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An Assessment of the NHS Cancer Plan for England

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An Assessment of the NHS Cancer Plan for England Articles Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England Bernard Rachet, Camille Maringe, Ula Nur, Manuela Quaresma, Anjali Shah, Laura M Woods, Libby Ellis, Sarah Walters, David Forman, John Steward, Michel P Coleman Summary Background The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of Lancet Oncol 2009; 10: 351–69 improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales Published Online until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus off er the opportunity March 20, 2009 for a fi rst formal assessment of the cancer plan in England, by comparing survival trends in England with those in DOI:10.1016/S1470- 2045(09)70028-2 Wales before, during, and after the implementation of the plan. See Leading Edge page 305 Methods See Refl ection and Reaction We analysed population-based survival in 2·2 million adults diagnosed with one of 21 common cancers pages 311 and 312 in England and Wales during 1996–2006 and followed up to Dec 31, 2007. We defi ned three calendar periods: Non-Communicable Disease 1996–2000 (before the cancer plan), 2001–03 (initialisation), and 2004–06 (implementation). We estimated year-on- Epidemiology Unit, London year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends School of Hygiene and Tropical between successive periods in England and separately in Wales. Changes between successive periods in mean Medicine, London, UK survival up to 5 years after diagnosis were analysed by country and by government offi ce region of England. Life (B Rachet MD, C Maringe MSc, U Nur PhD, M Quaresma MSc, tables for single year of age, sex, calendar year, deprivation category, and government offi ce region were used to A Shah PhD, L M Woods PhD, control for background mortality in all analyses. L Ellis MPH, S Walters MSc, Prof M P Coleman FFPH); Findings National Cancer Intelligence 1-year survival in England and Wales improved for most cancers in men and women diagnosed during Network, Queens House, 1996–2006 and followed until 2007, although not all trends were signifi cant. Annual trends were generally higher London, UK, and St James’s in Wales than in England during 1996–2000 and 2001–03, but higher in England than in Wales during 2004–06. Institute of Oncology, 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in St James’s University Hospital, Leeds, UK (Prof D Forman PhD); women. Diff erences in 3-year survival trends between England and Wales were less marked than the diff erences in and Welsh Cancer Intelligence 1-year survival. North–South diff erences in survival trends for the four most common cancers were not striking, and Surveillance Unit, Brunel but the North West region and Wales showed the smallest improvements during 2001–03 and 2004–06. House, Cardiff , UK (J Steward FFPH) Interpretation The fi ndings indicate slightly faster improvement in 1-year survival in England than in Wales during Correspondence to: 2004–06, whereas the opposite was true during 2001–03. This reversal of survival trends in 2001–03 and 2004–06 Prof M P Coleman, Cancer Research UK Cancer Survival between England and Wales is much less obvious for 3-year survival. These diff erent patterns of survival suggest Group, Non-Communicable some benefi cial eff ect of the NHS cancer plan for England, although the data do not so far provide a defi nitive Disease Epidemiology Unit, assessment of the eff ectiveness of the plan. London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK Funding Offi ce for National Statistics (contract NT-04/2355A); Cancer Research UK (programme grant C1336/A5735). [email protected] Introduction (MDTs) of specialists to oversee the care of each patient. In 1995, the Expert Advisory Group on Cancer published Annual funding for cancer services rose by about 35% the Calman-Hine report,1 in which they recommended in real terms over the three fi nancial years from 2001 to that strategic improvements be made to cancer services 2004. in England and Wales. However, no additional resources In Wales, the Cancer Services Expert Group were provided for the recommended improvements, recommended substantial changes to cancer services in and implementation of the recommendations was left 1996.4 Changes included the creation of MDTs and the to local initiative. By 1999, progress in improving cancer designation of specialist clinicians, but the approach services was seen as inadequate.2 relied heavily on clinical collaboration, supported by The National Health Service (NHS) cancer plan for directives from the devolved administration, rather England was published in late 2000.3 It was a than on a formal strategy. The full national cancer plan comprehensive 10-year strategy, designed to improve for Wales, Designed to Tackle Cancer,5 was not published prevention, early diagnosis, and screening, and to until late 2006. provide optimal treatment for all patients, thus 3-year progress reports on the NHS cancer plan were improving survival and quality of life. An important published in October, 2003,6,7 when, despite substantial feature was the creation of multi-disciplinary teams progress, it was acknowledged that it would take time www.thelancet.com/oncology Vol 10 April 2009 351 Articles before the eff ects of the plan could be assessed. Here, National Cancer Registry has collated data from regional we have chosen to examine survival trends during two cancer registries covering the entire population of 3-year periods after the introduction of the plan: England and Wales since 1962. Since 1971, the National 2001–03 and 2004–06. Population-based cancer survival Health Service Central Register (NHSCR) has provided serves as a broad measure of the overall eff ectiveness of notifi cation of the deaths of all cancer patients whose health services. Survival is generally improving, so to record was successfully fl agged with details of the initial measure the eff ect of the NHS cancer plan we looked cancer registration. for evidence of any acceleration in survival trends. Data for this study were extracted from the National Given the diffi culty of introducing systematic, Cancer Registry at the ONS after the linkage of cancer nationwide changes in the NHS, it would be surprising records with data on the patient’s vital status (alive, if survival trends for patients diagnosed in England emigrated, dead, not traced) at NHSCR. After powers to during 2001–03 were to diff er much from earlier trends legislate on health policy were devolved to UK national as a direct result of the plan. However, for patients assemblies from 1997, cancer registration in Wales diagnosed during 2004–06, at least 3 years after passed to the Welsh Cancer Intelligence and Surveillance implementation of the plan, any marked improvements Unit, but the National Cancer Registry at the ONS in the overall eff ectiveness of cancer services might continues to receive cancer data from Wales, and the reasonably be expected to show an eff ect on trends in vital status of all cancer patients in England and Wales short-term survival. is updated by the ONS. When the data were extracted Given the later implementation of a strategic cancer on Oct 17, 2008, the vital status at Dec 31, 2007, was plan in Wales, comparison of survival trends in England known for 99·6% of patients diagnosed with cancer and Wales over the same calendar periods could be during 1996–2006, without regional variation. The data instructive. A cancer plan that was implemented were received on Dec 15, 2008. nationwide cannot later be assessed in the same way as Cancers were defi ned by their anatomical location a randomised trial. But an observational comparison of (site), morphology, and behaviour (benign, in situ, or outcomes before and after the introduction of a plan in invasive). Tumour site was coded according to the tenth one of two adjacent countries, with similar societies revision of the International Classifi cation of Diseases and health systems, seemed to be a reasonable (ICD-10).10 Morphology and behaviour were coded alternative. Similar trends in cancer survival might be according to the second edition of the International expected in both countries up to 2000. But, if the cancer Classifi cation of Diseases for Oncology (ICD-O-2).11 We plan were eff ective, we would expect that England examined data for 21 common cancers, 17 in men and would experience a faster improvement in survival 18 in women. We analysed survival for laryngeal cancer than Wales after several years of latency. Up to 7 years in men only, and for breast cancer in women only. Data of follow-up are available for patients diagnosed since on stage at diagnosis were not available for all patients the introduction of the plan. 1-year survival trends and could not be usefully incorporated in our analyses. might be expected to accelerate more rapidly in Standard criteria were used to decide whether a tumour successive calendar periods in England than in Wales record was eligible for inclusion in the analyses.12 after the introduction of the plan, if the plan was Records were excluded if they contained data of eff ective. 3-year survival trends might also be diff erent inadequate quality or were for patients not resident in in England and Wales. England or Wales. 1·25 million of 8·4 million patients On Dec 10, 2008, the Offi ce for National Statistics registered with benign tumours (behaviour code 0), (ONS) published the offi cial national statistics on tumours of uncertain behaviour (code 1), in-situ survival for patients diagnosed with one of 21 common neoplasms (code 2) or a metastasis (code 6) were not cancers in England during 2000–04 and followed up to included.
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