Wolverhampton's Collaborative Cancer Strategy 2019-2024

Wolverhampton’s Collaborative Cancer Strategy 2019-2024

Improving cancer outcomes in Wolverhampton wolverhampton. gov.uk This strategy has been developed collaboratively between:

Contents

Foreword 3

Introduction 6

Wolverhampton Cancer Strategy 7

National Priorities for Cancer 9

Black Country Strategic Transformation Partnership (STP) 10 Priorities and Objectives

Overview of Local cancer Needs 11

Cancer incidence proﬁle 12

Overview of local cancer incidence 18

Objective 1 19 Reduce the growth in the number of new cancers

Objective 2 25 Improve survival of people diagnosed with cancer in Wolverhampton

Objective 3 36 Improve the quality of life of patients after treatment

2 City of Wolverhampton Council wolverhampton. gov.uk Foreword

Foreword

Over the next five years we aim to The number of people diagnosed and improve the outcomes for the population living with cancer each year will continue of Wolverhampton who are affected by to grow rapidly. The primary reasons for cancer. This document proposes a this are our ageing population and our strategy for achieving this. It includes a success in increasing survival rates. This series of actions across the patient will place significant additional demand pathway. The actions emphasise the on our health and social care services. importance of prevention, screening, Cancer survival in England has improved earlier diagnosis and of living with and significantly over the last 15 years. More beyond cancer in delivering outcomes than half of people receiving a cancer that matter to patients. The document diagnosis will now live ten years or recognises that no two patients are the more. But our mortality rates remain same, either in their cancer or their high. Additionally, unacceptable health and care needs. variability exists in access to and experience of care across different At its heart, it sets out a vision for what areas, sub-groups of the population and cancer patients should expect from our cancer types. There is much we could health service, health economy and do working in partnership with our partners: effective prevention, prompt citizens to improve patient experience and accurate diagnosis; informed choice and long-term quality of life, and to and convenient care; access to the best make our care more patient-centred. effective treatments, holistic support; and the best possible quality of life, including end of life care. It is crucial that patients are treated as individuals, with compassion, dignity and respect throughout. The strategy aims to work with patients and communities, as partners in improving cancer survival across the city.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 3 Foreword

“Working in partnership with the local “Cancer is a terrible disease which sadly population and its local health and social claims the lives of thousands of people every care partners is recognised by year. Whilst cancer survival rates in England Wolverhampton CCG as being key to the have improved signiﬁcantly over the last success of the delivery of cancer plans 15 years, early diagnosis is crucial for outlined in this strategy. We are clear that increasing these rates further. It is also there is a need to reduce the overall growth estimated that more than 40% of cancer in the number of all types of cancer cases cases each year are caused by aspects of within the city. As a CCG, we are working our lifestyles that we have the potential to closely with our GP members to ensure that, change such as smoking, obesity, poor diet within Primary Care across the city, we drive and excessive alcohol consumption. Working education and engagement to help to together we have the opportunity to slow increase screening uptake and early down the growth in the number of cases of diagnosis. We will aim to collaboratively cancer and through the commitment in this improve the survival of patients and their document improve the outcomes for those quality of life during and after treatment.” individuals affected Dr Helen Hibbs, Accountable Ofﬁcer, by cancer.” Wolverhampton CCG John Denley, Director for Public Health, City of Wolverhampton Council

“The Royal Wolverhampton NHS Trust is committed to working with partners to The Patient Advisory Cancer Team (PACT) improving the prevention, detection and are a group made up of Cancer patients and survivorship to end of life care for the local carers and have been advising healthcare population. We aim to reduce the growth in professionals in Wolverhampton for the past the number of all cancer cases, improve the 20 years. The PACT welcomes this strategy survival of people diagnosed with cancer and looks forward to its implementation. and improve the quality of life for those The aim of the PACT is to work together patients after treatment as well as provide with health professionals to improve the support for primary care to provide support quality of Cancer services in the city of to cancer patients and families within the Wolverhampton. This collaborative strategy community.” will go a long way to improve the experience David Loughton, Chief Executive, of patients at a difﬁcult time in their lives. The Royal Wolverhampton NHS Trust In line with the strategy we will continue to work with services in Wolverhampton, to ensure that patient experience and support is put at forefront of the development of services. Wolverhampton Patient Advisory Cancer Team (PACT)

4 City of Wolverhampton Council wolverhampton. gov.uk Foreword

Many thanks to the members of Wolverhampton PACT for agreeing to be photographed for this strategy

The Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020 encompasses a large number of recommendations. The strategy focuses on six strategic priorities to be achieved by 2020. These are:

• Radical upgrade in prevention and • Invest to deliver high quality services public health in respect of equipment, cancer drug treatments, novel treatments, e.g. • Achieving earlier diagnosis molecular diagnostics, workforce • Establish patient experience as being needs and research on a par with clinical effectiveness • Improve the commissioning of cancer and safety services • Transform our approach to support people living with and beyond cancer, e.g. stratiﬁed pathways of care and the implementation of the Recovery Package

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 5 Introduction

Introduction

The latest ﬁgures indicate that there will Cancer is the second largest cause of be two and a half million people living death in the UK behind cardiovascular with or beyond cancer in the UK in 2015, disease. Substantial resources are a ﬁgure that is increasing by 3.2% each already dedicated to cancer care in the year and a trend that, if it continues, UK (in 2008, this amounted to £5.13 could see 5.3 million people living with billion in direct costs to the NHS, with a cancer in the UK by 2040. 1 There are further £0.36 billion for hospice care), and more than 200 different types of cancer, as our population ages, cancer treatment but four tumour groups account for more and care will absorb an increasing than half of all new cases – breast, lung, proportion of healthcare expenditure. 2 bowel (colorectal) and prostate.

One in two people By 2020, almost By 2020, the proportion of people born after 1960 in one in two people who survive cancer will continue the UK will be (47%) will get cancer to rise, so that almost four in ten diagnosed with at some point in people (38%) who have had some sort of cancer their lives. 3 cancer will survive for more than during their lifetime. 3 a decade. 3

These numbers say little of the devastating personal impact that living with cancer can have on individuals, their families and carers. Wolverhampton CCG and partners are working collaboratively to reduce the incidence rate, increase awareness and early diagnosis, reduce recurrence of cancer in patients and to reduce the number of lives cancer takes each year.

6 City of Wolverhampton Council wolverhampton. gov.uk Wolverhampton Cancer Strategy

Wolverhampton Cancer Strategy

The aim of this document is to describe how local partners across Wolverhampton’s health and social care economy will strive to achieve excellence across the whole cancer pathway from prevention through to survivorship and the end of life.

Our Ambition This strategy sets out our local ambition to improve cancer outcomes in Wolverhampton over the next ﬁve years.

Our aims are that by 2024 we will see:

Fewer people being diagnosed with preventable cancer More people surviving for longer after a diagnosis More people having a positive experience of care and support More people enjoying a better long-term quality of life

We will achieve this by a greater focus on:

Earlier Improved Prevention detection treatment

Critically, we will focus on improving health and wellbeing across all the areas but also signiﬁcantly reducing inequalities and variations in outcomes between local areas and between different population groups.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 7 Wolverhampton Cancer Strategy

The strategy has three underpinning objectives aligned to the strategic priority areas and key initiatives described in the NHS Five Year Forward View to 2020/21 and the NHS Long Term Plan.

Objective one Objective two Objective three

Reduce the overall Improve survival of Improve the quality of growth in the number people diagnosed life of patients after of all cancer cases with cancer treatment and at the Page 19 Page 25 end of life Page 36

Key actions These objectives will be achieved through eight key actions:

Promote, encourage and Ensure prompt access 01 empower people to adopt 05 to diagnostic tests and healthier lifestyles referral pathways Page 19 Page 33

Increase diagnosis through Provide individualised care the national screening and support to cancer programmes before signs 02 06 patients and symptoms appear Page 38 Page 29

Reduce risks and improve Empower patients to long term outcomes for present early with cancer patients diagnosed with 03 signs and symptoms 07 cancer Page 30 Page 39

Support primary care to Monitor progress and manage patients in performance of the accordance with best 04 08 strategic aims practice guidelines Page 41 Page 31

8 City of Wolverhampton Council wolverhampton. gov.uk National Priorities for Cancer

National Priorities for Cancer

In July 2015, the National Cancer Strategy ‘Achieving World Class Cancer Outcomes’ was published. The strategy sets out a number of ambitions for outcomes which matter most to patients and society. For example, by 2020:

Stage 62% 1 or 2

A reduction in cancer incidence 62% of cancers will be and number of cancer cases linked diagnosed at an early stage to deprivation (stage 1 or 2)

75% of people with cancer 57% of people with cancer should survive to at least 1 year should survive to at least 10 years following diagnosis following diagnosis

Continuous improvement in patient experience and improved quality of life following diagnosis

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 9 Black Country Strategic Transformation Partnership (STP)

The Black Country and West Birmingham Sustainability and Transformation Partnership (STP)

Priorities and Objectives Priority Programme Deliverables: The Black Country and West Key deliverables for the Birmingham STP Cancer Board and Programme are: The Black Country and West Birmingham 1. To achieve all national cancer waiting Commissioners Group are working to time standards achieve a number of priorities, objectives and deliverables in order to improve 2. To work with providers to ensure the cancer outcomes for the resident implementation of nationally agreed population; deliver the National Cancer rapid assessment and diagnostic agenda, in line with the NHS Long Term pathways for lung, prostate and Plan and deliver the West Midlands colorectal cancers; Cancer Alliance Cancer Alliance priorities. priority to include Upper Gastrointestinal cancers The programme objectives are: 3. To agree and implement a plan to 1. Ensuring the effective implementation improve screening uptake of national cancer priorities. 4. To agree and implement a plan to 2. Working with partners to achieve improve early diagnosis improvements in cancer screening uptake and early diagnosis. 5. To support the Cancer Alliance in making progress towards 3. Commissioning cancer services that implementation of stratiﬁed cancer offer consistent and high-quality pathways services, including meeting national waiting time standards for diagnosis 6. To agree and implement a plan to and treatment improve implementation of the Recovery Package 4. Improving patient experience, including through implementation of the national Recovery Package For which the outcomes will be: 1. Shorter waiting times for patients 2. Improved screening uptake 3. More patients diagnosed early (stages 1 & 2) 4. Fewer patients diagnosed following emergency admission 5. Improved patient experience 6. Improved cancer survival

10 City of Wolverhampton Council wolverhampton. gov.uk Overview of local cancer needs

Overview of local cancer needs

Whilst a number of priorities such as Although older people make up 16.8% workforce capacity and the of the population; the city is witnessing modernisation of equipment are being an increase in comorbidities in the adult addressed at the national scale, there is population across Wolverhampton. The a great deal of work in prevention, early Black & Minority Ethnic (BME) diagnosis, patient treatment and care population in Wolverhampton is which has a local focus. increasing. At the time of the 2001 census, 22% of our city’s population Demographics (52,541 people) were from a BME background, which increased to 32% Wolverhampton consists of 20 wards (79,788 people) by the 2011 census. 4 and had an estimated population of 254,406 in 2015. Local cancer incidence data indicates that here is a correlation between There are high levels of deprivation in the deprivation, age, lifestyle factors and city, concentrated in a number of wards. cancer incidence. Screening data also In the 2015 Indices of Multiple highlights that there is a low take up of Deprivation, Wolverhampton was ranked screening services in less deprived areas as the 17th most deprived out of that have a high BME population. 5 England’s 326 local authorities; 54.4% of the Wolverhampton CCG population live in the 20% most deprived neighbourhoods in England, only 3% live in the 20% least deprived.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 11 Cancer Incidence Proﬁle

Cancer Incidence Proﬁle

Incidence of all Cancer

700 600 e t

a 500 0 R

0 d 0 ,

e 400 s 0 i 0 d r 1 300

a r d e n

p 200 a t

S 100 0 2011 2012 2013 2014 2015 2016 England 606.94 616.43 628.14 617.11 612.11 601.49 NHS W olverhampton CCG 622.29 594.28 648.76 612.81 616.61 592.85

(Source: Cancer Data, NCRAS) The incidence of cancer across Wolverhampton has remained consistent over the six- year period between 2011 and 2016, varying between 592.85 – 648.76 per 100,000 population. As of 2016, the standardised incidence rate for all cancer was statistically similar to the England average.

Incidence of Colorectal Cancer

90 80 70 e t

a 60 0 R

0 d 0 50 , e s 0 i 0 d 40 r 1

a r d e 30 n p a t 20 S 10 0 2011 2012 2013 2014 2015 2016 England 76.09 76.10 72.59 71.13 71.25 69.84 NHS W olverhampton CCG 77.90 67.79 86.38 78.89 68.97 86.92

(Source: Cancer Data, NCRAS) The incidence of colorectal cancer in Wolverhampton has varied over the six-year period between 2011 – 2016, not following a notable trend, whereas the England average has consistently decreased from 76.09 per 100,000 in 2011 to 69.84 per 100,000 in 2016. As of the most recent data point, 2016, the standardised incidence rate in Wolverhampton was signiﬁcantly higher than England.

12 City of Wolverhampton Council wolverhampton. gov.uk Cancer Incidence Proﬁle

Incidence of Breast Cancer

180 160 140 120 e t a 0

R 100

0 d 0 , e 80 s 0 i 0 d r 1 60

a r d e n p 40 a t

S 20 0 2011 2012 2013 2014 2015 2016 England 163.77 165.95 170.76 173.72 170.31 167.43 NHS W olverhampton CCG 169.78 150.17 172.95 166.48 169.40 163.83

(Source: Cancer Data, NCRAS) The incidence of breast cancer in Wolverhampton has remained steady between 2011 – 2016, varying between 150.17 and 172.95 per 100,000. The Wolverhampton ﬁgures have also remained statistically similar to the England averages over the 6-year period.

Percentage of Cancers diagnosed at early stage

50 40 e g a

t 30 n e c r

e 20 P 10 0 2012 2013 2014 2015 2016 England 41.60 45.66 50.66 52.36 52.56 West Midlands 41.45 44.30 50.93 52.05 52.32 Wolverhampton 41.42 44.85 51.00 50.74 52.97

(Source: Fingertips, PHE) The percentage of cancers, in Wolverhampton, that have been diagnosed at an early stage has increased significantly over the 5-year period between 2012 – 2016. The Wolverhampton figures have remained similar to the England and West Midlands figures throughout the 5-year period.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 13 Cancer Incidence Proﬁle

Under 75 mortality rate from cancer

160 140

e t 120 a 0 R

0 100 d 0 , e 0 s

i 80 0 d 1 r

a r 60 e d p n 40 a t

S 20 0 2010 – 12 2011 – 13 2012 – 14 2013 – 15 2014 – 16 England 146.48 144.36 141.51 138.78 136.82 West Midlands 148.81 147.75 146.26 143.56 141.88 Wolverhampton 158.36 152.43 158.76 159.54 165.32

(Source: Fingertips, PHE) Mortality from cancer in under 75’s has increased consistently between 2011-13 and 2014-16, whereas both England and West Midlands ﬁgures have decreased. Wolverhampton has been signiﬁcantly worse than England and the West Midlands between the 2012-14 and 2014-16 time periods. Cancer is the highest cause of death in England in under 75s. To ensure that there continues to be a reduction in the rate of premature mortality from cancer, there needs to be concerted action in both prevention and treatment. The inclusion of this indicator (alongside several other indicators in the Public Health and NHS Outcomes Frameworks) reinforces the Government’s commitment to reducing avoidable deaths through public health policy and interventions and sends out a clear signal that prevention of cancer is just as important as treatment.

14 City of Wolverhampton Council wolverhampton. gov.uk Cancer Incidence Proﬁle

Under 75 mortality rate from cancer considered preventable

t 60 a 0 R

0 d 0 ,

e 40 0 s i 0 d 1 r

a r 20 e d p n a t 10 S 0 2010 – 12 2011 – 13 2012 – 14 2013 – 15 2014 – 16 England 86.06 84.85 82.95 81.12 79.39 West Midlands 86.20 85.81 84.96 83.35 81.85 Wolverhampton 91.74 85.44 90.41 89.75 94.84

(Source: Fingertips, PHE) Mortality from cancer in under 75’s which is considered preventable varied considerably between 2010-12 and 2014-16, whereas both England and West Midlands figures have decreased consistently. In the most recent data point, 2014-16, Wolverhampton is significantly worse than England and the West Midlands. In the four previous data points, Wolverhampton was statistically similar to the England figures.

Under 75 mortality rate from breast cancer

10 e t a 0 R

0 8 d 0 , e 0 s i

0 6 d 1 r

a r e d 4 p n a t

S 2 0 2011 – 13 2012 – 14 2013 – 15 2014 – 16 England 11.65 11.30 10.92 10.75 West Midlands 12.09 11.40 10.84 10.76 Wolverhampton 10.27 11.33 10.82 12.68

(Sourc e: Fi ngertips, PHE) The rate of under 75 mortality from breast cancer, in Wolverhampton, varied between the 2011-13 and 2014-16 time periods, whereas England and West Midlands ﬁgures consistently decreased. However, the Wolverhampton rate was statistically similar to England and West Midlands rates at all of the 4 data points.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 15 Cancer Incidence Proﬁle

Under 75 mortality rate from colorectal cancer

e 12 t a 0 R

10 0 d 0 , e 0 s 8 i 0 d 1 r

a r 6 e d p n

a 4 t S 2 0 2011 – 13 2012 – 14 2013 – 15 2014 – 16 England 12.66 12.34 12.05 11.93 West Midlands 12.74 12.82 12.69 12.77 Wolverhampton 13.37 14.24 15.02 14.56

(Source: Fingertips, PHE) The rate of under 75 mortality from colorectal cancer in Wolverhampton has increased slightly over the time period between 2011-13 and 2014-16, whereas England and West Midlands remained fairly steady. The Wolverhampton rates were statistically similar to the England and West Midlands ﬁgures across all four data points.

Rate of deaths among people aged 65 years and over by condition, Wolverhampton

1,400

1,200 e t a

0 1,000 R

0 d 0 ,

e 800 0 s i 0 d 1 r 600

a r e d p n 400 a t

S 200 0 2010 – 12 2011 – 13 2012 – 14 2013 – 15 2014 – 16 Cardiovascular Disease 1,438.96 1,317.03 1,352.37 1,335.99 1,338.37 Cancer 1,210.46 1,244.66 1,257.01 1,248.55 1,204.30 Respira tor y Disease 727.89 703.20 663.93 639.28 585.10 (Source: Fingertips, PHE) The rate of deaths from cancer, in Wolverhampton in those aged 65 and over, have remained steady over the time period between 2010-12 and 2014-16. However, the rate of deaths from cancer is signiﬁcantly higher than the rate of deaths from Respiratory disease in the same population. In comparison to the rate of deaths in the same population, from cardiovascular disease, cancer has been signiﬁcantly lower at the two most recent data points.

16 City of Wolverhampton Council wolverhampton. gov.uk Cancer Incidence Proﬁle

One-year survival index (%) for all cancers combined

80 70 60 %

e 50 g a

t 40 n e

c 30 r e

P 20 10 0 2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015 All a ges Ages 55-64 Ages 75-99

England Wolverhampton

Emergency Presentation

Emergency diagnoses of invasive malignant tumours National The data shows the proportion of tumours diagnosed position in A&E by CCG, expressed as a percentage based on 2017 data 2012 2013 2014 2015 2016 2017 NHS Wolverhampton CCG 23.41% 22.95% 21.18% 23.25% 23.89% 20.75% 158/194 England 20.94% 20.25% 20.04% 19.84% 19.49% 18.75%

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 17 Overview of local cancer prevalence

Overview of local cancer prevalence

Cer vical Cer vical 22 (2%) 3 (1%) Prostate Prostate Br east Br east 376 (27%) 106 (28%) 508 (37%) 131 (35%)

South East of Wolverhampton Wolverhampton 2014-17 2014-17

Color ectal Lung Color ectal Lung 347 (25%) 124 (9%) 102 (27%) 35 (9%)

Cer vical Cer vical 6 (1%) 13 (2%) Prostate Prostate Br east Br east 144 (30%) 126 (25%) 192 (39%) 185 (36%)

South W est of North East of Wolverhampton Wolverhampton 2014-17 2014-17

Color ectal Lung Color ectal Lung 117 (24%) 28 (6%) 128 (25%) 61 (12%)

18 City of Wolverhampton Council wolverhampton. gov.uk Objective one: Reduce the growth in the number of new cancers

Objective one

Reduce the growth in the number of new cancers

Promote, encourage and empower people Key Action to adopt healthier lifestyles 01

What are we goi ng to do? In 2017, the City of Wolverhampton’s Literature suggests that these three Public Health department published improvements are key to reducing the ‘The vision for Public Health 2030: number of preventable cancers. It is Longer, healthier lives’, which outlines suggested that 4 in 10 cancers can be the council’s aims and objectives for the prevented by reducing a number of years ahead around inﬂuencing factors. Being smoke free and keeping a improvements in the health of the healthy weight can reduce an individuals population of Wolverhampton. risk of cancer most and contribute to the greatest reduction in the populations The council are aiming to continue the incidence of cancer. The council are also improvement in life expectancy for males committed to working towards keeping and females in the city, in order to do people well in their community, which this the document outlines would involve improvements in aspects improvements it expects to make. of the care and community services Three key improvements are: which those with cancer would require. • Reduce smoking prevalence • Increase physical activity and decrease obesity levels • Reduce Alcohol consumption

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 19 Objective one: Reduce the growth in the number of new cancers

The City of Wolverhampton Council will Why? also continue to support and endorse In 2014-15, there was an average of national and regional cancer prevention 511 new cancer diagnosis per 100,000 and awareness campaigns and of the population in Wolverhampton. strategies. These include: This is similar to the England average of • The new Tobacco Control Plan 523 per 100,000 and has been similar since 2009-10. 5 • The National Obesity Strategy Timescales associated with prevention • Public Health England’s Alcohol mean it inevitably takes time to have an Evidence Review impact on trends of increasing cancer • Use evidence-based social marketing cases, but there are proven ways to campaigns such as One You and reduce the risk of getting cancers; as 4 Change4Life locally to enhance in 10 cancers are preventable, it is consistent messages and branding critical that action is taken now to prevent cancers in the long term. • Develop local capacity to deliver Stop Although there is awareness in the Smoking Services and other services population of risks associated with some aimed at supporting people to adopt risk factors such as smoking, people are healthy lifestyles less aware of the connection between • Continue to offer support to our other more common lifestyle risk factors, hospital Trust to achieve smoke free particularly obesity. Other cancers such status in line with NHS England’s as cervical cancer are now largely stated intention for all acute trusts to preventable, but there is evidence of low become smoke free in 2018/19 public awareness and screening rates are falling year on year. Prevention • Raise awareness around NHS Health activity will centre on helping people to Checks in order to increase uptake change their behaviour in relation to diet, and support people to adopt healthy exercise, smoking and alcohol. High lifestyles levels of deprivation and factors such as • Promote uptake of the HPV higher smoking rates and rising levels of vaccination programme and respond obesity also impact on cancer survival. to any nationally determined changes to the programme • Seek opportunities to embed healthy lifestyle advice with appropriate signposting and referral in patient pathways including cancer pathways.

20 City of Wolverhampton Council wolverhampton. gov.uk Objective one: Reduce the growth in the number of new cancers

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 21 Objective one: Reduce the growth in the number of new cancers

Smoking Excess body weight Smoking is the largest single Being overweight is the biggest single preventable cause of cancer in the UK, preventable cause of cancer after linked with nearly 1 in 5 of all cancers smoking. It is linked with 1 in 20 cancers and 72% of lung cancers 6. As well as and related to up to 10 different types of cancer, tobacco use is also a signiﬁcant cancer, including two of the most factor in other local health inequalities, common four, bowel and breast, and with smoking attributable mortality two of the hardest to treat, pancreatic worse in Wolverhampton (305.6 per and oesophageal. 8 100,000) than the England average. Excess weight (BMI of 25 or above) Although smoking rates have declined in affects 65.8% of adults in recent years, many adults still smoke Wolverhampton, making this a (14.4% of adults in Wolverhampton). prevention priority which is already Whilst the adult rate has fallen there is a acknowledged in other local plans. marked inequality with the number of 22,099 adults in Wolverhampton were adult smokers in routine and manual recorded in their GP Practice records as occupations in Wolverhampton at obese, as of 2014-15. 9 (25.3%). The percentage of mothers smoking at the time of delivery has Excess weight in Wolverhampton is decreased slightly in recent years but is worse than the England average of currently signiﬁcantly worse in 61.3%. Recent research has showed a Wolverhampton (17.1%) compared to quarter of nurses in England to be the England average (10.7%). 7 obese (BMJ Online) Our strategy will include working with all local employers to address weight as a risk factor for cancer, but with particular support to our own trust staff, as this increases the validity of health promotion messaging. 10

22 City of Wolverhampton Council wolverhampton. gov.uk Objective one: Reduce the growth in the number of new cancers

Diet Alcohol Diet is the second largest combined Alcohol is linked with 4% of cancers. cause of preventable cancers linked 15.0% of adults in Wolverhampton with 1 in 10 cancers when the various report drinking more than 14 units of elements of diet are combined. 8 alcohol in a week and 6.6% report binge Not eating enough fruit and vegetables, drinking. vii There were 1,647 hospital intake of processed and red meat, lack admission episodes for alcohol-specific of dietary fibre and having too much salt conditions in 2016-17, at a rate of 698 all contribute to this significant per 100,000 population. This is preventable behaviour. Local data significantly higher than England (563 shows that dietary habits in per 100,000) and Wolverhampton Wolverhampton are worse than the figures have been increasing since England average with deprived areas 2008-09, whereas England figures have showing significantly lower intake of fruit remained similar. Wolverhampton figures and vegetables. Only 54.1% of adults in are currently higher for both females and Wolverhampton met the recommended males, compared to England. 9 “5 a day” in 2016-17 compared to almost 57.4% in England. 9

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 23 Objective one: Reduce the growth in the number of new cancers

Health Data Statements

Life expectancy at birth is 7.3 years lower for men -7.3 -7 and 7.0 years lower for women in the most deprived areas of Wolverhampton than in the least deprived areas.

Age standardised The rate of rate of mortality alcohol-related considered This is worse hospital admissions This is worse preventable from all than the England in Wolverhampton is than the England cancers in persons average (182.8 1,497 per 100,000. average (1,258 aged under 75 is per 100,000) . per 100,000). 239.6 per 100,000.

The rate of smoking Under 75 mortality attributable mortality from cancer in in Wolverhampton is This is worse Wolverhampton in This is worse 305.6 per 100,000. than the England 2014-16 was than the England average (272.0 165.3 per 100,000. average (136.8 This represented per 100,000). per 100,000). 1,238 deaths between 2014-16 (both of these are worse than 2016).

(Source: Fingertips, PHE)

24 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Objective two

Improve Survival of people diagnosed with cancer in Wolverhampton

Improving survival is dependent on In Wolverhampton 53.0% of cancers are diagnosing cancers earlier. Diagnosing currently diagnosed at an early stage (1 cancers at an earlier stage means better or 2) suggesting early presentation. This outcomes for patients, both in terms of is higher the than England average of reduced risk of dying from cancer and 52.4%. 11 However as seen in section 6, also quality of life as well as reduced the mortality rates are higher for some treatment costs and better patient cancer types. 9 experience. Nationally, over 53% of cancers occur in The impact of earlier diagnosis is stark. people aged 50-74 and it is estimated For example, one-year survival for lung that 70% of people with cancer have cancer increases from under 17% when one or more long term condition which diagnosed at stage 4 to 83% when can lead to reduced survival and higher diagnosed at stage 1. For breast cancer, levels of need (Cancer and other Long one year survival is 63% when Term conditions Macmillan Cancer diagnosed at stage 4 but survival is Support 2015). 12 similar to the general population when diagnosed at stage 1. Although stage at diagnosis has a different impact on survival for each different cancer type, those diagnosed at stage 4 generally experience much worse one-year survival.

Cancer screening provides an opportunity to diagnose cancer at an earlier stage before signs and symptoms have developed and when treatment may be less complex and outcomes better. The cervical cancer and bowel scope cancer screening programmes also help to prevent cancer cases. Improving screening uptake is therefore a priority and given signiﬁcant local variation in uptake, there is a considerable opportunity to reduce local variations in outcomes. In the UK, around 6% of cancers are diagnosed via screening.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 25 Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

4 IN 10 CANCER CASES CAN BE PREVENTED ...

Be smok e fr ee

Keep a heal th y w eigh t

Be sa fe in the sun

Avoid c ertain substanc es a t w ork such as asbest os

Protect against certain in fections such as HPV and H.Pyl ori

...MAKE A Drink less al cohol CHANGE TO REDUCE Ea t a high ﬁbr e die t THE RISK OF Avoid unnec essary r adia tion CANCER including r adon gas and x-r ays

Cut do wn on pr oc essed mea t

Avoid air pollution

Breastf eed if possible Be mor e activ e Minimise HR T use Lar ger cir cles indica te mor e UK canc er cases Cir cle siz e her e is no t r ela tiv e t o o ther in fogr aphics based on B rown e t al 2018. Sour ce: B rown e t al, B ritish J ournal o f C anc er , 2018

LET’S BEA T CANCER SOONER cruk.or g/ pr ev en tion

PREVUK

26 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Cancer National Screening programmes

Breast screening

Breast screening is offered 203 38 every 3 years to women new breast cancers deaths from breast aged 50-70 and women diagnosed a year in cancer a year in aged over 70 can self-refer Wolverhampton Wolverhampton to screening. About three in every 200 women screened are 68% 27% diagnosed with a cancer that of Wolverhampton of female breast would never have been residents go for breast cancers in England found without screening. screening were diagnosed via (Below the national screening (2016) average of 72%)

Bowel cancer screening

Bowel cancer screening encompasses two 151 65 programmes. new bowel cancers deaths from breast Firstly, a home testing kit for diagnosed a year in cancer a year in blood in a stool sample for Wolverhampton Wolverhampton people aged 60-74 (with self- referral for those aged over 75). And the bowel scope screening 52% 10% test is a test for those aged 55 of Wolverhampton of bowel cancers (which involves ﬁnding and residents go for bowel in England were removing any small bowel cancer screening diagnosed via growths, called polyps that (Below the national screening (2016) could eventually turn into average of 58%) cancer).

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 27 Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Cervical cancer screening

Cervical cancer screening 67.8% 26% checks the health of cells in the of Wolverhampton of cervical cancers cervix. It is offered every 3 years residents go for (in-situ) in England to those aged 25-49 and every screening were diagnosed via 5 years to those aged 50-64. (Below the national screening (2016) average of 72.1%)

Breast cancers Colorectal Cervical cancers diagnosed diagnosed diagnosed via screening via screening via screening NHS Wolverhampton CCG 26% 8% Not available England 28% 8% Not available

(Sources: Fingertips, PHE and NCRAS)

28 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Diagnose cancers through screening programmes Key Action before signs and symptoms appear 02

What are we going to do? • In order to increase cancer screening • Continue awareness work to increase uptake for all screening programmes earlier diagnosis and improve poorer we will be working collaboratively with cancer survival for lung, colorectal City of Wolverhampton Public Health, and breast PHE, Bowel Cancer Screening Hub, • Improve screening uptake with the Breast Screening Service and Cancer introduction FIT Bowel screening kit Research UK (CRUK) to develop in 2019 robust plans to support GP Practices, Healthy Living Pharmacies and the • Deliver targeted education events and wider community to increase cancer work collaboratively with other screening uptake Primary Care staff including Healthy Living Pharmacy staff, Care • Continue collaborative action with Navigators and practice cancer Cancer Alliance to review and champions. improve the lung cancer pathway (National Optimal Lung Pathway) and • Increase the number of practices who respond to national directives when engage with and routinely receive a released visit from Cancer Research UK (CRUK).

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 29 Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Empower patients to present early with cancer Key Action signs and symptoms 03

What are we going to do? • Support and share Be Clear on • Support Healthy Living Pharmacies to Cancer Campaign; liaise with develop prevention, risk reduction secondary care regarding the and cancer screening promotion potential for increase in activity, • Large scale promotion of cancer capacity and demand. Carryout screening programmes capacity and demand prediction review • Local targeted cancer awareness campaigns • There will be an annual patient stakeholder event to seek patient • Use social media and other forms of views and carer feedback communication to share cancer awareness campaigns throughout the • Share Be Clear on Cancer year with NHS colleagues and key Campaigns with NHS Colleagues partners • Develop and disseminate Cancer • Work with Making Every Contact screening programme Leaﬂets to GP Count (MECC)/Local Authority (LA) to Practices and at community events increase awareness, screening and • Support key partners to share prevention with core groups awareness raising messages

30 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Support primary care to manage patients in Key Action accordance with best practice 04

What are we going to do? • Support development of and • Support the National Cancer implementation of West Midlands Diagnosis Audit Cancer Alliance Primary Care • Embed effective safety netting Strategy systems and processes in Primary • Support Primary Care to manage Care for patients presenting with patients in accordance with best possible cancers practice • Support and enhance Primary and • Ensure education and training on Secondary Care communication cancer detection and management is through educational events delivered to Primary Care • Ensure robust communications • Share clinical decision/risk regarding pathways, new initiatives assessment tools for use in Primary and best practice Care and in the community (CCG in • Support peer review in primary care collaboration with CRUK and Macmillan)

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 31 Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Why? Assuming early presentation with signs • Younger patients and those from BME and symptoms of cancer takes place, communities accessing a potential diagnosis of early • Deprivation - incidence is associated cancer is dependent upon appropriate with socio-economic deprivation for investigation and referral within Primary most cancer types in males and Care. Ideally, as many people with cancer females. For the majority of cancer as possible should be diagnosed via the types incidence rates are higher in the urgent suspected cancer referral (two more deprived groups. The deprivation week wait) pathway which ensures timely gap is greatest for smoking-related access to tests and specialist care. cancers such as laryngeal, lung and Misleading or vague symptoms or any oral cavity cancers. other presentation, for which the GP • Some types of cancer (e.g. ovarian suspects there may be a cancer but the cancer) patients symptoms don’t lend themselves to a clear investigative pathways is Evidence around best practice is suggested to disproportionally rise in the changing all the time and we need to following groups: support our local GP’s and Practice Nurses to stay up-to-date with this through education, training and on-going engagement.

32 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhamptonv

Ensure prompt access to diagnostic tests Key Action and referral pathways 05

What are we going to do? Why? • Review and manage diagnostic The National Institute for Health and capacity to support increased use of Care Excellence (NICE) considers the appropriate diagnostic tests in line very best evidence available and with NICE guidance publishes detailed guidance on what excellent cancer care looks like. It is • Review all breaches and compare crucial that local patients receive care against timed pathways that complies with this guidance. New • Ensure cancer pathways comply with NICE guidance indicates that where latest NICE guidance patients present with symptoms with a 3% or higher risk of cancer, they should • Provide sustainable access to cancer be referred for further tests on a fast nurse specialists to ensure provision track pathway. This threshold for referral of support throughout their pathway is likely to increase demand on including tertiary referrals diagnostic and treatment services which • Review and improve multidisciplinary need to be reviewed and managed. team (MDT) processes to ensure In particular, there is a need to focus seamless coordination of patient care further on the cancer 62-day referral to • Implementation of the nationally treatment standard ahead of the agreed rapid assessment and introduction of a new standard to give diagnostic pathways for lung, patients a deﬁnitive diagnosis within 28 prostate, colorectal and local days by 2020. pathway for upper GI. • Ensure Straight To Test (SST) for Lower GI continues to work well

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 33 Objective two: Improve Survival of people diagnosed with cancer in Wolverhampton

Key challenges Meeting the 62-day referral to treatment The Trust has a Recovery Action Plan in national standard remains a challenge place. They are supported by an locally. The challenge to meet the target Intensive Support Team (IST), NHS is multi–faceted and complex. The Royal England, NHS Inspectorate, West Wolverhampton NHS Trust has seen an Midlands Cancer Alliance and increase in referrals in particular for Wolverhampton Clinical Commissioning urology and breast patients over the Group to identify gaps, improve past few years. The Trust is a tertiary performance and improve quality. centre and receives additional referrals Wolverhampton CCG and The Royal from across the region in particular for Wolverhampton NHS Trust will continue urology and gynaecological patients. to strive to improve the national 62-day referral to treatment waiting time Improvements in technology and the standard, to ensure patient safety and introduction of robotic surgery for care quality within the patient pathway. prostate cancer have had an impact on the number of patients choosing to opt The local health economy cannot work for this procedure. Robotic surgery towards these improvements without offers improved outcomes for patients additional resources and expertise and a reduced recovery period. particularly in relation to workforce However, the capacity to deliver robotic development and equipment. We look surgery within national waiting time towards the West Midlands Cancer standards requires additional resources Alliance for further leadership, additional within the workforce and additional resources and guidance in meeting the theatre capacity. 62-day referral to treatment standard and rolling out the national framework There are additional pressures within the for the 28-day Faster Diagnosis system. For example, within the Standard in 2020. diagnostic pathway there is national shortage of radiologists. The shortage of Meeting the 62-day referral to treatment radiologists has had an impact on the standard is linked to additional Trusts workforce; the current workforce investment from West Midlands Cancer remains static; as we see a signiﬁcant Alliance; additional investment will increase in the number of referrals into enable ongoing improvements in the local cancer services. diagnostic pathway. Failure to meet the Standard will reduce the level of additional funding available locally.

34 City of Wolverhampton Council wolverhampton. gov.uk Objective two: Improve Survival of people diagnosed with cancer in Wolverhamptonv

Secondary Care Support There are two very important elements MDT is ‘gold standard’ in terms of in ensuring access to excellent cancer delivering cancer care, ensuring better care. One of these is access to a access to treatment. However, there is a Cancer Nurse Specialist (CNS). Cancer need to ensure that local MDTs are Nurse Specialists are experts in a operating as effectively and as efﬁciently particular area of cancer nursing. They as possible, placing more emphasis on provide information, advice and support more complex patients. to patients; liaise with other healthcare Domains that are considered important professionals in what can be quite for effective MDT Working are: complex cancer pathways to offer coordinated and personalised care and • Structure can drive improvements in patient care • Clinical Decision Making and outcomes. They also act as key contacts within the Multidisciplinary • Team Governance Team (MDT). • Professional Development and Education The Trust’s Operational policy should reﬂect these domains and be reviewed on a yearly basis.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 35 Objective three: Improve the quality of life of patients after treatment

Objective three

Improve the quality of life of patients after treatment (access to the Recovery Package and other support)

What are we going to do? Why? • Ensure all patients with cancer Cancer increasingly affects many receive a Holistic Needs Assessment residents of Wolverhampton with their (HNA) own speciﬁc needs. It is therefore essential that the care received is • Ensure all patients with cancer personalised and tailored to ensure that receive a written individualised care experience of cancer care is as positive and support plan as possible and that best outcomes for • Ensure all patients receive a patients are achieved. Treatment Summary Many patients treated for a primary • Maximise the opportunities cancer will also develop secondary or associated with the Cancer Care metastatic cancer, which can often be review in primary care incurable. Nevertheless, these patients may live for many years with the • Seek the continuation of funding for disease, and they should be given the the Macmillan Primary Care Facilitator treatment and support they need to live within the CCG for as long and as well as possible, managing their cancer effectively as a chronic condition. The experience and quality of life that patients have through and beyond diagnosis and treatment is equally as important as clinical effectiveness and safety. Because the majority of cancer patients are over the age of 65, it is also the case that many have multiple morbidities. It is estimated that 70% of cancer patients have at least one other long-term condition that needs managing and over a quarter have at least three other such conditions.

36 City of Wolverhampton Council wolverhampton. gov.uk Objective three: Improve the quality of life of patients after treatment

Cancer is not the only condition where Wolverhampton CCG through primary survival has dramatically improved and care providers are responsible for the people are now living long-term with the fourth element: ensuring that timely, high consequences of their condition or quality, high impact Cancer Care treatment. Many of the services that Reviews (CCR’s) are delivered to all would benefit those living with cancer eligible cancer patients within 6 months would also benefit those with other long- of their cancer diagnosis. term conditions. Royal Wolverhampton NHS Trust and NHS Operational Planning and the CCG are working collaboratively to Contracting guidance 2017–2019 develop a patient led Recovery requires all elements of the Recovery Programme which ensures a joint up Package to be available to all cancer approach to recovery during treatment patients by 2020. A Recovery Package within acute services and throughout is a package of intervention known to months and years of recovery in improve outcomes. The acute provider community and neighbourhood settings. (RWT) is responsible for the All cancer patients should be offered at implementation of three of four various different stages of their pathway elements: a Holistic Needs Assessment, • Delivery of Holistic Needs encompassing physical, financial, Assessments and care plans psychosocial, and information and support needs as well as consideration • Provide Treatment Summaries for the of co-morbidities. This assessment GP and patient should be used to develop a written • Provide access to Health and individualised care and support plan Wellbeing events and information which is shared with GPs and owned by patients themselves. Risk stratified follow-up pathways have been shown to improve quality of care.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 37 Objective three: Improve the quality of life of patients after treatment

Reduce risks and improve long term outcomes Key Action amongst those diagnosed with cancer 06

What are we going to do? • Ensure that patients with cancer receive healthy lifestyle advice and where appropriate signposting and referral to health and wellbeing services • Ensure that cancer patients at the end of their cancer treatment are risk stratiﬁed and have a clear and appropriate follow up in place • Ensure all patients are aware of short- and long-term side effects of treatment and key signs of recurrence and secondary cancers. Advice as to how these should be managed including key contacts for advice and care should also be provided.

38 City of Wolverhampton Council wolverhampton. gov.uk Objective three: Improve the quality of life of patients after treatment

Key Action Actively monitor progress and performance 07

What are we going to do? The national cancer strategy for 2015- 2020 ‘Achieving World Class Cancer • Promote a Cancer dashboard that Outcomes’ sets out ambitious national brings together information on cancer targets to be achieved by the end of outcomes, performance, quality and March 2020: patient experience • A visible reduction in age- • Receive performance updates from standardised cancer incidence rates Wolverhampton CCG’s Performance and a reduction in the number of Team cases linked to deprivation • Regularly review RWT’s cancer • Improved screening uptake with 75% improvement plan and performance uptake for bowel FIT screening at monthly contract review meetings • 50% of patients referred by a GP with • Monitor our progress through the symptoms receive a definitive Wolverhampton CCG’s Cancer diagnosis or cancer excluded within 2 Strategy Group using the Cancer weeks Dashboard to escalate concerns through local delivery Boards. • Deliver a definitive diagnosis for 95% of patients within 28 day by 2020 • Use audit and benchmarking data and local intelligence to identify and • Reduction in emergency manage areas for improvement presentations including PHE Fingertips and GP • 62% of cancers diagnosed early at Practice Profiles. stage 1 or 2 (and an increase in the • Utilise National Cancer Diagnostic proportion of cancers staged) Audit • 85% meeting 62-day cancer waiting • Review and respond to National time targets Cancer Patient Satisfaction Survey • A treatment summary to be • Respond to the CCG Improvement & completed at the end of every phase Assessment Framework outcomes. of acute treatment and sent to the patient and their GP.

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 39 Objective three: Improve the quality of life of patients after treatment

• 57% of patients surviving cancer for Achieving this locally will not be easy ten years or more and will require proactive monitoring using the best available data and • One-year survival for all cancers 75% intelligence in order to ensure that we or more with improved survival are on track and to enable us to amongst older people respond to emerging issues and needs. • Reduction in under 75 mortality for We will therefore use both a cancer commissioner and provider local dashboard of cancer metrics, as well as • Continuous improvement in patient local proﬁles for general practice in order experience with a reduction in to provide timely feedback on progress. variation (as evidenced by the Cancer In addition, we will make use of routinely Patient Experience Survey) available data such as PHE’s Cancer Proﬁles on their Fingertips tool.

40 City of Wolverhampton Council wolverhampton. gov.uk Objective three: Improve the quality of life of patients after treatment

Support and complement the work of the Key Action End of Life Care Strategy 08

What are we going to do? • Commission high quality integrated palliative and end of life care services • Implement the RESPECT agenda locally

wolverhampton. gov.uk Wolverhampton’s Collaborative Cancer Strategy 2019-2024 41 References

References

1 Maddams, J., Utley, M. and Møller, H. (2012). Projections of cancer prevalence in the United Kingdom, 2010–2040. British Journal of Cancer, 107(7), pp.1195-1202. 2 Featherstone, H. and Whitham, L. (2010). The cost of cancer. [online] Policy Exchange. Available at: https://policyexchange.org.uk/wp-content/uploads/2016/09/the-cost-of-cancer-feb-10.pdf [Accessed 6 Oct. 2018]. 3 Macmillan Cancer Support (2013). Cancer mortality trends: 1992–2020. [online] Available at: https://www.macmillan.org.uk/documents/aboutus/newsroom/mortality-trends-2013-executive- summary-final.pdf [Accessed 1 Dec. 2018]. 4 Wolverhampton.gov.uk. (2018). Joint Strategic Needs Assessment | City of Wolverhampton Council. [online] Available at: http://www.wolverhampton.gov.uk/jsna [Accessed 5 Jun. 2019]. 5 Public Health England. (2019). Public Health Profiles - Search results for 'Cancer'. [online] Fingertips.phe.org.uk. Available at: https://fingertips.phe.org.uk/search/cancer#page/0/gid/1/pat/6/par/E12000005/ati/102/are/E0 8000031 [Accessed 5 Dec. 2018]. 6 Cancer Research UK. (2018). Lung cancer statistics. [online] Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer- type/lung-cancer [Accessed 20 Oct. 2018]. 7 Public Health England. (2019). Public Health Profiles - Search results for 'Smoking'. [online] Fingertips.phe.org.uk. Available at: https://fingertips.phe.org.uk/search/smoking#page/0/gid/1/pat/6/par/E12000005/ati/102/are/E 08000031 [Accessed 5 Jun. 2019]. 8 Cancer Research UK. (2018). Does obesity cause cancer? [online] Available at: https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/obesity-weight-and- cancer/does-obesity-cause-cancer [Accessed 5 Nov. 2018]. 9 Fingertips.phe.org.uk. (2019). Public Health Profiles. [online] Available at: https://fingertips.phe.org.uk/profile/cancerservices [Accessed 8 Nov. 2018]. 10 Kyle, R., Wills, J., Mahoney, C., Hoyle, L., Kelly, M. and Atherton, I. (2017). Obesity prevalence among healthcare professionals in England: a cross-sectional study using the Health Survey for England. BMJ Open, 7(12), p.e018498. 11 Public Health England. (2019). Public Health Profiles - Cancer diagnosed at early stage. [online] Fingertips.phe.org.uk. Available at: https://fingertips.phe.org.uk/search/early%20diagnosis#page/4/gid/1/pat/6/par/E12000005/ati/ 102/are/E08000031/iid/90834/age/1/sex/4 [Accessed 5 Nov. 2018]. 12 Macmillan Cancer Support (2015). The burden of cancer and other long-term health conditions. [online] Macmillan Cancer Support. Available at: https://www.macmillan.org.uk/documents/press/cancerandotherlong-termconditions.pdf [Accessed 5 Nov. 2018]. 13 Ahmad, A., Ormiston-Smith, N. and Sasieni, P. (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, 112(5), pp.943-947.

42 City of Wolverhampton Council wolverhampton. gov.uk 14 Cancer Research UK (2015). Achieving World-Class Cancer Outcomes. [online] Cancer Research UK, p. 9. Available at: https://www.cancerresearchuk.org/sites/default/files/achieving_world- class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf [Accessed 5 Oct. 2018]. 15 Cancer Research UK (2015). Achieving World-Class Cancer Outcomes. [online] Cancer Research UK, p. 59. Available at: https://www.cancerresearchuk.org/sites/default/files/achieving_world- class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf [Accessed 5 Oct. 2018]. 16 Cancer Research UK (2015). Achieving World-Class Cancer Outcomes. [online] Cancer Research UK, p. 13. Available at: https://www.cancerresearchuk.org/sites/default/files/achieving_world- class_cancer_outcomes_-_a_strategy_for_england_2015-2020.pdf [Accessed 5 Oct. 2018]. 17 Cancer Research UK. (2016). Breast cancer survival statistics. [online] Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by- cancer-type/breast-cancer/survival#heading-Three [Accessed 13 Nov. 2018]. 18 Hounsome, L. and Rowlands, S. (2016). Cancer survival by stage at diagnosis for England (experimental statistics) - Office for National Statistics. [online] Ons.gov.uk. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsa nddiseases/bulletins/cancersurvivalbystageatdiagnosisforenglandexperimentalstatistics/ad ultsdiagnosed20122013and2014andfollowedupto2015 [Accessed 5 Dec. 2018]. 19 Macmillan Cancer Support (2014). Evaluation of Phase 1 of the One-to-One Support Implementation Project - Baseline Report. [online] Available at: https://www.macmillan.org.uk/_images/onetoonesupportbaselinereport_tcm9- 280170.pdf [Accessed 1 Nov. 2018]. 20 Ncin.org.uk. (2016). Routes to diagnosis. [online] Available at: http://www.ncin.org.uk/publications/routes_to_diagnosis [Accessed 5 Sep. 2018]. 21 Ncin.org.uk. (2018). Cancer outcome metrics. [online] Available at: http://www.ncin.org.uk/cancer_type_and_topic_specific_work/topic_specific_work/cance r_outcome_metrics [Accessed 5 Nov. 2018]. C w W Y a i o o u t y l o d u v

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