female colorectal cancer in these CCGs? CCGs with the highest age-standardised rates: Mortality: Hammersmith and Fulham (M) and Tower Hamlets (F) Incidence: Wandsworth (M) and West Essex West Essex had significantly higher incidence than England, but no CCGs had significantly higher mortality All but 5 CCGs had more cancers diagnosed as late stage than early stage (2013) 49London Cancer Intelligence

Breast cancer ( ) Ealing and Hounslow (the only 2 CCGs) had the highest grouping of both the age-standardised incidence and mortality rate CCGs with the highest age-standardised rates: Mortality: Newham Incidence: Hounslow No CCGs had a significantly higher mortality or incidence compared to England Kingston staged 47% of cases as unknown (2013) Prostate cancer ( ) Lambeth had the highest age-standardised incidence and mortality rate 11 CCGs had significantly higher incidence than England 9 CCGs had significantly higher mortality than England Barking & Dagenham, Waltham Forest, Greenwich and Lambeth were in both groups Camden, Haringey, Bromley, Central London and Kingston had >40% un-staged cancers (2013) Both LC and LCA had more cases diagnosed than expected, but fewer deaths 50London Cancer Intelligence

Pancreatic cancer ( ) CCGs with the highest age-standardised rates: Mortality: Barking & Dagenham (M) and Wandsworth (F) Incidence: Barking & Dagenham (M) and Greenwich (F) Barking & Dagenham had significantly higher incidence and mortality than England Also, Greenwich had significantly higher incidence (but not mortality), and Hillingdon had significantly higher mortality (but not incidence) Waltham Forest, Newham, Wandsworth, West London and Hounslow had >60% of cases diagnosed as late stage (2013) LC males and LCA females had excess cases and deaths compared to the general population Oesophagael cancer ( ).Two thirds of the cases and deaths were among males CCGs with the highest age-standardised rates: Mortality: Barking & Dagenham (M) and Bexley (F) Incidence: Merton (M) and Tower Hamlets (F) No CCGs had a significantly higher mortality or incidence compared to England Tower Hamlets, Bromley and Lewisham had >70% cases diagnosed as late stage (2013) 51London Cancer Intelligence

Liver cancer ( ) Two thirds of cases and deaths were among males CCGs with the highest age-standardised rates: Mortality: Southwark (M & F) Incidence: Southwark (M) and Tower Hamlets (F) 6 CCGs had signficantly higher incidence and mortality than England (3 had both: Barking & Dagenham, Tower Hamlets and Camden) Mortality rates have increased over time ( ) Majority are recorded as unknown stage (2013) Stomach cancer ( ) Two thirds of cases and deaths were among males CCGs with the highest age-standardised rates: Mortality: Tower Hamlets (M) and City and Hackney (F) Incidence: City and Hackney (M) and Barking & Dagenham (F) City and Hackney had significantly higher incidence and mortality compared to England Incidence rate has fallen sharply over time ( ) Islington had 80% as unknown stage (2013) 52London Cancer Intelligence

Bladder cancer ( ) Majority males (70% cases, 66% deaths) CCGs with the highest age-standardised rates: Mortality: Lewisham (M) & Tower Hamlets (F) Incidence: Greenwich (M) & Southwark (F) Southwark is the only CCG with a significantly higher incidence rate than England (for all persons) Male incidence and mortality has decreased over time, females has stayed stable ( ) More cases diagnosed among females in LCA than expected from the general population Head and neck cancer ( ) CCGs with the highest age-standardised rates: Mortality: Tower Hamlets (M & F) Incidence: Hammersmith and Fulham (M) & Central London (F) 7 CCGs had significantly higher incidence than England, 5 had significantly higher mortality: 4 CCGs were in both groups: Tower Hamlets, Camden, Ealing and Hammersmith and Fulham 15 CCGs had the greatest proportion of cancers recorded as unknown stage (2013) LC and LCA (M & F) had more deaths than expected from the general population 53London Cancer Intelligence

Melanoma of skin cancer ( ) CCGs with the highest age-standardised rates: Mortality: Sutton (M) & Kingston (F) Incidence: Richmond (M & F) Richmond has significantly higher incidence than England Incidence rate has increased sharply between 2001 and 2013, but the mortality rate has remained stable (for both M & F) Kingston has very poor staging completeness (2013) Kidney cancer ( ) CCGs with the highest age-standardised rates: Mortality: Barking and Dagenham (M) & Hammersmith and Fulham (F) Incidence: Lambeth (M) & Hammersmith and Fulham (F) No CCGs with significantly higher incidence or mortality than England Male incidence has increased sharply during London Cancer Intelligence

Brain cancer ( ) Bromley had the highest number of cases and deaths during CCGs with the highest age-standardised rates: Mortality: Bromley (M) & Sutton (F) Incidence: Havering (M) & Sutton (F) Sutton had a significantly higher incidence rate than England Non-Hodgkin Lymphoma ( ) CCGs with the highest age-standardised rates: Mortality: Enfield (M) & Havering (F) Incidence: Lambeth (M) & Wandsworth (F) 3 CCGs had a significantly higher incidence rate than England: Barnet, Lambeth & Wandsworth Majority of cases are recorded as unknown stage (2013) In LCA, there were 112 excess cases than expected in females 55London Cancer Intelligence

Cervix uteri cancer ( ) CCGs with the highest age-standardised rates: Mortality: Haringey Incidence: Lambeth Lambeth had a significantly higher incidence rate than England Both incidence and mortality rate have decreased over time Kingston and Hammersmith & Fulham had >70% of cases as unknown stage (2013) Corpus uteri cancer ( ) CCGs with the highest age-standardised rates: Mortality: Haringey Incidence: City and Hackney 4 CCGs had significantly higher incidence rates than England, and 3 CCGs had higher mortality: Redbridge had both Mortality has increased over time ( ) There were excess cases diagnosed and deaths, as compared to expected from the general population 56London Cancer Intelligence

Ovarian cancer ( ) CCGs with the highest age-standardised rates: Mortality: Bexley and Waltham Forest Incidence: Lewisham 4 CCGs had significantly higher incidence rates than England, and 3 CCGs had higher mortality: Redbridge had both Sutton, Greenwich and Bexley had >60% of cases diagnosed as late stage (2013) 57London Cancer Intelligence

Summary 58London Cancer Intelligence

London had significantly lower incidence and mortality rates compared to England Males had higher incidence and mortality rates than females Cancers of concern: Head and neck (incidence & mortality) Liver (mortality) Corpus uteri (incidence & mortality) Lung cancer (mortality) Liver cancer and corpus uteri cancer mortality rates have increased over time ( ) Positive: stomach, bladder and cervix uteri cancer incidence rates have decreased over time 59London Cancer Intelligence All Cancers

Largest burden of cases in terms of absolute numbers is breast cancer for females and prostate cancers for males In London overall, head & neck, liver, lung, prostate, stomach, corpus uteri and NHL had excess cancer cases compared to expected Head & neck, liver, pancreas, lung, stomach, corpus uteri and NHL had excess cancer deaths compared to expected Barking & Dagenham and Tower Hamlets most commonly had the highest incidence rate, or a significantly higher rate than England Screening uptake is poor ( ) : Camden and Islington are two CCGs of concern with screening, and bowel screening has the worst uptake of the three programs 60London Cancer Intelligence All Cancers