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Cancer is the largest cause of premature death (below the age of 75 years) (NHSIC, 2013) in England and the second biggest cause of mortality for all ages after cardiovascular disease.  Overall, more than one in four people die from cancer and about 40% die when aged less than 65 years.  More than one in two people will be diagnosed with cancer in their lifetime (Ahmad, 2015)


The major factor that increases an individual’s risk of cancer is increasing age so this chapter is relevant to adult care.  However, according to Cancer Research UK much cancer is preventable and the main modifiable risk factors are using tobacco, being overweight, eating unhealthy diets and drinking excessive alcohol.


The Department of Health has published ‘Living Well for Longer’, 2013, which is about reducing avoidable, premature mortality caused by the big killer diseases, among which is cancer.  Premature mortality is death aged less than 75 years and it is hoped that England’s this will become the lowest amongst our European peers.  It has been shown that we have a long way to go.  Longer Lives compares overall and specific disease premature mortality from similarly deprived local authorities and shows that Bedford Borough is 3rd best out of 15 for premature mortality caused by cancer in 2012-14.


Facts, Figures, Trends

Numbers of people affected by Cancer

Incidence of Cancer


502 men and 407 women had been newly diagnosed with cancer of all ages in Bedford Borough in 2013.  Figure 1 shows the standardised timeline.  The recent rates in men were higher than the national data; women were slightly lower.  The incidence was slowly increasing and in 2013 the main cancers were:


o   Men:        Prostate (37%) and Colorectal (10%)

o   Women:  Breast (31%) and Colorectal (11%)


Figure 1: Incidence of all cancers for all ages (directly standardised), 1995-2013




Cancer 1



Cancer 2



Source: Health & Social Care Information Centre, 2015

Modifiable risk factors.  The results for modifiable risk factors in Bedford Borough were


Physical activity

similar rate compared to similar local authorities, 2014


Excess weight in adults

similar rate compared to that of England, 2012


Alcohol related admission to hospital- narrow definition (persons)

better rate compared to similar local authorities, 2013/14




Fruit & veg ‘5-a-day’

similar rate compared to similar local authorities, 2014/15


Current smoking prevalence in adults

similar rate compared to similar local authorities, 2013/14

If the sun is strong or you are at risk of burning, skin cancer primary prevention includes:


  •  Spend time in the shade between 11am and 3pm
  • Cover up with a t-shirt, hat and sunglasses
  •  Use a sunscreen with a protection level of at least SPF15 and 4 stars.  Use it generously and reapply regularly


Harm caused by Cancer

Cancer Mortality


Premature mortality (below the age of 75 years) from cancer in England and Bedford Borough fell between 1995 and 2013 as shown in Figure 2.  England was generally higher than Bedford Borough and males had higher rates than females.  Cancer caused the most premature deaths in Bedford Borough (43.0%) followed by circulatory diseases (19.7%) in 2013.

Figure 2






Source: Health & Social Care Information Centre, 2015


  • The most common cancers resulting in death in those aged 75 years or under were lung, colorectal, oesophageal and prostate cancers for males and breast, lung and colorectal cancers for females (see Figure 3)
  • Although there are more than 200 different types of cancer, breast, lung, bowel and prostate together account for over half of all cases newly diagnosed


Figure 3: Standardised cancer mortalities under the age of 75 by sex for Bedford Borough



Source: Health & Social Care Information Centre, 2015

Years of Life Lost (YLL)

Years of Life Lost (YLL) measures the number of years a person would have lived if they had not died prematurely at less than 75 years.  It is useful for highlighting causes of death that affect younger people.  The rate for males was higher than for females but there is no statistical significance between Bedford Borough and England (see Figure 4).


Figure 4: Years of Life Lost due to mortality below 75y for all cancers 2011-13 (pooled)



Source: Health & Social Care Information Centre, 2015


Death at home from all cancer

33% of Bedfordshire CCG deaths happened at hospital where the underlying cause was cancer, 2011-13.  That was had a statistically lower proportion compared with England (38%).  This proportion had fallen considerably over the last 10 years.

Ethnicity and Cancer

The National Cancer Intelligence Network (NCIN) report on Ethnicity (2009) suggested that:


  • Overall, the incidence of cancer in the minority ethnic population (BME) was lower than that of the white British population
  • Much of the difference in incidence was attributable to differences in lifestyle and behaviours (such as tobacco consumption, diet, obesity and alcohol)
  • Certain minority ethnic groups have higher incidence of specific cancers; for example prostate cancer in Black African and Black African Caribbean men.  No reason has yet been found to explain this but it has been suggested that there may be a genetic link
  • Survival rates for people with cancer may also be affected by ethnicity.  This may reflect later presentation among minority ethnic groups.  There is increasing evidence that this is a factor in the relatively poor survival of Black African/Black African Caribbean women with breast cancer
  • In 2012, NCIN found that there are differences in the incidence of lung cancer between ethnic groups.  Lung cancer was most common in White and Bangladeshi men.  Compared with women from other ethnic groups, lung cancer was more common in White women (Jack, 2011)



Projected future position if no action taken & Scope for improvement



In 2008-10, Bedfordshire CCG’s breast, colorectal, lung and urology 1-year survival rates were similar to England’s figures.

Cancer survival rates are increasing in both Bedfordshire and England.  Cancer awareness and early diagnosis are the most important factors to improving survival (Foot, Kings Fund, 201)  Cancer diagnosed at an early stage was 57.9% at Bedford Borough was better than the rate of the similar local authorities (44.4%), 2013.  Despite this, cancer survival in England remains poor in relation to comparable countries.

According to a survey undertaken by You Go for Macmillan Cancer Support (2011) 37% of those who return to work after cancer treatment say they experience some kind of discrimination from their employer or colleagues while 9% feel harassed to the point they feel they cannot stay in their job. 1 in 10 of those returning to work said their employer failed to make reasonable changes to enable them to do their job.

Surviving cancer exposes an individual to continuing physical and mental health problems, and therefore not all cancer survivors

will wish to return to paid employment.


Current activity & services

Cancer prevention

In 2010, around 43% of cancer cases seen in the UK were caused by cell changes brought about by lifestyle and environmental factors.(Parkin, 2011)  This has been presented in Figure 5

By far the largest modifiable risk factor for cancer is smoking, although excess weight, unhealthy diets and alcohol together with smoking causes about one third of those diagnosed in the UK each year for cancer


Figure 5  How many cancers can be prevented?




National Awareness and Early Diagnosis Initiative (NAEDI)

  • To improve early diagnosis and awareness, Bedfordshire CCG, in collaboration with the cancer networks, is aiming to improve patient awareness of cancer symptoms and early diagnosis by primary care.  They have four main work streams which are:
    • Achieving early presentation by public and patients to primary care, increasing public awareness of cancer signs and symptoms/seriousness and overcoming barriers to presentation and improving user experience (see Figure 6)
    • Optimising clinical practice and systems aims to prompt onward referral within and between primary and secondary care by increasing GP awareness of symptoms and interaction with patients and understanding the interface between primary and secondary care including any disincentives to referral
    • Improving GP access to diagnostics to begin to have greater access to non-obstetric ultrasound (ovarian cancer), flexible sigmoidoscopy/colonoscopy (bowel cancer) and brain MRI scans
    • Research, evaluation and monitoring
  • NHS Bedfordshire/Bedfordshire CCG has taken part in a number of NAEDI initiatives including the Cancer Awareness Measure, 2010 (see under ‘Local Views’)


Figure 6:  The NAEDI pathway

Cancer Graph 7

Source:The National Awareness and Early Diagnosis Initiative in England: assembling the evidence, M A Richards


In February- March 2016 there will a campaign using the Be Clear on Cancer brand, a national campaign to raise awareness of the symptoms of kidney and bladder cancer.  It will include TV, press, radio advertising and events.  Key messages will highlight finding kidney or bladder cancer early makes it more treatable and encouraged people who have symptoms to go to their doctor straight away.  The Be Clear on Cancer brand was developed by the Department of Health and has been in use since January 2011 to promote awareness and early diagnosis of cancer locally, regionally and nationally.


A Macmillan GP has been appointed to work across the entire Bedfordshire area.  The GP acts on the whole cancer journey from supporting early diagnosis of cancer, living with cancer and supporting people to die well in primary and community care settings as well as performing practice visits, education events and engaging with the CCGs.  Recently Macmillan has been working on:

  • electronic cancer decision support tool which they hope will speed up the decision to refer
  • GP’s different referral styles and identifies and matches up targeted tools and interventions that best suit their style of referring


Cancer awareness champions work within Bedfordshire and are aiming to talk to hard to reach groups.  Two are trained currently and they met about 4-6 groups a year.  Cancer Research UK (CRUK) will be appointing a GP engagement facilitator to work with practices this summer 2015.


Cancer screening programmes

The NHS Breast Screening Programme, NHS Cervical Screening Programme and the NHS Bowel Cancer Screening Programme are nationally coordinated and are not organised by GP practices.  All national screening programmes have national standards to be met and are subjected to rigorous external quality assurance processes.  Full details of the evidence base, national standards and annual statistical data are available from the website: http://www.cancerscreening.nhs.uk/.  The levels of deprivation, ethnic groups and non-English speakers may influence screening performance.


Breast Screening

This programme offers mammographic screening on a 3-yearly basis for women aged 50—70 with older women able to self-refer.  The age extension has started bringing all women aged 47—73 into the programme over a 6 year period so that by 2017 all women will be offered their first screen between ages 47—50 and eight subsequent screens offered at 3-yearly intervals.  Age extension is being introduced as a randomised process in line with national guidance.  This means that with some GP practices, women aged 47—50 will be included whereas in others women aged 70—73.  However by 2017 all women in the wider age range will be invited.


Along with this age extension, breast screening is being transferred to a digital X-ray equipment to improve the quality of the images.


Table 1:  Breast screening coverage: proportion of women aged 53—70 screened in the last year: Bedford Borough & National target



Source: Public Health England, 2015



There are a number of performance measures for the screening programme.  These include:

  • Round length (women being invited within the 3 yearly time period)
  • Screen to assessment to ensure that those women who need further assessment receive it within a short time period
  • Issuing of normal results so that women receive the results of screening quickly


Cervical screening

This programme offers screening for women aged 25—49 every three years and for women aged 50—64 every five years.

Table 2 shows that women in Bedford Borough had a lower rate compared with the national target coverage (80.0%) for cervical screening in all ages applicable (25-64 years).  Coverage is lower in the 25-49 age-group than 50-64 years.  If GP practice deprivation was low, the performance tended to be high.



Cervical screening


This programme offers screening for women aged 25—49 every three years and for women aged 50—64 every five years.

Table 2 shows that women in Bedford Borough had a slightly higher than national rates of coverage for cervical screening in all age groups but did not achieve the national target (80.0%).  Bedford Borough’s results have fallen slightly.  Coverage is lower in the 25-49 age-group than 50-64 years.  If GP practice deprivation was low, the performance tended to be high.


Table 2: Cervical screening coverage: proportion of women aged 25—49 and 50—64 being screened within 3.5 or 5.5 years respectively: Bedford Borough & National target



Source: Public Health England, 2015

There are a number of performance measures for the cervical screening programme.  These include:

  • Turnaround time – ensuring that women receive their results within 14 days of their screening sample being taken. 
  • Waiting times for those needing assessment within colposcopy following a positive screening result. 
  • Receiving results from colposcopy within 8 weeks



Bowel screening

This programme commenced in 2009 offering screening to those aged 60—69.  The screening is offered on a 2-yearly cycle.  The uptake was counted as the percentage who returned their Faecal Occult Blood test (FOBt) test kits within 12 weeks.  In October 2012 NHS Bedfordshire offered age-extension so that screening was available to those aged 60—74 years.


Table 3 contains the data of the uptake for Bedford Borough and the regional target.  Performance was above target.  There has been a national drop in uptake as the programme develops and recalls previous participants.  If GP practice deprivation was low, the performance tended to be high


Table 3:  Bowel screening uptake, all ages



Source:Public Health England, 2015

Local Views

Anglia Cancer Network commissioned a social market research company to conduct an evaluation of the ‘Be Clear on Cancer’ campaign in December 2011 (Anglia Cancer Network, 2011).  Using the Cancer Awareness Measure carried out in 2010.(Stubbings, 2009 and Gleed, 2010) as a comparison, the unprompted cancer awareness of the signs and symptoms of cancer had increased:


  • unexplained bleeding                        57%         (15% increase)
  • unexplained pain                               39%         (21% increase)
  • change in bowel/bladder habits      15%           (5% increase)
  • cough/hoarseness                             30%         (10% increase)
  • loss of appetite                                    28%           (6% increase)
  • nausea/sickness                                13%           (5% increase)
  • difficulty swallowing                          20%           (6% increase)


The Cancer Awareness Measure (CAM) in 2010 concluded that:


  • Campaigns should raise awareness of symptoms, lifestyle risk factors and cancer screening programmes, particularly with bowel cancer
  • Specific campaigns would be beneficial if they were targeted at males, students, BME Groups and deprived areas


National & Local Strategies (Best Practices)

National Institute for Health and Clinical Excellence (NICE):


  • Guidance covering several different cancers including ‘do not do’ recommendations
  • NICE up-dated the guidance for Suspected Cancer in May 2015


  • An independent taskforce for cancer was established in 2015 to develop a five-year strategy for cancer services.  The strategy will aim to improve survival rates and save thousands of lives.  The taskforce has been asked to deliver the vision set out in the NHS Five Year Forward View and will work across the entire health system
  • National Cancer Intelligence Network (NCIN) is part of Public Health England .The NCIN is a UK-wide initiative, working to drive improvements in standards of cancer care and clinical outcomes by improving and using the information collected about cancer patients for analysis, publication and research including the Cancer Commissioning Toolkit
  • In NHS England’s The Forward View into action: Planning for 2015/16, four broad programmes were proposed:
    • Effective population screening (for prevention of some cancers as well as early detection);
    • Raising awareness of symptoms to promote earlier presentation of patients with potential symptoms of cancer in general practice;
    • Earlier and more accurate diagnosis of the symptoms of cancer by GPs; and
    • Ensuring timely access to diagnostics


In January 2015, NHS England published three handbooks to support commissioners and practitioners in planning services for people with long term conditions (LTCs), in order to achieve more effective, personalised care for this group.  They are case finding and risk stratification; personalised care and support planning; and multi-disciplinary team (MDT) working http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ltc-care/

  • Cancer Research UK


What are the key inequalities?

  • Generally, the incidence increases with more disadvantaged groups, especially for tobacco and other lifestyle-related cancers.  However, according to Cancer Research UK, for cancers of the breast, prostate and malignant melanoma it is more common in those with higher socioeconomic status.
  • In general men are at significantly greater risk than women from nearly all of the common cancers that occur in both sexes (National Cancer Intelligence Network, 2009).
  • The report ‘Reducing premature mortality from Cancer, July 2011’ found that lung cancer has the greatest impact on mortality rates in the most deprived areas of Bedfordshire (Kitcat, 2011)


What are the unmet needs/ service gaps?

According to ‘Macmillan Cancer Support (2013) nationally, 500,000 people are facing poor health or disability after treatment for cancer.  Many of these problems can persist for at least 10 years after treatment.



Bedford Borough Council:

  • Increased awareness by the commissioners of those patients with poor health and disability as a result of side effects of cancer treatment
  • Increased use of the Lifestyle hubs for cancer patients
  • Continued emphasis on the delivery of an effective stop smoking service


Bedfordshire Clinical Commissioning Group

  • Increase awareness of GPs and BCCG of patients with poor health and disability as a result of side effects of cancer treatment
  • Increase the concept of cancer rehabilitation being similar to cardiac and pulmonary rehabilitation programmes
  • Increasing awareness of symptoms of cancer.  The National Awareness and Early Diagnosis programmes has shown some promising results and will be continued and expanded
  • Continued emphasis on the delivery of an effective stop smoking service
  • Promotion and evaluation of the GP cancer practice profiles within primary care by the Macmillan GP and partners
  • Close working with both the Strategic Clinical Networks under NHS England to improve outcomes for Bedfordshire residents
  • Establishing links with user and hard to reach groups


This chapter links to the following chapters in the JSNA




NHS Information Centre https://indicators.ic.nhs.uk/webview [accessed July 2013]

Ahmad, A et al (February 2015) Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born from 1930 to 1960 British Journal of Cancer 2015 http://www.nature.com/bjc/journal/vaop/ncurrent/full/bjc2014606a.html [accessed 04/02/2015)

Cancer Research UK http://scienceblog.cancerresearchuk.org/2011/12/07/the-causes-of-cancer-you-can-control/

National Cancer Intelligence Network and Cancer Research UK (2009). Cancer Incidence and Survival by Major Ethnic Group, England 2002-2006

Ruth H Jack, Elizabeth A Davies, Henrik Møller. Lung cancer incidence and survival in different ethnic groups in South East England. British Journal of Cancer 2011;105(7):1049-53

C Foot, T Harrison (June 2011).  How to improve cancer survival.  Explaining England’s relatively poor rates.  The King’s Fund.

Macmillan Cancer Support/YouGov online survey of 2,142 UK adults living with cancer. Fieldwork took place 26 November – 14 December 2012

DM Parkin (2011). The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer, 105 (Supplement 2)

Anglia Cancer Network (December 2011).  An Evaluation of the ‘Be Clear on Cancer’ Campaign- Bedfordshire PCT

Stubbings S et al, British Journal of Cancer (2009) 101, S13-S17, ‘Development of a measurement tool to assess public awareness of cancer’

A Gleed. Sub-Regional Overview: Bedfordshire.  A population survey for the National Cancer Awareness Measure (CAM), January 2010

National Institute for Health and Clinical Excellence http://guidance.nice.org.uk/Topic/Cancer [accessed 13/12/2011]

National Cancer Intelligence Network http://www.ncin.org.uk/ [accessed 14/12/2011]

NHS Cancer Commissioning Toolkit.  http://www.cancertoolkit.co.uk/ [accessed 14/12/2011]

Cancer Research UK http://info.cancerresearchuk.org/ [accessed 14/12/2011]

Social inequality in incidence of and survival from cancer in a population-based study in Denmark, 1994-2003: Summary of findings (2008) European Journal of Cancer, 44 (14), pp. 2074-2085.

National Cancer Intelligence Network, Cancer Research UK, Leeds Metropolitan University and Men’s Health Forum (2009). The Excess Burden of Cancer in Men in the UK

Kitcat, J et al (2011).  Reducing premature mortality from Cancer

Macmillan Cancer Support (2013).  Throwing light on the consequences of cancer and its treatment http://www.ncsi.org.uk/wp-content/uploads/MAC14312_CoT_Throwing-light_report_FINAL.pdf [accessed 25/07/2013]


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