HEALTH NEEDS ASSESSMENT: LUNG CANCER

April 2010

A report assessing the lung cancer need of the population of Bolton

Mark Cook
Public Health Intelligence
NHS Bolton

Acknowledgements

Billie Moores
Consultant in Public Health
NHS Bolton

Kathy Sandler
Cancer and Palliative Care
Royal Bolton Hospital

David Holt
Head of Public Health Intelligence
NHS Bolton

2

Introduction
This health needs assessment will
investigate and examine lung cancer in
Bolton.
Lung cancer is the most common cancer
in the world1, the majority of cases of
which are caused by cigarette smoking. In
the UK breast cancer is now the cancer
with the highest incidence2, but lung
cancer (the former highest) still accounts
for 1 in 7 new cancer cases. For men,
lung cancer is the second most common
form of cancer after prostate; for women
lung cancer is the third most common
cancer following breast and bowel.
Second hand smoke has become an
important aspect of lung cancer and other
smoking related illnesses. The importance
attributed to second hand smoke led to the
Smokefree legislation in England on 1st
July 2007 that prohibited smoking in public
places and workplaces. The impact of this
legislation can be expected to have
positive health benefits into the future, not
least as it encouraged many people to
quit.
The histology of lung cancer identifies two
predominant types of lung cancer – small
cell lung cancers and non-small cell lung
cancers. Non-small cell lung cancers
account for around 80% of all cases. The
main types of non-small cell lung cancers
are squamous cell carcinoma,
adenocarcinoma, and large cell
carcinoma. In the UK squamous cell
carcinoma is the most common. All those
mentioned have been linked to cigarette
smoking, however, adenocarcinoma is the
most common in non-smokers. Small cell
lung cancer is so called because the
cancer cells are small, and this type of
cancer is almost always caused by
smoking. Small cell lung cancer is very
1
Ferlay, J., Autier, P., Boniol, M., Heanue, M., Colombet,
M. and P. Boyle (2007) „Estimates of the cancer incidence
and mortality in Europe in 2006‟, Annals of Oncology,
18(3):581-92.
2 3
Since 1997.
aggressive and spreads beyond the lungs
very early on in the disease3.
From a financial perspective, NHS
Bolton‟s Strategic Plan 2009-2014
highlights that the PCT spends slightly
less per head of population on cancers
and tumours when compared to other
similar PCTs; however, performance is
similar to or better than others:
“This indicates that we should
consider increasing efficiency and
spending. Interventions within the
Strategic Plan to increases
spending and efficiency focus on
cancer prevention, early symptom
recognition, cancer information
services, one stop cancer
diagnostics, and provision of
therapy services closer to home”
(NHS Bolton, 2010, pg.151)
In a needs assessment it is vital to draw
out the key points and gaps from the
information presented. In this light, Part 1.
will summarise the main findings of this
assessment and reflect on the key
inequalities identified, the key gaps in
knowledge/services, the risks of not
delivering on targets, consideration of
what is coming on the horizon for lung
cancer, and what NHS Bolton should be
doing next.
Part 2. will involve a more detailed
analysis of available epidemiology,
targets, current performance, the views of
local people, presentation of relevant
national and local strategies, and analysis
of current activity and service provision.
This will present the findings that inform
the conclusions of Part 1.
Cancer Research UK (2010) www.cancerresearchuk.org
Key inequalities

 Mortality
 Incidence/prevalence
 Survival
 Pathway
 Smoking

Key gaps in knowledge/services and

priority areas

 Diagnosis
 Treatment
 Mortality
 Incidence
 Survival
 Smoking
 General

Risks of not delivering on targets

On the horizon

 Lung cancer screening

 NICE guidance PART 1.
 Diagnostic tests
 Radiotherapy
 Smoking
 Illegal tobacco
 Problems to overcome

Key inequalities
The epidemiology of cancer across the
Greater Manchester and Cheshire Cancer
Network reveals two main issues:
1. Excess incidence of cancer in the
population is caused by negative
lifestyle factors, of which smoking
is the principal for this assessment;
2. There is a tendency for late
presentation and this reduces the
opportunity for cure in the Network.
Furthermore, across the Network the
aetiology and causes of most cancers,
and especially lung cancer, result in an
uneven distribution with cancer being
more common in the elderly and deprived
communities4.
Mortality
60.7% of lung cancer in Bolton is
premature (<75 years). This is
much higher than England, the
North West, and Bolton‟s statistical
peers;
Bolton has the lowest percentage
decrease in lung cancer mortality
since 1995/97 of its statistical peer
group;
For both genders in Bolton lung
cancer is the most important
cancer to tackle in terms of
Bolton‟s life expectancy gap to
England;
The male mortality rate in Bolton is
falling, the female rate, though
lower, is static;
Those living in the most deprived
quintiles of Bolton take an unfair
4 One year survival rates are similar
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy,
Greater Manchester Public Health Practice Unit, Salford.
share of the mortality burden due
to lung cancer.
Incidence/prevalence
In Bolton lung cancer has the
greatest percentage difference
from England of the major cancers;
Female incidence is lower than
male, but as seen in the mortality
trend, male incidence is falling as
female incidence is static;
Incidence of lung cancer in Bolton
falls almost exclusively upon those
aged over 50 years old;
Hospitalised prevalence is very
high in Town Centre, Halliwell
Road, Highfield & New Bury,
Townleys, Deane & Middle Hulton,
and Tonge Fold.
Survival
Lung cancer has one of the lowest
survival outcomes of any cancer;
When the National Lung Cancer
Audit began there was a 4-fold
difference in five year survival
rates between the better and
poorer performing regions. The
resultant emphasis has been upon
standardisation of services across
the country;
The Greater Manchester and
Cheshire Cancer Network
demonstrates increasing survival
rates at one, three, and five years,
the exception being the male five
year survival rate;
Only 7% of Bolton lung cancer
patients are alive five years after
diagnosis;
to the UK – this means that
treatments are similar to the
standard of the UK;
Lower five year survival rate than
the UK – this suggests that more
people present with advanced
disease in the Network than the
UK.
Pathway
Typically, 77% of lung cancer
patients are unaware of the
symptoms of lung cancer prior to
diagnosis;
In Bolton there is a high level of
misdiagnosis of lung cancer (two
week referrals actually diagnosed
as lung cancer), but through this
the PCT does achieve a greater
proportion of diagnoses urgently
referred from a GP (as opposed to
non-urgent routes). In Bolton,
other cancers have a relatively
lower proportion of two week
referrals actually diagnosed with
cancer;
Deprivation quintile pattern of two
week referrals to Royal Bolton for
Bolton residents does not match
the severe decline across quintiles
seen in mortality;
Those in NRS areas in Bolton are
likely to be diagnosed (when
referred to the Royal Bolton) when
one year older than those not living
in NRS areas;
70% of all Bolton‟s male referrals
to Royal Bolton are from non-NRS
areas. We know NRS areas have
higher smoking prevalence, higher
incidence of lung cancer, and
higher mortality from lung cancer –
whilst there are more men in
Bolton living outside NRS areas,
we should still expect a higher
proportion than 30% of referrals to
come from NRS areas. For
comparison, this figure is 48.7% for
women, which is more reasonable
given that NRS areas account for
32% of Bolton‟s population;
Women from NRS areas
diagnosed with lung cancer at the
Royal Bolton are referred at a very
late age. There is a similar picture
for men from non-NRS areas;
The Greater Manchester and
Cheshire Cancer Network as a
whole needs to perform better on
percentage of patients receiving
active treatments to standardise
with England;
Radiotherapy treatment varies
widely between Networks. For
Bolton Hospitals Trust 33% of all
cases of lung cancer received
radiotherapy, which is higher than
both the Greater Manchester and
Cheshire Cancer Network and
England;
The latest national mean
chemotherapy rate for PS0-1 stage
IIIb or IV is 48%. Similar to the
Network as a whole, this figure is
27.8% for Bolton Hospitals Trust.
The National Lung Cancer Audit
recommends trusts below the
national mean should be reviewed;
There is an uneven picture of
Bolton people accessing end of life
care at Royal Bolton. It is not
equitable – the missing people
from the lower quintiles must turn
to care at some point, and this may
be as an emergency admission;
Bolton PCT has a Deaths at Home
target of 50% by 2011. The latest
official figure (2006/08) is 18.7%.
Nationally, policy has drawn
attention towards a „mis-match‟
between individual‟s preferences
for where they would like to die
and their actual place of death.
Bolton is lower than England, the
North West, and many of its
statistical peers on this stage of the
pathway, but recent small
increases are apparent.
Smoking
The pattern of smoking in Bolton
closely resemble the pattern of
lung cancer incidence and
mortality;
Men in Bolton are more likely to
smoke than women and the
proportion of women smoking has
fallen at a slightly faster rate than
men;
Men in Bolton are also more likely
to be heavy smokers (20+
cigarettes a day);
Smoking is strongly associated
with socioeconomic deprivation
and in Bolton this means poorer
communities continue to exhibit
higher prevalence rates. There is
almost a 3-fold difference between
the highest and lowest prevalence
across Bolton MSOAs;
Smoking prevalence is 10% higher
in NRS areas compared to the
general population;
At first sight South Asian groups
have a lower smoking prevalence
in Bolton than the White British
population, however this is almost
exclusively due to the very low
prevalence found in South Asian
women. South Asian men have a
smoking prevalence similar to the
White British population;
The only areas to show significant
decreases in smoking prevalence
between 2001 and 2007 are Tonge
Moor & Hall i‟th‟ Wood,
Leverhulme & Darcy Lever, and
Westhoughton East;
In general the higher proportions of
ex-smokers are seen in areas with
low rates of current smokers;
Nationally, 70% of routine and
manual smokers want to give up
but are not acting upon this need;
Adolescent smoking is not
reducing with the general
population;
In Bolton the successful quit rate is
lower in the more deprived
quintiles relative to the smoking
population;
With the exception of Tonge Moor
& Hall i‟th‟ Wood all the MSOAs of
greatest smoking prevalence fall
below the average quit rate in
Bolton;
The Smoke Free Homes initiative
has the potential to reach more
homes across Bolton.
Key gaps in knowledge/services and
priority areas
As lung cancer has such a low survival
rate in Bolton, emphasis must of necessity
be upon prevention and end of life care.
NHS Bolton must take the weighting of
prevention, treatment, and palliative care
into account when planning services. For
curative services it is vital there are
systematic assessment processes that
allow patients with an operable Stage of
cancer and a suitable performance status
to receive timely diagnoses and active
treatments. This is especially important
when seeking to improve the resection
rate. However, the bulk of patients require
palliative services, and these must be of
the highest standard based around
symptom control and end of life care.
Here, as many patients as able and who
desire it should receive care in the
community and have the choice of dying
at home.
Thus, the majority of funding and
resources are taken up by palliative and
terminal care services, but funding must
also be available for preventative and
early presentation/diagnosis strategies.
Smoking is the major prevention issue and
this will be an independent priority for NHS
Bolton into the future as it impacts upon
many disease areas and is the chief
modifiable source of health inequalities in
the borough.
Diagnosis
There are three major reasons for
delays in diagnosis of lung cancer:
1. Patients presenting
later;
2. Diagnoses being
missed in primary care;
3. GPs having limited
access to appropriate
diagnostic tests.
Point 1. above is true in Bolton.
Point 2. above is a known risk, but
overall in Bolton a higher
proportion of referrals come from
primary care compared to other
areas. More information is needed
on Point 3.;
Active case finding is a valuable
tool in achieving speedier lung
cancer diagnoses;
The Greater Manchester and
Cheshire Cancer Network identify
five recommendations to affect
early diagnosis at population level
for cancers for which screening is
not available:
1. Increase awareness of
cancer symptoms
among the population,
including health
professionals;
2. High risk groups should
be identified and
receive tailored
interventions and
information;
3. Reduce the fear of
cancer, in particular by
focusing on modern
advances and
improvements in
survival;
4. Ensure all population
groups have
opportunities to discuss
health worries and have
easy access to
appropriate diagnostic
services;
5. Ensure health
professionals follow
correct procedures for
cancer diagnosis.
Individual GPs can be expected to
have very little experience of lung
cancer diagnosis – despite the
high mortality lung cancer is rare at
GP level with a new case expected
every eight months;
The Royal Bolton data used in this
assessment covers a five year
period and yet at GP level
numbers are relatively small. For
this reason, and given the previous
point, it is unwise to focus on
individual practices. Rather, the
data justifies treating primary care
as a whole for this issue, with
perhaps greater emphasis on high
risk groups such as practices with
the highest smoking population or
the demographically older
practices;
In line with the ideas of
proportionate universalism a
greater intensity of services and
effort should be directed at the
more deprived areas of Bolton as
these have the greatest level of
need and account for a
disproportionate share of lung
cancer mortality in Bolton – there
needs to be more two week diagnosis we need to overcome
referrals from lower quintiles. the stigma in both the general
public and in health professionals.

Treatment
Pathway

The All Party Parliamentary Group

On Cancer identified four chief The NAEDI pathway demonstrates that
concerns with lung cancer efforts should be targeted early on in the
treatment in the UK: pathway to prevent more advanced
disease at diagnosis and the consequent
1. The need for more
poor survival rates and avoidable deaths
radiotherapy services; we experience in Bolton. Because of low
2. Access to drugs must public awareness/negative beliefs about
be improved; lung cancer, there is a late presentation to
3. A cancer nurse hospital services. Delays in access to
specialist should be primary care, in primary care itself, and in
provided for all patients; secondary care are all evident in the
cancer pathway and can all be improved
4. There is an
upon.
undertreatment for
older people. Whilst issues around low uptake of
Treatment services must be screening are not relevant for lung cancer
standardised with the rest of the at present, there are gaps where further
country to provide an equal level of gains can be made by reducing late
presentation to GPs as well as the
service and improvements in
proportion ending up as emergency
outcomes; presentations, especially in the more
Patients who see a cancer nurse deprived sections of Bolton‟s at-risk
specialist are more likely to receive population.
active treatment and so this
proportion should be improved;
Mortality
The negative connotations
associated with lung cancer affects
both its low public profile and the The most significant gap in Bolton
ability of sufferers to come forward. is that between diagnosis and
On both sides this is largely a active treatment and mortality.
result of the „put up and shut up‟ More must be done to improve
attitude stemming from the belief timely two week referrals from the
that “it‟s their own fault for more deprived quintiles of Bolton
smoking”. This attitude must as this can be expected to greatly
change if early diagnosis and impact upon the mortality rate and
treatment outcomes are to the inequalities in lung cancer that
improve; go beyond those at the smoking
87% of patients and 84% of nurses level;
believe stigma affects late The National Lung Cancer Audit
presentation. Following the identifies improvements in the
recommendation of the Roy Castle resection rates for lung cancer as
Foundation, in order to improve the main treatment method to
upon early presentation and improve outcomes;
Resection rates should be
monitored because of their
influence upon mortality and
survival.
Incidence
Bolton PCT and the Greater
Manchester and Cheshire Cancer
Network must improve incidence
monitoring as the latest official
figure is 2004/06 and this is
unacceptable. This is important as
increases in incidence results in
increases in mortality, unless
treatment improves, and so either
way monitoring here is valuable;
Incidence is also the measure of
the effectiveness of prevention
strategies;
More recent figures of premature
incidence are especially important;
Symptom education and efforts at
early diagnosis should be targeted
at those over 50 years old;
Concerning Vital Signs indicator
cancer emergency bed days per
100,000 weighted population,
many of these bed days are the
result of side effects of treatment
(especially chemotherapy and
radiotherapy). Such bed usage
should be minimised by adequate
provision of individualised patient
care, including a specialist out of
hours service and effective
community support.
Survival
Early diagnosis is key to survival.
One year survival rates and stage
at presentation are measures of
early diagnosis not currently locally
available to all concerned;
Improving the resection rate should
be a key goal in improving survival
in Bolton;
Early diagnosis + effective
treatment = good survival;
NCEI survey of NHS Trusts found
that projects to tackle inequalities
were typically focused on
awareness and early diagnosis
rather than living with and after
cancer.
Smoking
From the Bolton Health and
Lifestyle Survey 2007 we know
that the higher proportions of ex-
smokers are generally seen in
areas with low rates of current
smokers. These areas are
commonly the less deprived areas,
suggesting that people living in
these areas are able to quit
smoking more easily than people
in more deprived parts of Bolton;
Cessation rates in deprived areas
of Bolton are below those in more
affluent areas. Smoking cessation
services need to be more equitable
in successful outcomes to
positively impact upon inequalities
for lung cancer and the overall
health of Bolton‟s most deprived
residents;
When we rank Bolton against its
statistical peers for the rate of
successful quitters in 2008/09
Bolton is shown to have performed
poorly in comparison;
There is a clear disparity between
those areas within Bolton with the
highest smoking prevalence and
those with the highest quit rate;
We need to know the smoking
prevalence in Bolton after the
legislation. This will come from the
Bolton Health and Lifestyle Survey
2010 which will be carried out
towards the end of the year;
Quitting smoking before middle
age eliminates most of the risk of
lung cancer from tobacco, and so
the group prior to middle age is key
for targeted initiatives;
Advertising, notice boards, face to
face events, leaflets, and the Quit
It campaign account for a very
minor proportion of all referrals to
NHS Bolton‟s Stop Smoking
Service. Across all quintiles self-
referral is the most significant
referral method to the service. Of
importance, PAMU (Princess Anne
Maternity Unit) is the second most
significant method for those in the
most deprived quintile (19%),
whilst accounting for very few in
the higher quintiles. The Royal
Bolton is consistent across all
quintiles as are GPs. Interestingly,
around 12% of all referrals in
quintiles 1, 2, and 5 come via a
pharmacy.
General
Continued participation in the
National Lung Cancer Audit with
the highest possible level of
submitted data completeness
should be encouraged;
There is a need to establish
statistical peer acute trusts for the
Royal Bolton so we can see how
well it is developing beneath the
Greater Manchester and Cheshire
Cancer Network compared to
similar trusts under different
Networks.
What works/examples of good practice
Three main sources discussed in this
assessment that identify local delays in
diagnosis and seek to learn from and
address issues discovered:
1. Primary care cancer audit: Greater
Midlands Cancer Network
(http://info.cancerresearchuk.org/pro
d_consump/groups/cr_common/@nr
e/@hea/documents/generalcontent/c
r_016171.pdf);
2. Cancer in primary care: An
analysis of significant event audits
(SEA) for diagnosis of lung cancer
and cancers in teenagers and
young adults 2008-2009
(http://info.cancerresearchuk.org/pro
d_consump/groups/cr_common/@nr
e/@hea/documents/generalcontent/
014366.pdf);
3. Doncaster PCT lung cancer social
marketing project (appendix d.).
These pieces of work focus on primary
care as, excluding prevention, the start of
the pathway (early presentation and
diagnosis) is a key gap where outcomes
for lung cancer can be improved at a
national and local level. Gains here will
enable more patients to be suitable for
active treatment later on in the care
pathway.
Risks of not delivering on targets
Mortality is the overall measure of cancer
control. As shown at the start of this
assessment, lung cancer is a key cause of
premature mortality in Bolton, and for this
reason is one of the disease areas holding
a serious influence upon the life
expectancy of Bolton as a whole.
More people die from lung cancer in
Bolton than England because more people
develop lung cancer. Prevention is the
key to reducing inequalities. Furthermore, test that works, and effective
whilst we must accept that work here will treatments for the cancer detected”
not demonstrate a noticeable outcome for (Greater Manchester Public Health Practice
Unit, 2010, pg.14)
perhaps decades, its importance is
justified also by the plain fact that active
There are currently three screening
treatments are typically unpleasant and
programmes in England: breast, cervical,
not always successful5.
and bowel screening. Studies have
clearly demonstrated that screening these
Improvements in earlier diagnosis and
types of cancer reduces mortality. No
successful treatment have more
such test is yet available for lung cancer.
immediate but more limited results than
prevention.
Typically, lung cancer is identified on a
Chest X-Ray, but by the time it is visible
If NHS Bolton fails to deliver on these
on an X-Ray the disease is usually
fronts then its lung cancer mortality rate
advanced. Researchers are currently
will not decline as fast as England or its
considering approaches concerning a
statistical peers. The PCT has been found
spiral CT scan and a special type of
to have made very poor progress in
bronchoscopy as potential screening
reducing mortality since 1995/97
methods6, but nothing substantial is on the
compared to its peers, who all face similar
horizon at present.
challenges, and if this continues the
influence lung cancer mortality has upon
the life expectancy gap to England will
NICE guidance
increase and we can expect the gap to
widen as the PCT loses ground here.
NICE are producing guidance on school-
Similarly, the internal life expectancy gap
based anti-smoking campaigns in 2010;
can be expected to widen as lung cancer
when available the recommendations
mortality is very strongly associated with
should be implemented in line with the
deprivation in Bolton.
views of the Greater Manchester and
Cheshire Cancer Networks‟ Prevention,
Early Detection, and Inequalities strategy.
On the horizon

Diagnostic tests
Lung cancer screening
In September 2009 the Prime Minister
announced that GPs in England will have
“Screening programmes are used
speedier access to diagnostic tests for
to detect asymptomatic cancers
less clear cut cases of cancer. The
and pre-cancerous changes. For a
scheme will initially be targeted at lung,
cancer screening programme to be
colorectal, and ovarian cancers but is
successful it must be able to
expected to be expanded to all cancers
identify some cancers at a point in
within the next five years.
their natural history when cure is
still an option. This is a complex
problem requiring an
Radiotherapy
understanding of the natural
history of the disease, a diagnostic

5
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy, 6
Greater Manchester Public Health Practice Unit, Salford. Cancer Research UK (2010) www.cancerresearchuk.org
Demand on radiotherapy services is increases in data and
expected to increase over the next ten 7
publications ;
years. There is little local primary care
data concerning lung cancer at the
Smoking level of the primary care audits
given above.

We can expect continued falls in smoking

prevalence until the core group of smokers
are reached where further reductions will
become more difficult.

Illegal tobacco

As taxation increases the illicit tobacco

market in Bolton is becoming a problem.

Children and deprived communities will be

less affected by increases in taxes on
cigarette smoking as smuggled and illicit
tobacco becomes more prevalent.

Problems to overcome

There exist problems in dealing with this

issue beyond those immediate to NHS
Bolton. The chief of these are:

There is wide variation in outcome

and management of lung cancer
within the UK. NHS Bolton can
work towards standardisation, but
much of this is reliant upon other
PCTs and the Greater Manchester
and Cheshire Cancer Network
itself;
There are multiple referral routes
for lung cancer;
Many non-specialists are involved
in the diagnosis and care of lung
cancer patients;
There is an increasing complexity
of diagnosis, staging, and
treatment, furthered by substantial

7
Adapted from North West Cancer Intelligence Service
(2010) www.nwph.net
Epidemiological profile

 Mortality
 Incidence and prevalence
 Summary: Cancer Commissioning
Toolkit
 Inequalities in cancer

Targets

 Vital Signs
 Bolton Vision Partnership (LSP)
 Strategic Plan
 Mortality monitoring rates
 Waiting times
 Smoking target

Felt need and local views

 Perception of lung cancer: public

views
 Perception of lung cancer and
treatment: patient views
 Reaching Out: Understanding
health attitudes of hard to reach
groups in the North West
PART 2.
National and local strategies

 Cancer Reform Strategy

 The Cancer Plan for the North West
to 2012
 GMCCN Prevention, Early
Detection, and Inequalities
 End of Life Care
 Bolton End of Life Care
 Bolton JSNA
 High Quality Care For All
 North West Healthier Horizons
 NHS Bolton Primary Medical
Services Commissioning Strategy

Current activity and services

 Prevention
 Curative
 Mortality in hospital
 End of life care
 National Lung Cancer Audit: Points
of focus for the future

Programme budgeting

Geodemographic segmentation
 mortality rate in Bolton‟s male population
Epidemiological profile compared to the national average. This is
portrayed on the below charts where
Bolton is shown in a similar position for
men as for persons overall, but lies within
Mortality the deviation limits for female mortality.

Table a. shows the actual SMRs for lung

This section will forward an examination of
lung cancer mortality in Bolton with
reference to national and local data
sources.
Throughout this assessment Bolton will be
benchmarked against its statistical peers,
as well as against national and regional
averages. For more detail on Bolton‟s
statistical peers (those areas most like
Bolton) see Appendix a.
cancer mortality for Bolton and its
statistical peers.
It is clear that more men die of lung cancer
in Bolton than women, reflecting both the
national and local picture; the mortality
rate in Bolton for lung cancer is 27%
higher than the national average for men,
and 19% higher for women. Bolton‟s male
mortality rate is higher than the regional
average, while the female rate is lower.

For context, the Greater Manchester and
Cheshire Cancer Network has a higher
mortality rate than England. Of the excess
cancer deaths in the Network 69% are
excess deaths from lung cancer8.
Bolton in comparison
Furthermore, Bolton is slightly above
average for its statistical peer group for
male mortality and below this average for
female mortality. Comapred to the peer
group, Dudley PCT demonstrates a very
low cancer mortality rate.

The lethality of lung cancer makes

mortality figures a good estimate for
incidence and prevalence. In Bolton 164
people (87 men and 77 women) died of
lung cancer in 2008 (6.4% of all deaths),
of which 98 (51 men and 47 women) were
premature (<75 years of age) (9.4% of all
premature deaths).

The below funnel plots show the all age

SMR mortality ratio for every PCT in
England for the period 2006/08. Bolton is
highlighted red, whilst it statistical peers
are highlighted blue. The funnels denote
the deviation from the average score for
England (100), with Bolton, like many of its
peers, being significantly beyond these
limits.

Divided by gender we see that the high

mortality ratio in Bolton from lung cancer is
due in considerable part to the very high

8
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy,
Greater Manchester Public Health Practice Unit, Salford.
Table a. Lung cancer SMR mortality, all ages
2006/08 Males Females
OBS SMR 95% Confidence OBS SMR 95% Confidence
Lower Upper Lower Upper

England 47676 100 99.1 100.9 35612 100 99.0 101.0

North West 7632 119 116.8 122.2 6330 130 126.9 133.3

Bolton 295 127 112.7 142.1 209 119 103.2 136.0

Heywood, Middleton, & Rochdale 220 127 110.6 144.8 191 144 124.5 166.1
Tameside & Glossop 282 130 115.4 146.3 207 125 108.6 143.3
Oldham 242 133 116.8 150.9 212 150 130.7 171.8
Coventry 273 104 91.9 117.0 198 101 87.3 115.9
Walsall 291 118 105.1 132.7 185 101 86.7 116.2
Ashton, Leigh, & Wigan 330 120 107.6 133.9 271 132 116.5 148.4
Bury 195 121 104.4 138.9 174 140 120.2 162.8
Dudley 305 99 87.9 110.3 181 78 67.4 90.8
Kirklees 373 109 98.3 120.7 326 125 111.4 138.9
Bradford & Airedale 446 115 104.7 126.3 403 133 120.4 146.7
Salford 291 153 136.1 171.8 292 201 178.4 225.1
Halton & St. Helens 318 119 106.7 133.4 280 139 123.0 156.1
Wakefield 390 130 117.8 144.1 315 139 124.4 155.6
Rotherham 316 132 118.2 147.8 223 125 108.8 142.1
Sandwell 335 130 116.6 144.9 221 112 97.8 127.8
 Table b. Lung cancer SMR mortality, premature (<75 years)
2006/08 Males Females
OBS SMR 95% Confidence OBS SMR 95% Confidence
Lower Upper Lower Upper

England 25473 100 98.8 101.2 17957 100 98.5 101.5

North West 4232 120 116.3 123.6 3317 133 128.6 137.7

Bolton 177 135 115.5 156.0 129 142 118.7 169.0

Heywood, Middleton, & Rochdale 120 124 102.6 148.0 107 155 127.2 187.6
Tameside & Glossop 168 136 116.5 158.5 102 118 95.8 142.7
Oldham 139 133 111.7 156.9 117 157 130.2 188.7
Coventry 150 111 94.1 130.4 109 113 92.8 136.3
Walsall 155 115 97.7 134.7 100 106 86.3 128.9
Ashton, Leigh, & Wigan 175 104 89.6 121.1 151 132 111.8 154.8
Bury 110 121 99.2 145.5 89 136 108.8 166.8
Dudley 158 92 78.2 107.5 84 71 56.4 87.5
Kirklees 212 111 96.6 127.0 168 125 106.6 145.1
Bradford & Airedale 247 117 102.8 132.4 212 140 121.7 160.0
Salford 160 153 130.0 178.4 149 207 175.5 243.6
Halton & St. Helens 190 122 105.0 140.3 157 142 120.4 165.6
Wakefield 211 125 109.0 143.4 165 140 119.2 162.8
Rotherham 195 144 124.5 165.7 132 139 116.2 164.7
Sandwell 191 139 119.8 159.9 106 109 88.9 131.3

The difference in mortality between Bolton
and England is more apparent when we
consider premature (<75 years) deaths.
In table b. Bolton is shown to be
considerably greater than the national
average; 35% higher for male mortality,
and 42% higher for female mortality. The
female figure in particular is of concern.
Following Salford (207) as an outlier,
Oldham (157), and Heywood, Middleton,
and Rochdale (155) it is the fourth highest
female rate for the statistical peer group.
Again, Dudley PCT has very low lung
cancer mortality.
Nationally, 52.1% of all lung cancer deaths
over the period 2006/08 were premature;
this figure increases to 54.1% for the
North West. The average for the above
statistical peer group is 54.7%. For
Bolton, this figure is 60.7% and, along with
Rotherham (60.7%), is the highest for the
entire peer group. The proportion of
deaths under the age of 75 compared to
England vastly influences the SMR and
should be seen as a major issue to tackle.
Another important factor in evaluating lung
cancer mortality in Bolton is how this has
changed respective to its statistical peers.
As shown on the below chart, Bolton has
only achieved a very small decrease in the
lung cancer mortality rate since 1995/97
compared to its peers. Excluding
Tameside and Glossop, for which no data
is available prior to 2002, Bolton has
achieved the lowest percentage decrease
over this period. This is not a result of
Bolton have a lower directly standardised
rate compared to its peers, as Bolton is
almost exactly average for the group.
Dudley had the lowest rate in 1995/97 and
retains this position in 2006/08, and yet
has still made the third greatest
percentage reduction.
For percentage change within the peer
group there is a clear divide between male
and female mortality. Every PCT shows
decreases in male mortality since 1995/97
and again Bolton is second from bottom in
the magnitude of the change. However, a
large proportion of the peer group show
increases in female mortality over this
period, Bolton showing the third highest
(the second if we exclude Tameside and
Glossop).
The reducing male rate remains higher
than the female rate, and as depicted on
the funnel plots previously, when
standardised to the national average
Bolton is within the deviation limits for this
indicator; however, the local increases
seen in the female rate since 1995/97 are
important, and if this continues, and the
male rate continues to fall at a slower rate
than statistically similar areas, then it may
prove vital in forcing Bolton PCT beyond
the deviation limits for female mortality,
and pose a greater influence on the local
lung cancer mortality rate overall.
Trends all three areas is the decline evident in the
higher male trend and the lack of change
The first chart below shows the lung in the female trend. The male rate has
cancer mortality trend for Bolton, the North fallen for all three areas and this is widely
West, and England. The figures are acknowledged to be a result of the falling
directly standardised rates for the period smoking prevalence, which has been
1993-2008. particularly noticeable in men in the UK9.

The Bolton trend lines for both male and The same pattern is largely carried over
female are more erratic than those into premature mortality (<75 years).
representing England and the North West
because of the relatively fewer numbers
involved in the calculation. Taking this
into account, Bolton has largely been
between the lower national rate and higher
regional rate for both sexes for all age
lung cancer mortality. Most noticeable for 9
Cancer Research UK (2010) www.cancerresearchuk.org
Cancer Research UK highlights the
significance of the reducing gap between
the falling male lung cancer mortality rate
and the static/increasing female rate:
“In the 1950s the male/female ratio for
lung cancer cases was 6:1 but with
decreasing male rates and increasing
female rates, the ratio is now 4:3” (Source:
Cancer Research UK, 2010, www.cancerresearchuk.org)
Age is another important factor for
assessing lung cancer trends. Lung
cancer is rarely diagnosed in those less
than 40 years old, with the majority of
cases in the UK affecting people over the
age of 60. The plot below shows the
number of deaths in Bolton between 2002
and 2008 from malignant neoplasm of
trachea, bronchus, and lung (ICD-10 code
C33-C34) by age.
We know that more men die from these
conditions than women, but the below
chart demonstrates there to be little
difference between the age at which the
greater proportion of deaths occur for
each sex. This is an important indicator
given the high proportion of premature
deaths in Bolton from lung cancer.
The average age of death from lung
cancer in Bolton varies by almost two
years depending on demography. Table
c. shows the mean age of death from lung
cancer for all deaths recorded between
2002 and 2008 by deprivation quintile.
Over the total period the mean age of
death from lung cancer is shown to
increase from 71 years in the most
deprived quintile to 73 years in the least
deprived.

Table c. Most deprived Quintile 2 Quintile 3 Quintile 4 Least deprived

2002 71.4 69.6 73.9 72.8 69.5

2003 71.2 69.0 72.3 73.4 75.5
2004 70.6 72.9 75.7 73.5 74.8
2005 70.8 74.3 73.5 74.4 73.5
2006 70.7 73.1 72.2 72.4 72.8
2007 71.0 69.6 69.9 74.8 70.8
2008 71.4 73.9 71.3 68.8 73.4

Total 71.0 71.7 72.6 72.9 72.9

Differences are also present for
Neighbourhood Renewal Strategy (NRS)
Areas in Bolton. Hall i‟th Wood and
Johnson Fold NRS areas must be
excluded from discussion as these areas
experienced too few deaths from lung
cancer between 2002 and 2008 to justify
any solid conclusion. However, several
NRS Areas do fall below the mean age of
death in non-NRS Areas.
Impact on life expectancy
The charts on the following page display
trend data for the causes of the life
expectancy gap between Bolton and
England.
The charts are ranked by the greatest
cause of the gap for the latest available
data (2006/08).
For men, lung cancer is the fifth most
considerable cause contributing to the
gap, while for women it is the sixth. For
both genders it is the most important
cancer to tackle in this respect.
The contribution made to the overall
female gap in life expectancy between
Bolton and England as a result of lung
cancer has shown decreases since
1995/97 (see table c. below). In contrast,
no consistent change is evident for Bolton
men (table d.).
Table d. and five years. The five year survival rate
Gap in life expectancy between Bolton and England as a
result of lung cancer mortality (months)
for men is the only exception.

The general increase in survival reflects

Period Males Females
the national picture. The latest available
figure (2001/05) shows that in the Network
1995/97 -2.00 -2.02 26.6% of men and 27.7% of women are
1998/00 -1.96 -1.57 alive one year after diagnosis, 9.5% of
2001/03 -0.47 -0.83 men and 11.3% of women are alive three
2004/06 -1.14 -0.39 years after diagnosis, and 6.7% of men
2005/07 -2.31 -0.95 and 8.3% of women are alive five years
2006/08 -1.09 -0.51 after diagnosis.

Survival

England has poor cancer survival rates

compared to other countries. Good
survival is a product of early diagnosis and
effective treatment. Survival is calculated
from diagnosis to death and so survival
will automatically increase the earlier the
lung cancer is diagnosed. One year
survival is used to measure early
diagnosis (as is stage at presentation).

NWCIS state that late presentation is

probably not more common in the Greater
Manchester and Cheshire Cancer Network
than England, but that late presentation is
more common in England as a whole
compared to other countries10.

Overall, lung cancer has one of the lowest

survival outcomes of any cancer. The
reason for this is that over two-thirds of all
diagnoses are made at a late stage when
curative treatment is no longer possible11.
Furthermore, because of the age profile of
lung cancer (predominantly affecting those
over 60) patients often have co-morbidities
making them unfit for stronger treatments.
As a result, earlier diagnosis and referral
techniques have the potential to make
dramatic improvements to lung cancer
survival rates.

From the graph below, the Greater

Manchester and Cheshire Cancer Network
is proven to have increasing lung cancer
survival rates at one year, three years,

10
North West Cancer Intelligence Service (2010)
www.nwph.net
11
The Information Centre (2006) National Lung Cancer
Audit: Report for the audit period 2005, The IC, London.
Overall, the Greater Manchester and
Cheshire Network has lower five year
survival rates than England but one year
survival rates tend to be similar to other
parts of the country. This pattern indicates
that a greater proportion of cancer patients
present with the disease when it is at an
incurable stage, but that the treatment of
cancer is as effective in the Network as it
is in the rest of the country12.
As with the majority of cancer types, those
diagnosed at a younger age have higher
survival rates than those diagnosed in
older age groups. Age is often related to
the stage of the disease when diagnosed.
National data shows that those diagnosed
with the early stage of the disease have a
higher survival rate than those suffering
the metastatic stage of the disease (the
process in which cancer cells break away
from the primary tumour and spread to
other areas of the body and form
secondary tumours). This reinforces the
importance of early diagnosis and
treatment. The potential early diagnosis
offers for survival rates for lung cancer has
been quantified by SIGN; SIGNs
12
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy,
Greater Manchester Public Health Practice Unit, Salford.
estimates reveal that if non-small cell lung
cancer is detected at an operable stage,
then five year survival rates for stage IA
patients may increase to 54-80% and
survival of stage IB patients may reach 38-
65%13.
In addition to those diagnosed early,
inequalities in survival also subsist as a
result of socioeconomic deprivation. A
study undertaken by Coleman et al in
2001 found that between 1986 and 1990
an estimated 1,200 deaths from lung
cancer could have been avoided if all
socioeconomic groups had the same
survival rate as the most affluent group14.
NCIS have also demonstrated15 that at
national level, age-standardised relative
survival for the Asian ethnic group is
significantly higher than the White
population at both one and three years.
Variation here is also influenced by gender
and age. For all male age groups the
13
Scottish Intercollegiate Guidelines Network (2005)
Management of patients with lung cancer, SIGN,
Edinburgh.
14
Coleman, M. et al (2001) Trends in socioeconomic
inequalities in cancer survival in England and Wales,
Cancer, 91:208-16.
15
National Cancer Intelligence Network (2009) Cancer
Incidence and Survival By Major Ethnic Group, NCIS,
London.
Asian group has a higher relative survival
than the White population, while there is
no significant difference between the
White and Black population groups. The
Asian group has significantly higher
relative survival for those diagnosed aged
15-64 than the White and Black
populations at both one and three years.
However, for females diagnosed aged 65-
99 survival is higher at one year, but not at
three years.

Most of the avoidable deaths from cancers

are likely to be attributable to late
diagnosis and/or patients not receiving
curative treatments. The Department of
Health, the NHS National Cancer Action
Team, and Cancer Research UK have
published the NAEDI Pathway16 which
summarises the main problems and
identifies the chief areas in the lung
cancer pathway where gains may
potentially be made:

16
National Awareness and Early Diagnosis Team (2010)
www.ncin.org.uk

Incidence and prevalence of lung
cancer
This section will forward an examination of
lung cancer incidence and prevalence in
Bolton with reference to national and local
data sources.
Incidence
Unless treatment becomes more effective
an increase in incidence leads to an
increase in mortality.
The chart below shows the percentage
difference in directly standardised
incidence rate between Bolton and
England for major cancers. Bar‟s above
the x-axis show that Bolton is higher than
the England rate. For lung cancer the
Bolton incidence rate in 2004/06 was
17.4% higher than the equivalent rate for
England as a whole. Furthermore, of the
major cancers lung cancer demonstrates
the greatest percentage difference from
England.
The percentage gap in lung cancer
incidence between Bolton and England
has only been consistently greater than
10% since the mid-1990s, with the latest
figure (17.3%) being one of the highest
when compared to the trend. Prior to this
the two rates were very high but very
similar; the England rate has changed
quicker than the Bolton rate and this is
why we have such a wide gap today.
Incidence records new cases of lung
cancer and so is more representative of
the disease in the population. As it
records the rate of new cases in the
population, incidence should be used to
measure the effectiveness of prevention
strategies.
rate is far higher than the female for all
areas; however, the male rate shows a
downward trend, while the female
incidence rate, like the mortality rate seen
earlier, is static.

In 2006 (the latest year for which reliable

incidence data is available) there were
209 new cases of lung cancer in Bolton.
Geographically, there is a clear
North/South divide concerning lung cancer
incidence, with the highest rates seen in
Scotland and the North of England17.
Furthermore, higher rates are found in
urban areas compared to rural areas -
largely a product of the higher smoking
prevalence in urban areas18.

The charts below show all age lung cancer

incidence for Bolton and its statistical
peers. The male lung cancer incidence

17
Quinn, M., Cooper, N. and S. Rowan (2005) Cancer
Atlas of the United Kingdom and Ireland 1991-2000, Office
for National Statistics, London.
18
Pearce J. and P. Boyle (2005) „Is the urban excess in
lung cancer in Scotland explained by patterns of
smoking?‟, Social Science and Medicine, 60(12):2833-43.
The graph below shows lung cancer
incidence in Bolton over the period 2002
to 2006 by age group. Firstly, male
incidence is consistently a lot higher than
female; secondly, male incidence
continues to increase and peaks at the
eldest age group (85+), while incidence for
women declines after age group 75-79.
For both points Bolton follows the national
pattern. The incidence of lung cancer is
almost exclusively represented by those
aged over 50 years, and increases rapidly
from there. The age groups illustrated are
those to target for symptom education and
early diagnosis efforts, however, the
greatest impact upon future incidence
rates is smoking prevention for younger
age groups.
Lung cancer is one of the most
preventable types of cancer. As smoking
levels decrease so will lung cancer
incidence. For this reason, as mentioned,
incidence is the measure of how
successful prevention strategies are. In
particular, incidence in those aged under
75 years should be monitored; the
monitoring of incidence above this age is
more complex as everyone must die of
something and cancer incidence increases
significantly with old age19. The Greater
Manchester and Cheshire Cancer
Network‟s Prevention, Early Detection,
and Inequalities strategy states, with
respect to all cancers:
“The aim of the strategy should be
to preventing as much cancer as
possible from occurring in all age
groups but the measurement of
progress should be confined to
people under the age of 75” (Greater
Manchester Public Health Practice Unit, 2010,
pg.13)
With this in mind the chart below depicts
the lung cancer incidence trend for people
less than 75 years old in Bolton since
19
Greater Manchester Public Health Practice Unit (2010)
The Greater Manchester and Cheshire Cancer Network
Prevention, Early Detection, and Inequalities Strategy,
Greater Manchester Public Health Practice Unit, Salford.
1985. Figures are directly standardised
rates and are presented as three year
rolling averages. The trend has
historically been resistant to significant
decreases, but whilst there are no
consecutive significant changes, and we
should not expect any, there have been
small significant changes between
different points in time. However, the
latest official incidence figure is for
2004/06 and this makes monitoring
difficult. Whilst accepting that prevention
methods at present cannot be expected to
result in observable changes until years
and decades into the future, we should
work towards processes enabling timelier
monitoring of local lung cancer incidence.
As with all age incidence of lung cancer
the decrease in the premature rate is
mainly a result of decreases in the male
incidence rate, the female rate showing far
greater stability (table e.).
Table e.
Bolton PCT: Lung cancer (C33-C34) incidence <75 years

Persons Male Female

1985-1987 51.35 77.09 25.61

1986-1988 50.75 75.95 25.54
1987-1989 47.46 66.33 28.59
1988-1990 51.15 70.36 31.94
1989-1991 53.14 71.88 34.39
1990-1992 51.62 70.54 32.70
1991-1993 50.54 67.69 33.40
1992-1994 44.95 60.41 29.48
1993-1995 47.83 65.78 29.88
1994-1996 46.42 65.63 27.20
1995-1997 48.83 67.28 30.39
1996-1998 46.41 62.08 30.74
1997-1999 50.65 66.79 34.51
1998-2000 49.48 64.69 34.27
1999-2001 48.18 61.44 34.93
2000-2002 41.04 50.58 31.51
2001-2003 38.67 47.92 29.42
2002-2004 37.14 44.55 29.73
2003-2005 38.77 45.70 31.84
2004-2006 41.92 49.00 34.84
Mesothelioma is a cancer of the
mesothelial cells that cover the outer
surface of most of the internal organs and
is most often diagnosed in the pleura
(pleural mesothelioma). By far the most
common cause of mesothelioma is
exposure to asbestos and for this reason
is much more common in men than
women (as men are more likely to work in
the building/construction industry where
risk of exposure is increased). The above
shows the incidence trend for persons of
all ages in Bolton compared to England.
The figures are directly standardised rates
and are presented as three year rolling
averages. England has shown a steady
increase of new cases of mesothelioma,
although compared to incidence of lung
cancer the rate is extremely small. As
evident, the confidence intervals at local
level are very wide, making monitoring
and assessment of mesothelioma cases in
the Bolton population difficult as few
conclusions can be drawn.
Prevalence
Prevalence of lung cancer is low. This is a
result of the relatively low survival rates for
the condition which mean there are very
few people living with lung cancer
compared to other cancers.
The best estimates we have of the
prevalence of lung cancer in Bolton are
from disease prevalence models. The
Association of Public Health Observatories
(APHO) produces models for a range of
diseases and conditions. The latest
available estimates for lung cancer are for
2004 only.
The model estimates a 1-year prevalence
of 77 individuals (45 men and 32 women)
in Bolton. In this instance 1-year
prevalence refers to those patients
diagnosed with lung cancer (ICD-10 C33-
C34) up to one year before 31st December
2004 and who are still alive on that date.
This equates to a standardised rate of
23.7 (per 100,000 European Standard
Population). This figure is 31.8 for men in
Bolton and 18.4 for women. Bolton is
higher than the national estimate;
standardised rate of 19.1 (per 100,000
European Standard Population). This is
24.3 for men in England overall, and 14.8
for women.
The model estimates a five-year
prevalence of 141 individuals (78 men and
63 women) in Bolton. Here, 5-year
prevalence refers to those patients
diagnosed with lung cancer (ICD-10 C33-
C34) up to five years before 31st
December 2004 and who are still alive on
that date. This equates to a standardised
rate of 44.2 (per 100,000 European
Standard Population). This figure is 54.0
for men in Bolton and 37.5 for women.
Again, these figures are higher than those
calculated for England; standardised rate
of 36.7 (per 100,000 European Standard
Population). This is 45.8 for men in
England, and 29.4 for women.
At present, there is no Quality and
Outcomes Framework (QOF) register for
lung cancer.
Hospitalised prevalence measures the
number of people attending hospital for
particular diagnoses. Table f. measures
lung cancer hospitalised prevalence within
the North West; data are indirect
standardised ratios and are for the period
2003/04 to 2007/08.
England is the reference base for the ratio,
showing Bolton to have a hospitalised
prevalence 13% higher than the national
average. However, this position itself is
average for areas in the North West
region.

Table f. Hospitalised prevalence: Lung cancer 2003/04 - 2007/08

South Lakeland 65
Eden 70
Congleton 79
Ribble Valley 79
Fylde 86
Vale Royal 86
Macclesfield 86
Crewe and Nantwich 88
Warrington 89
Chester 90
Hyndburn 94
Lancaster 96
Chorley 100
West Lancashire 101
South Ribble 103
Barrow in Furness 104
Allerdale 106
Wyre 106
Copeland 107
Stockport 107
St. Helens 108
Carlisle 113
Bolton 113
Rossendale 113
Ellesmere Port & Neston 115
Pendle 116
Blackburn with Darwen 117
Sefton 117
 Tameside 118
Preston 120
Bury 122
Trafford 122
Wirral 122
Oldham 126
Blackpool 127
Wigan 128
Rochdale 140
Halton 146
Burnley 151
Manchester 171
Salford 174
Knowsley 176
Liverpool 192

Despite being around average for the Bolton with the Bolton and regional
North West, areas such as the Town averages.
Centre, Halliwell Road, Breightmet N &
Withins, Tonge Fold, Lower Deane & The Variation due to socioeconomic
Willows, and Sweetlove within Bolton all deprivation
have a hospitalised prevalence far greater
than Bolton and the North West; several The NWPHO has analysed the influence
being almost 100% higher than the deprivation has upon observed rates of
average for England. This is portrayed on
the above radar chart which compares
hospitalised prevalence for small areas in
various conditions20. Those conditions MSOA population and hospitalised
showing an extremely strong relationship prevalence of lung cancer.
with deprivation (greater than 3-fold to 10-
fold variation from the least to the most
deprived quintile) were found to be:

Self-harm;
Violence;
COPD;
Alcohol related conditions.

Other conditions show a 2- to 3-fold

variation with deprivation:

Asthma, lung cancer, respiratory

conditions, and smoking related
deaths;
Diabetes and heart disease;
Mental health problems.

Therefore, lung cancer has been shown to

be strongly associated with socioeconomic
deprivation. The adjacent map shows the
areas of greatest deprivation within Bolton.
The greatest deprivation is concentrated in
the urban areas around the Town Centre,
and include many of those with the highest
hospitalised prevalence from the previous
section.

Latest national analyses of lung cancer

incidence and deprivation demonstrate
incidence to be nearly 2.5 times higher in
the most deprived sectors of the
population compared to the least
deprived21. This matches the findings of
the NWPHO discussed above.

The association between socioeconomic

deprivation and lung cancer is evident
locally. The below chart plots hospitalised
prevalence of lung cancer by MSOA in
Bolton alongside prevalence of all benefit
claims (a proxy measure for deprivation)
to show clear correspondence.

There is clear correlation between all

benefit claimants as a percent of the

20
North West Public Health Observatory (2006) Where
Wealth Means Health, NWPHO, Liverpool.
21
Cancer Research UK (2010)
www.cancerresearchuk.org
Smoking is very strongly associated with
socioeconomic deprivation, as well as
living in an urban environment, and this
contributes significantly to the variation in
hospitalised prevalence across the
borough. For this reason smoking
cessation is vital in the areas of greatest
socioeconomic deprivation.
In addition to the above, it is important to
note that nationally, the association
between lung cancer and deprivation is
stronger for women than it is for men22.
Variation due to ethnicity
The largest ethnic minority communities in
Bolton are those of Indian (17,000) and
Pakistani (6,500) origin. However, Bolton
also has significant Bangladeshi, Polish,
Ukrainian, Irish, and many other
communities.
Males and females in the Asian, Chinese,
and Mixed ethnic groups all have a
significantly lower risk of getting cancer
(all cancers C00-D48) than the White
population. At national level these groups
22
Cancer Research UK (2010)
www.cancerresearchuk.org
(all ages and both sexes) are between
20% and 60% less likely to get cancer
than the White ethnic group. Also, Black
females are between 10% and 40% less
likely to get cancer than White females.
However, there is no significant difference
in risk for Black males and White males.
In general, BME groups have a
significantly lower risk of getting cancer
(with the exception of liver cancer, mouth
cancer, and cervical cancer depending of
the age and sex of the individual). For the
four major cancers (lung, colorectal,
breast, and prostate), BME groups, and in
particular those of Asian origin, are found
to have a lower risk.
Whilst nationally lung cancer incidence is
lower in the South Asian population, it is
increasing23, and this group accounts for
11% (28,710) of the population of Bolton.
The following is taken from the North West
Public Health Observatory and depicts
how prevalence of lung cancer varies by
main ethnic group in the North West.
23
Smith, L., Peake, M. and J. Botha (2003) „Recent
changes in lung cancer incidence for south Asians: a
population based register study‟, British Medical Journal,
326(7380):81-2.
 which should be investigated by a
Summary: Cancer Commissioning PCT. The Toolkit states that two
Toolkit areas of action are available to PCTs;
the first is to raise public awareness of
The following is taken from the Cancer the signs and symptoms of lung
Commissioning Toolkit and shows Bolton cancer as well as encourage people to
PCT in comparison to national figures for seek help earlier, and the second is to
a range of lung cancer indicators. The work with primary care professionals
blue arrow represents the national level to ensure that patients presenting with
and the orange arrow represents the level appropriate symptoms are investigated
of Bolton PCT. The traffic light system
thoroughly and referred to hospital
depicts how each area is performing
against national targets and benchmarks. without delay. Five year survival rates
are known to be very influenced by
The data included in incidence and socioeconomic status and uptake and
survival figures relates to the June 2008 compliance with suitable high quality
data submission to CIS. treatment. The Toolkit recommends
that as well as the points discussed
1. Incidence shows that Bolton PCT is
previously, PCTs should also be
closer to the red area of the traffic
aware and make others aware of the
light system than the national figure,
influence socioeconomic status has
but the difference is not too great
upon presentation and treatment
(incidence rate of 50 per 100,000 in
compliance and factor this into any
England compared to a local rate of
action. Furthermore, PCTs should
55 per 100,000);
ensure that treatment and supportive
2. In terms of survival for lung cancer, the
care are suitable, of high quality, and
local level matches the national for
are available in sufficient quantity to
both one year and five year survival
serve the needs of the population;
(one year: National 28.2%, Bolton
3. Bolton PCT is almost in the red area
28%; five year: National 7.7%, Bolton
when benchmarked to the rest of the
7.7%). Early diagnosis is vital to
country for mortality of lung cancer,
survival as in general the earlier one is
48.9 per 100,000 compared to 41.2
diagnosed with lung cancer the more
per 100,000 for England;
likely it is to be operable and curable.
4. Bolton PCT is in the red for
That the UK has such a low rate of
percentage of successful quitters at
early diagnosis is a major reason for
four weeks with 43.7% compared to
the higher mortality rate and lower
an England average figure of 50.2%.
survival rate from lung cancer
From April 2008, success rates
compared to the rest of Europe. The
outside the range of 35% to 70% must
Cancer Reform Strategy includes early
be checked by the service and the
diagnosis as a priority at national and
reasons for the variation explained.
local level. The most suitable indicator
This is not the case at present for
for this is the stage at which cancer is
Bolton. Success rates are influenced
diagnosed, but this is not universally
by the intensity of service delivery and
available data. Staging information in
the population served. Furthermore,
Bolton will be discussed later in this
low success rates may indicate
assessment. However, low one year
populations with high deprivation and
survival rates can serve as a proxy
high levels of mental health problems.
indicator for very late presentation,
Smoking quitters at local level are
 analysed in more detail later on in this
assessment;
5. Over the previous eight years, while
elective day case episodes (usually
for chemotherapy) have increased,
inpatient admissions for cancer
admissions have also risen by 25%
nationally. The majority of this
increase is a result of emergency
cancer inpatient episodes and
emergency bed days rising by 2.5%
every year. An indicator for local
action in Vital Signs measures the
number of emergency bed days for
cancer per head of unified weighted
population. It is important to be aware
that many of the emergency
admissions are the result of the side
effects of treatment, especially
chemotherapy and radiotherapy.
PCTs should work to ensure that
emergency bed usage is minimised
by the provision on individualised
patient care, including a specialist out
of hours service and effective
community support. At present,
Bolton PCT is performing better than
the national average on this indicator
with 452 cancer emergency bed days
per 100,000 population compared to
473 per 100,000 in England as a
whole;
 Table g. Percent two-week referrals Percent cases diagnosed
diagnosed with lung cancer through non-urgent routes

Bolton 25.1 51.7

Heywood, Middleton, & Rochdale 33.1 59.4

Tameside & Glossop 28.2 45.5
Oldham 46.0 51.1
Coventry 32.3 48.0
Walsall 17.0 90.2
Ashton, Leigh, & Wigan 30.0 65.3
Bury 28.3 61.4
Dudley 32.9 83.6
Kirklees 39.1 56.5
Bradford & Airedale 22.8 72.5
Salford 20.7 52.1
Halton & St. Helens 26.5 55.0
Wakefield 38.4 56.0
Rotherham 26.9 68.4
Sandwell 22.7 87.3

England 32.2 58.9

6. All patients referred by their GP green) of lung cancer cases

with a suspected cancer must be
seen within two weeks. The
operational standard set by the
Department of Health is 100% and
many organisations have met this
target now for many years,
including Bolton. However, the
indicator above allows us to
measure the percentage of these
referrals that are actually
diagnosed with cancer – lung
cancer in the case of this
assessment. Bolton is shown in
the red for this indicator (table g.)
with only 25.1% of all two-week
referrals being diagnosed with
cancer, compared to a 32.2%
average for England. This means
that there is a significant proportion
of misdiagnosis of lung cancer at
primary care in Bolton. Despite
this, Bolton has a comparatively
low percentage (almost in the
diagnosed through non-urgent
referral routes (51.7% compared to
58.9% for England). This means
that whilst there is a relatively high
level of misdiagnosis of lung
cancer at primary care level,
primary care does pick up a
greater proportion of lung cancer
cases overall compared to other
areas. There is wide variation
across the country in the
percentage of cases diagnosed
through non-urgent routes; if
relatively high numbers of patients
are diagnosed through non-urgent
referrals, this would merit
investigation by the PCT. Two-
week referrals will be analysed in
more detail later on in this
assessment;
7. Bolton‟s statistical peers
demonstrate wide variation when
benchmarked against the rest of
 the country (table g.). As above
amber means the PCT is within the
average scale nationally, red
means the performance is poor,
and green means the PCT
performs well relative to the rest of
the country. Bolton does have
peers who perform well despite
facing similar difficulties.
Tameside and Glossop, Coventry,
Kirklees, and Wakefield all perform
well, whilst Oldham is the only peer
PCT to be within the green scale
for both indicators, with almost half
of all two-week referrals for lung
cancer actually being diagnosed as
such;
8. As depicted in table h., when
compared with the rest of the
Table h.
Percent two-week referrals
Bolton
Lung
Breast
Colorectal
Haematology
Head and Neck
Gynaecology
Skin
Upper GI
Urology
country Bolton PCT never scores
in the green range for any type of
cancer for these two indicators.
However, Bolton PCT does score
within the average amber scale for
both indicators for a number of
cancer areas, but lung cancer
along with colorectal cancer, head
and neck cancer, and urology fail
to perform to this level;
9. Bolton meets both its waits targets
for lung cancer and scores higher
than the national average in both
cases (98.1% for the sixty-two day
target compared to 93.9%, and
99.9% for the thirty-one day target
compared to 99.6%). More detail
of waits is given in the „Targets‟
section to follow.
Percent cases diagnosed
diagnosed with cancer through non-urgent routes
25.1 51.7
11.7 53.6
6.9 69.4
51.0 77.5
5.8 66.7
9.5 53.8
8.3 57.0
7.2 62.4
22.1 61.0

Inequalities in cancer
The Report of the All Party Parliamentary
Group on Cancer‟s Inquiry into Inequalities
in Cancer was published in December
2009. The Inquiry reviewed written
evidence from ninety stakeholders and
listened to oral evidence from cancer
patients, charities, cancer service
providers, and policy makers. The Inquiry
was designed to:
Assess the inequalities in cancer
that currently exist;
Seek out examples of good
practice in tackling inequalities;
Consider what more can be done
by 2012 and beyond to improve
outcomes and establish greater
equality in cancer care;
Make key recommendations to
Government, the National Cancer
Equality Initiative (NCEI), and the
NHS on tackling cancer
inequalities.
The Inquiry defines cancer inequalities
thus:
“The differences between
individual‟s cancer experience or
outcome which result from their
social-economic status, race, age,
gender, disability, religion or belief,
sexual orientation, cancer type, or
geographical location” (Source: All
Party Parliamentary Group On Cancer, 2009,
pg.9)
The following are the main findings of the
Inquiry.
Socioeconomic status
The Report makes clear that socio-
economic status is a fundamental
determinant of inequalities in cancer
outcome. Historically, survival rates from
most types of cancer have been
increasing, but because survival has
increased at a faster rate amongst more
affluent groups the inequalities gap has
widened. This situation is exacerbated by
the differing perception of lifestyle factors
between socioeconomic groups as a risk
for cancer, and lifestyle factors are again
associated with socioeconomic status.
This is of particular importance for lung
cancer in which smoking is the chief
determinant.
Smoking is the main preventable cause of
lung cancer. Prevalence of smoking is far
lower in the more affluent groups of British
society than their more socioeconomically
deprived peers. So much so that smoking
is identified as the single greatest cause of
inequalities in death rates between the
rich and the poor in Britain. This
association supports the increasing
taxation of cigarettes, and this strategy is
effective in reducing smoking prevalence,
but in the future this may prove
counterproductive as it encourages the
growth of the black market, many products
within which will not be regulated to meet
current standards.
Ethnicity
Taking all cancers into account the NCIN
report Cancer Incidence and Survival by
Major Ethnic Group 2002-2006 published
in the summer of 2009 demonstrated that
Black Caribbean and African men have
higher prostate cancer rates, South Asians
have higher mouth cancer rates, and
South Asian women have lower breast
cancer rates compared to the general
population. Risk factors are also higher
for some ethnic groups: 40% of
Bangladeshi men smoke compared to the
national figure of 24%, obesity rates are
higher amongst Black African, Black
Caribbean, and Pakistani women, while
56% of men and 36% of women of Irish
origin drink alcohol beyond the
recommended daily limit compared 11%
and 6% in the general population
respectively.
In addition, independent of socioeconomic
status, there is a lower uptake of
screening amongst minority ethnic groups
compared to the general population.
Finally, in Cancer Black Care‟s evidence
to the Inquiry, it was reported that there is
a lower awareness of the links between
obesity and alcohol and risk of cancer,
and that in some communities a cancer
diagnosis is seen as „the will of God‟, while
in others it may affect the marriage
prospects and children of the individual
involved.
Age
Cancer risk increases with age, and this is
particularly true of lung cancer. In addition
more young people smoke (36%)
compared to the general population (24%)
with 80% of smokers starting by the age of
18.
Recruitment to clinical trials usually
excludes those aged 14-25 and those over
65. The latter is particularly important for
lung cancer where the average age of
diagnosis in Bolton (see later in
assessment) is 69.6 years; the national
average is between 60 and 85 years.
The older a patient is at diagnosis the less
likely they are to be offered intensive
treatments aimed at a cure for their
cancer. The National Lung Cancer Audit
found that older patients with lung cancer
are less likely to receive radical treatment
for their disease.
Gender
After excluding gender specific cancers
and breast cancer men have a 60%
increased risk of developing cancer and a
70% increased risk of dying from cancer
compared to women. Each year in the UK
28% of all male deaths are from cancer
compared to 23% of all female deaths.
Prior to the introduction of bowel cancer
screening, the only screening programmes
available in the UK were for cervical and
breast cancer.
The causes of these inequalities are not
fully understood, but the major factors are
felt to be lifestyle related and occupational
exposure to certain risk factors. Smoking
prevalence is higher in men nationally and
in Bolton.
Disability
Through the combination of lifestyle and
genetic risk factors people with disabilities
appear to have a lower risk of some
cancers but an increased risk of
leukaemia, oesophageal, and stomach
cancers.
Sexual orientation
There is little data concerning cancer and
sexual orientation.
Of importance to this assessment,
smoking rates are far higher in gay and
bisexual men (41%) compared to the
general population (24%).
In addition, Stonewall‟s evidence to the
Inquiry asserted that the way in which
information regarding prevention and early
detection is presented may further
contribute to inequalities, the example
given that literature depicting a man and a
woman in a relationship may not be
viewed as relevant to the gay and lesbian
community.
Cancer type
There are wide variations in incidence,
mortality, and survival rates depending on
cancer type. What the Inquiry refers to as
the „Big 4‟ (breast, lung, colorectal, and
prostate) represent 54% of all new cases
of cancer and account for 47% of all
cancer deaths. Nationally, lung cancer
alone is responsible for 35,000 deaths –
more than 20% of all cancer deaths.
Less is known about rare cancers. Also,
diagnosis is harder to achieve for cancer
types where symptoms are non-specific,
of which lung cancer is one.
Geographical location
Incidence of cancer varies by geography.
In addition to the findings of the Inquiry,
the National Lung Cancer Audit was
established to record information about
process and outcomes in lung cancer to
explain the wide variations in outcome.
There was originally a four-fold difference
in five year survival rates between the
better and poorer performing regions for
people diagnosed with lung cancer. As
well as seeking to improve practice and
performance overall, the audit also aims at
encouraging the standardisation of lung
cancer services as far as possible.
Within the cancer journey
Inequalities also affect people at different
stages of the cancer journey.
In general, the earlier a cancer is
diagnosed and treated the greater the
chance of a successful outcome, and this
is especially the case with lung cancer.
However, awareness of the symptoms of
cancer is lower in socioeconomically
deprived groups, in some BME groups,
and in men.
Inequalities persist into screening
programmes. At present, there is no
screening for lung cancer.
As noted previously in this assessment,
low survival rates in the UK compared to
other European countries is due in
significant part to delays in diagnosis. The
reasons for delay appear to be a
combination of factors: patients presenting
later, cancer diagnoses being missed in
primary care, and GPs having limited
access to appropriate diagnostic tests.
NAEDI has undertaken a national audit to
better understand cancer diagnosis at
primary care (last updated in August
2009). Lung cancer features heavily in
this audit and as such will be discussed in
more detail later in this assessment. In
September 2009, the Prime Minister
announced GPs in England will have
speedier access to diagnostic tests for
less clear cut cases of cancer. This
scheme will initially be targeted at lung,
colorectal, and ovarian cancers but is
expected to be expanded to all cancers
within the next five years.
The Inquiry found four main issues
concerning cancer treatment:
There is a need for more
radiotherapy services;
Access to cancer drugs for NHS
patients must be improved;
A cancer nurse specialist should
be provided for all patients;
There is an under-treatment for
older people.
Regarding radiotherapy, the Inquiry was
informed by Professor Mike Richards,
National Cancer Director, that the current
shortage of radiographers was being
addressed and a programme of greater
investment in radiotherapy equipment is
underway which should enable the NHS to
meet its radiotherapy target for 2010.
Furthermore, these developments should
also help address the geographical
inequalities in cancer treatment.
Concerning cancer drugs two main
problems were raised to the Inquiry:
There is a difficulty in obtaining the
drugs needed;
There is a problem with the
appraisal process operated by
NICE.
The difficulty in obtaining the drugs
needed frequently arises because of the
differing patterns of prescribing between
PCTs across the country. However,
Professor Mike Richards gave evidence to
the effect that there has been a
progressive reduction in the variation
between PCTs.
Professor Mike Richards‟ publication
Improving access to medicines for NHS
patients published in 2008 has led to NICE
issuing supplementary guidance directed
at improving access to more expensive
drug treatments for end-of-life patients.
Also, Professor Michael Rawlins,
Chairman of NICE, informed the Inquiry
that drug referrals were now being made
earlier. By mid-2010, Professor Rawlins
stated that there should be no drug
product where the gap between market
authorisation and release of NICE
guidance should take more than six
months.
In contrast to this a patient with kidney
cancer informed the Inquiry:
“There were no NICE drugs
available for me. I had to take the
PCT to appeal. It was the most
stressful and harrowing experience
of my life. These drugs are
available to people throughout the
United States and Europe” (Source:
All Party Parliamentary Group On Cancer, 2009,
pg.15)
The Inquiry concluded that for some
patients access to cancer drugs remains a
major problem and the exceptional funding
process (where a patient requiring drug
treatment for a rare cancer not approved
by NICE can apply for the costs to be met
by the local PCT) can be a major source
of distress for cancer patients, their
families, and their carers.
From the evidence there was considerable
praise for cancer nurse specialists.
However, not all patients have access to
them.
As mentioned previously, in general older
people with cancer receive less intensive
and less radical treatments compared to
younger people. It is accepted that some
older people may be physically unable to
undergo more intensive treatment, may
have co-morbidities, and may present later
than younger people, but for some this is
not the case; Joanne Rule, Co-Chair of
the National Cancer Equality Initiative
(NCEI) highlighted the lack of a
comprehensive assessment of older
people to measure fitness for treatment,
adding:
“The data suggests ageism as a
hypothesis to explain the degree of
under-treatment” (Source: All Party
Parliamentary Group On Cancer, 2009, pg.15)
Patient experience also varied across
cancer types, whilst the importance of
information to empower patients to make
informed decisions about their care and
treatment was emphasised.
Finally, the Inquiry drew attention to a
NCEI survey of NHS trusts that found that
projects to tackle inequalities were
typically focused on awareness and early
diagnosis rather than living with and after
cancer.
 Targets
This section will present the major targets
in Bolton that relate to lung cancer.
Vital Signs
There are a large number of Vital Signs
indicators that directly or indirectly apply to
lung cancer in Bolton. These include:
Proportion of patients waiting no
more than 31 days for second or
subsequent cancer treatment;
Proportion of patients with
suspected cancer detected by
hospital specialists who wait less
than 62 days from referral to
treatment;
Proportion of people with long term
conditions supported to be
independent and in control of their
condition;
All age, all cause mortality rate;
Under 75s cancer mortality rate;
Cancer emergency bed days per
100,000 weighted population;
Smoking prevalence among
people aged 16 years and over
and aged 16 and over in routine
and manual groups;
Proportion of all deaths that occur
at home.
Additionally there are wider Vital Signs
targets that apply to patients‟ access to
and experience of healthcare services.
These include:
Improving primary care;
Percentage of patients seen within
18 weeks for admitted and non-
admitted pathways;
Patients experience of access to
primary care;
Patient reported unmet care
needs;
Self reported experience of
patients and users;
Patient and user reported measure
of respect and dignity in their
treatment.
Bolton Vision Partnership (LSP)
Bolton Our Vision 2007 to 2017, which is
Bolton‟s Community Strategy, proposed
that Bolton in 2017 would be a place
where everyone has an improved quality
of life and the confidence to achieve their
ambitions. The two main aims are to
narrow the gap between the most and
least well off and to ensure economic
prosperity. Both of these aims, when
realised, will have a substantial impact on
health improvement and healthy life
expectancy.
The relevant shared targets to lung cancer
within the Community Strategy are also
reflected in the Local Area Agreement and
relate to:
Reducing the gap in life
expectancy;
Increasing overall life expectancy
by reducing the All Age, All Cause
mortality rate;
Increasing the number of smoking
quitters;
Increasing the number of people
with long term conditions living
independently an in control of their
condition.
Strategic Plan 2009 – 2014
Cancer is one of the seven priority areas
in Bolton, as identified in NHS Bolton‟s
Strategic Plan 2009-2014. This Plan
identified the biggest cancer issue in
Bolton as the number of people in
deprived areas developing lung cancer,
which is nearly twice the national average
(see prevalence section above). For this
reason the cancer outcome target for the
future is the reduction of lung cancer
mortality from a rate of 48.32 (per
100,000) in 2006 to 43.44 in 2014.
The lung cancer rate is erratic and so
projections are difficult. However, the
below chart applies a simple linear model
to the trend with the 2014 target for
reference.
From this simple model we cannot expect
to meet the target; but the nature of the
trend, especially the range of its variation
after 2000, means that no definite
judgment can be made.

Mortality monitoring rates
The 2005 – 2007 annual period (xiii) is
most representative of the baseline above.
From this period there has been no
significant change, either positive or
negative, in the lung cancer mortality rate.
Although we cannot expect a significant
difference for consecutive periods, the rate
over time is relatively stable, and the
consistency evident in recent periods
(periods more recent than the official data
on the previous chart), bodes well for
meeting, or at least remaining close to, the
2014 target.
Though not involved in this target, the
mortality rate for the most deprived quintile
in Bolton shows little change but remains
significantly greater than the Bolton
average.
Table i.
Monthly monitoring mortality rate: DSR (per 100,000) Lung cancer ICD-10 C33–C34

Bolton
Monitoring England
Year Bolton (nchod) monitoring Quintile 1 Percentage gap
period (nchod)
rate

i 41.39 59.47 30.40%

ii 42.20 64.70 34.77%
iii 44.34 67.98 34.78%
iv 44.30 69.31 36.09%
2003/05 v 44.60 44.25 73.40 39.71% 38.64
vi 44.22 70.91 37.64%
vii 44.69 69.28 35.50%
viii 43.87 71.34 38.50%
2004/06 ix 44.43 44.39 73.73 39.79% 38.47
x 44.32 72.72 39.05%
xi 46.42 77.90 40.42%
xii 48.82 78.40 37.74%
2005/07 xiii 49.46 49.09 77.90 36.98% 38.49
xiv 48.49 75.06 35.40%
xv 48.50 73.28 33.81%
xvi 48.13 73.22 34.26%
2006/08 xvii 48.68 48.61 74.65 34.88% 38.55
xviii 48.23 73.25 34.15%
xix 48.01 75.37 36.30%
xx 47.98 71.43 32.83%

Waiting Times
The Cancer Plan published in 2000 states
the NHS should:
“offer patients a maximum one
month wait from an urgent referral
for suspected cancer to the
beginning of treatment. Where
patients wait longer, this should be
because of the needs of the
diagnostic process or their
personal choice, not because of in-
built delays in the system of care”
(Source: NHS Cancer Plan, 2000, pg.50)
The Department of Health collect data to
monitor progress made towards the NHS
Cancer Plan. Waiting time data allows the
Department of Health to monitor several
cancer targets, viz. the „two week‟ target
wait from urgent GP referral to first
outpatient appointment for all patients with
suspected cancer, the one month target
from diagnosis to treatment for all cancers,
the one month target from diagnosis to
treatment for breast cancer, the two month
target from GP referral to treatment for all
cancers, the two month target from GP
referral to treatment for breast cancer, and
the one month target from GP referral to
treatment for children‟s cancers, testicular
cancers, and acute leukaemia.
Obviously, not all these are relevant to the
current assessment, but as there is no
specific lung cancer target the general
cancer targets will be discussed. (The
basis for reporting waiting times changed
in January 2009 to bring them in line with
the Cancer Reform Strategy. Also, from
2005/06 quarter 2 there has been a
change in the way the referral to treatment
figures are calculated at Trust level. Both
these changes affect the data, and so care
is recommended).
The first chart below shows all suspected
lung cancer cases seen from urgent
referrals received within 24 hours by Royal
Bolton Hospital. All cases met the latest
„two-week target‟ wait from urgent GP
referral to first outpatient appointment with
suspected cancer. The second chart
shows how Royal Bolton Hospital has
performed against the one month target
from diagnosis to treatment for all cancers.
The bars illustrate the total number treated
with the line showing the percentage of
these treated within 31 days. The Royal
Bolton maintained 100% record for a
considerable period but has latterly begun
to fall.

Smoking target
Bolton‟s Community Strategy has a target
to reduce smoking prevalence to 19.5% by
2011. The latest survey data is for 2007
(Bolton Health & Lifestyle Survey) and has
prevalence at 23% in Bolton. The 2009
Place Survey found a smoking prevalence
of 18%, but this survey has a very small
sample size compared to the health and
lifestyle survey.
A mathematical model of projected
smoking prevalence is not appropriate as
we cannot accurately judge the affect the
smoking legislation has had upon
prevalence in Bolton.
However, we can compare the relationship
of smoking to lung cancer mortality and
predict changes in the numbers of deaths
if smoking prevalence continues to fall.
The below chart shows the relationship
between smoking prevalence and DSR
mortality rate for lung cancer across North
West local authorities24 (data is from the
24
Excluding Congleton, Crewe and Nantwich, Ellesmere
Port and Neston, Macclesfield, and Vale Royal.
NWPHO Health Profiler and nchod
respectively).
A relationship of r² = 0.72 was found
between the two variables, and with
reference to the weight given correlations
in the North West Children and Young
People‟s Health Indicators report, this is
adjudged a strong significant correlation.
Using this information we can construct a
simple linear regression model based on
the general linear regression model (y = α
+ βx + ε) to estimate a dependent variable
from an independent variable.
The community strategy target for
smoking is to reduce prevalence to 19.5%
by 2011; this is the independent variable.
By reducing Bolton‟s smoking prevalence
to 19.5% we can estimate how the Bolton
DSR for lung cancer over a future three
year period will reduce.
In Bolton, the model predicts a reduction
from 48.68 (per 100,000 ESP) for 2006/08
to 40.75 (per 100,000 ESP) for a three
year period where the smoking prevalence
is 19.5%. While we cannot reliably predict
the actual number of deaths this means
due to the nature of DSRs, it should be
stated that the 2006/08 DSR is calculated
from 504 deaths (over the three year
period) and so a reduction of the
aforementioned degree can be expected
to reduce the number of deaths by a
relatively significant amount. In reality,
reducing smoking prevalence will largely
only have an effect on populations further
into the future as it does not kill instantly,
but the model demonstrates the quantified
potential impact we can expect if such
interventions are successful.
It should be borne in mind that the
confidence intervals in the regression
calculation are wide as there are
significant variations in the mortality rate.
Also, the use of smoking prevalence trend
data will provide more defined estimates,
but such data is only available at England
level and so a point in time from the North
West, in which Bolton informs the
calculation, was judged a more accurate
starting point. Finally, these models are
not meant to provide precise reductions in
deaths we can expect by 2011 if the
smoking reduction intervention is
successful, but rather, quantify the
improvements this can be expected to
have further into the future. In addition,
there are wider determinants of health to
consider and using more up-to-date
smoking prevalence data will improve the
accuracy of the estimates, but 2003/05 is
the latest available local authority smoking
prevalence at time of writing and so this
must be used. Further accuracy can be
added to the model by using several
independent variables to explain as much
as the variation in the dependent variable,
mortality, as practically possible.
Suggested additional independent
variables are deprivation and ethnicity.
The following charts are from NWPHOs
Local Smoking Profiles and show the
effect of reducing smoking mortality upon
the mortality and morbidity of lung cancer
in the Greater Manchester region. Little
effect can be expected to be made on
mortality as it is already decreasing with
smoking prevalence, but morbidity shows
a greater difference between the various
scenarios on smoking attributable smoking
overall.
(Source: NWPHO, 2010)
 Felt need and local views
Lung cancer in the UK has traditionally
suffered from a low public profile. This
lack of awareness in the general public
has fostered negative perceptions of the
disease and led to a relatively poor
understanding of the early signs and
symptoms of lung cancer. Furthermore,
stigma has historically been associated
with lung cancer because of the strong
relationship with smoking – the general
public frequently being found in past
studies to adopt the view that „it is their
own fault for smoking‟.
Early diagnosis is especially important for
lung cancer where treatment options are
entirely dependent upon the stage of the
disease and the fitness of the patient to
undergo invasive surgery and other
procedures. This need to improve the
stage at which people are diagnosed and
referred to appropriate specialist care
must be addressed if mortality and
survival rates are to be improved. That
there are gaps in the pathway, especially
at the population level and primary care is
known:
“There is ample evidence of delays
between the onset of symptoms
and patients reaching specialist
care and these delays have a
patient component and a clinician
component. Thus any efforts to
encourage earlier referral would
ideally include elements of
increasing the awareness and
knowledge of both the general
public and non-specialist health
care professionals” (NHS Evidence,
www.library.nhs.uk, 2010)
Seen in this light it is necessary for this
assessment to establish the views of the
general public, health professionals, and
lung cancer patients regarding the illness,
its cause, and its impact.
Perceptions of lung cancer: public
views
The Cancer Research Campaign 2000
MORI conducted a poll for The Cancer
Research Campaign in 2000 in order to
ascertain people‟s views on lung cancer.
MORI interviewed a representative quota
sample of 2,024 adults aged 16+ across
Great Britain.
From the poll, 70% of those interviewed
believe that smokers who develop lung
cancer have brought the disease on
themselves. This notion of lung cancer as
„self-inflicted‟ found by MORI, and the
resulting negative associations, is a
recurring theme in the wider literature.
The Cancer Research Campaign argue
the perception of lung cancer as self-
inflicted not only contributes to the low
public profile the disease receives in
comparison with other cancers and major
killers, but also negatively influences the
perception of those suffering with the
illness:
“If you think it's your own fault that
you have got lung cancer, you're
more likely to 'put up and shut up'
and that's exactly the attitude we
need to change" (Source: Prof. Gordon
McVie, Director General of The Cancer
Research Campaign (2000))
This „put up and shut up‟ attitude
increases the difficulty of raising the public
profile of lung cancer. However, despite
the negativity surrounding lung cancer,
especially for those who developed the
disease from smoking, where the NHS is
concerned views are more positive. The
study found that 84% of those polled
believe that lung cancer sufferers were as
deserving of NHS treatment as other
cancer patients.
Lung cancer patients, perhaps already
more disempowered than other types of
patient, have traditionally felt clinicians
and health professionals to view their
condition negatively. Whether this is true
or not health professionals need to ensure
that patients are empowered and are dealt
with enthusiastically:

“There has been a wall of silence
surrounding lung cancer for far too
long. We need to break this down
and show that we do care for
patients with the disease -
regardless of whether or not they
developed it because of smoking"
(Prof. Gordon McVie, Director General of The
Cancer Research Campaign (2000))
Roy Castle Foundation: UK Lung Cancer
Attitude Assessment 2008
Although lung cancer mortality rates in the
UK are amongst the highest in the world,
the public and health professional
perceptions of the disease are largely
negative. In 2008 the Roy Castle Lung
Cancer Foundation canvassed opinion on
a range of issues relating to lung cancer
from patients, clinical nurse specialists,
and clinicians. Several important results
were discovered:
Consensus across all three groups
was found concerning the lack of
awareness of symptoms of lung
cancer. More nurses thought this
to be the case than clinicians (90%
compared to 77%), while 77% of
patients admitted they were
unaware of the symptoms of lung
cancer before they were
diagnosed;
Stigma around lung cancer was a
central theme. In the clinician
group only 66% believed there
continues to be a stigma
associated with a diagnosis of lung
cancer. This figure was much
higher for patients and nurses
(94% and 98% respectively);
Most seriously, 87% of patients
and 84% of nurses believed that
this stigma impacts upon late
presentation with symptoms of
lung cancer.
The Foundation concludes that while there
have been improvements in the
management of lung cancer in recent
years, the disease remains seriously
stigmatised. The recommendation being
that to impact positively upon lung cancer
mortality, and especially early presentation
and diagnosis, we need to overcome the
stigma associated with the disease
amongst both the general public and
health professionals.
Perceptions of lung cancer and
treatment: patients
Stigma, shame, and blame experienced
by patients with lung cancer: qualitative
study, BMJ 200425
This study draws on narrative interviews
with lung cancer patients recruited through
general practices, oncologists, chest
physicians, and support groups. Patients
were asked to tell the story of their illness
from the time they first suspected they had
a problem. Amongst many topics,
researchers were particularly interested in
how patients perceived the cause of their
illness and how other people reacted to
their diagnosis of lung cancer. Major
themes that emerged were stigma, guilt,
and shame.
The study found that the stigma
associated with lung cancer is primarily
due the association between smoking and
the disease, the perception of the disease
as self-inflicted, its high mortality rate, and
the type of death involved:
“Respondent: I think they [others]
are frightened... it's like when you
get a death in the family, people
will cross the road so as not to
actually have to bring up the
subject, and I think it's the same
with cancer.
Interviewee: Do you think it's the
same with all cancers or more so with lung
cancer?
Respondent: I think more so with
lung cancer because people think
25
Chapple, A., Ziebland, S. and A. McPherson (2004)
„Stigma, shame, and blame experienced by patients with
lung cancer: qualitative study‟, British Medical Journal,
328:1470
 you're dirty because you smoked.
But I don't think they really realise
it's not only from smoking, there's
other things that it's caused by. But
also I think that they can't bear to
think that they're going to see you
suffer. With a lot of cancers you
don't actually suffer, with lung
cancer your breathing is very bad
and you're gasping for breath and I
think that is the bit they don't want
to know... with lung cancer people
automatically think you've brought
it on yourself and it's a sort of
stigma (LC29, retired community
support worker, aged 56, recruited
through support group)” (Chappel, A.
et al, 2004, pg.3)
The study found that older people are less
likely to be blamed for having lung cancer
than young people. The study posits that
this may be because older people became
addicted to cigarettes when smoking was
socially acceptable and before the
dangers to health were widely known.
The study also discovered fears relating to
lack of access to medical care. Patients
were found to speak highly of their doctors
and other health professionals whilst
showing concern about delays in
diagnosis. The study cites the following
as an example:
“The first time you go to the
doctor's with a bad cough and
coughing up phlegm in the
mornings the doctor will almost
certainly say to you, "Do you
smoke?" and once you've said yes,
you're sent packing with a bottle of
cough medicine. If you went to the
doctor's with a small lump the size
of a pea on your breast you'd be
straight into the hospital but you
can be coughing up phlegm for
years and nobody will offer you a
hospital appointment... you are just
pushed to the back of the queue.
And it's quite unfair really, people
who go with problems with drink
related or people who fall off a cliff
through rock climbing are not
stigmatised the same way that
smokers are (LC18, retired welder,
aged 55, recruited through support
group)” (Chappel, A. et al, 2004, pg.2)
Importantly, the shame and guilt felt from
developing a disease widely considered
self-inflicted, even by some of the patients
themselves, hindered to an extent their
desire to seek help. This situation was felt
to be exacerbated further by the grim
outlook a diagnosis of lung cancer is
believed to confer. Similar fears as those
felt towards access to care were also
evident concerning funding for lung
cancer:
“If you compare the amount of
money that's allocated to breast
cancer for research and screening
programmes and so forth and
compare that with those of lung
cancer there is a huge difference,
there is a massive difference to the
point where one has to ask the
question, "Why is there such a
difference?", and you know I can
only assume that it's because it's
self-inflicted and it's because it's
smoking related. (LC12, retired
rigger, aged 43, recruited through
support group)” (Chappel, A. et al, pg.4)
Overall, patients reported far reaching
consequences of the stigma they
experienced. Interaction with family,
friends, and doctors were all reported to
be negatively affected as a result, with
many, particularly those who have never
smoked or who had quit years previously,
feeling unjustly blamed for their illness.
Those who resisted blame and stigma, but
who accepted that smoking caused their
illness, highlight the unscrupulous policies
of the tobacco industry as being ultimately
responsible.
The foremost conclusions of the research:
Lung cancer patients perceive
themselves as stigmatised
because others associate the
illness with smoking and dying in a
particularly unpleasant way;
 Stigmatisation has serious
consequences, the most important
of which is putting patients off from
initially seeking support;
Care and sensitivity is needed from
healthcare professionals when
treating patients with illnesses
considered self-inflicted;
Whilst efforts to help people quit
smoking are vital in combating lung
cancer, clinical and educational
interventions should be presented
with care so as not to add to the
stigma experienced by patients;
The negative perception of lung
cancer is perhaps best deflected
onto the Machiavellian role of the
global tobacco industry.
Lung cancer treatment in Bolton (Royal
Bolton Hospital) 2009
The Department of Cancer and Palliative
Care at the Royal Bolton Hospital NHS
Foundation Trust conduct a patient
satisfaction survey for lung cancer patients
with a view to improving the experience of
patients.
The most recently available audit of this
survey is from February 2009.
Over 80% of respondents replied they
were satisfied with the service they
received during their visit to the lung clinic.
Additional comments lay emphasis on
satisfaction with the information received.
Furthermore, following consultation over
90% of patients said they were given the
name and telephone number of the Key
Worker should they wish to contact them.
Whilst 92% recalled that the Specialist
Nurse (Key Worker) explained their role to
them, only 42% replied that the Specialist
Nurse/Consultant offered written
information about the lung multi-
disciplinary team, and only 69% claiming
that written information given was
understandable and useful.
For measures of dignity and respect,
courtesy, and privacy virtually 100% of
respondents replied positively towards this
aspect of their treatment. However, only
84% left their appointment feeling like they
understood their diagnosis and the steps
of their treatment.
All respondents said they were fully
involved in decisions about their treatment
and care. In contrast, only around half of
those surveyed replied that clinical staff
asked their permission to discuss their
care and treatment with family and friends.
A similar result was found when
questioned about whether family and
friends had enough time to discuss the
patients care and treatment with clinical
staff. Over 80% of patients said they were
kept informed about how long they would
stay in hospital and that all information
they received was consistent.
Between ten and twenty minutes was
spent explaining their cancer to the
majority of patients (over 60%), with 20%
spending ten minutes. Over 80% of all
patients understood the explanation given.
Furthermore, over 90% said they were
informed they had cancer in a sensitive
way.
Prior to leaving hospital only around 50%
of patients were told how long it would be
before they could resume their normal
activities such as doing household chores,
driving, or returning to work. Over 70% of
patients were told about local and national
support groups for people with lung
cancer. Less than 40% were offered
additional professional support to help
cope with the emotional impact of their
condition/treatment (for example the
services of a counsellor or psychologist);
however, less than 20% replied they were
not offered this support but would have
liked it, the remainder saying no but that
they did not want any support. Almost
70% of patients replied that the hospital
doctors and nurses discussed with them
whether they would need any nursing or
other health services after they left
hospital (for example a community nurse,
stoma nurse, health visitor, or
physiotherapist).
On leaving hospital over 90% of patients
were informed of whom to contact if they
became worried about their condition or
treatment. Almost 70% were given their
next outpatient appointment before they
left the hospital.
Reaching Out: Understanding the
health attitudes of harder to reach
groups in the North West26
As lung cancer and smoking are so
strongly associated with socioeconomic
deprivation it is important to understand
the hard to reach groups suffering the
inequalities in lung cancer incidence and
mortality.
In order to better understand the
challenges facing the North West and its
healthcare services, and in recognition of
the aims of the Marmot Review, NHS
North West, Our Life, and Pfizer
interviewed 258 volunteers within
Cumbria, Lancashire, Merseyside, Greater
Manchester, and Cheshire. The aim of
the research was to provide information
about the attitudes around health and
lifestyles for harder to reach groups;
therefore each participant had to be a non-
routine user of primary care, be
economically deprived (in receipt of
benefits or with a household income of
less than £11,000), and have a health risk
factor (smoking, drinking, obesity, chronic
condition etc.).
The findings of the research suggest that
the majority of respondents are registered
with a GP (89%), but that they do not
regularly visit their local surgery or medical
centre. GPs remain influential figures to
this population with a large majority
responding they would seek help for
health conditions from their GP and that
they would not feel embarrassed
discussing their problems and issues with
their GP. However, concerning lifestyle
issues such as smoking and obesity this
population group does not see the NHS as
26
NHS North West, Our Life, and Pfizer (2010) Reaching
Out: Understanding the health attitudes of harder to reach
groups in the North West, The North West Project,
Manchester.
the primary source of help. Rather, 64%
believe it is their own responsibility to
manage their own health if they become
ill.
Of those that have visited their GP in the
twelve months prior to the research the
majority attended mainly for benefit
purposes or for their children, rather than
their own health needs.
“So, while respondents understand
the role of the NHS in dealing with
specific health problems and
issues, like diagnosing illnesses
and dispensing medicines, there is
a lack of awareness of the role that
the NHS can play in helping to
tackle various lifestyle health
issues at an early stage” (Source:
Reaching Out, 2010, pg.13)
Across almost all areas investigated,
respondents believed they were
significantly healthier than they were. As
an example, of those interviewed 26%
were clinically obese yet only 7%
recognised themselves as overweight. As
another example only 6% believed they
were binge drinkers, when in reality 40%
were. Furthermore, health awareness
was only triggered at the point of
diagnosis in over half of respondents
(52%). The study concludes that this low
health-awareness and the extent of
potential problems may be one reason for
this group not using preventative health
services.
For those surveyed the value of family
was significantly ranked above health in
order of importance.
Where access to information is concerned
only 36% use the internet and 37% read
national newspapers; the majority (55%)
read local newspapers. Whilst indicative
of a sedentary lifestyle, 81% of those
surveyed responded that watching TV is
their most common social activity.
The top three barriers identified by
respondents as preventing them leading a
healthier lifestyle were „Lack of money‟
(54%) and „My own laziness‟ (52%).
Furthermore, 40% of respondents who
smoke heavily do not worry about their
health at the present time while 46% of
those clinically obese are not currently
trying to lose weight. However, 40% of
respondents would like to live longer than
they actually expect to live. Whilst 84% of
all those surveyed do not currently worry
about their health, 64% expect that they
are likely to worry about the impact their
health will have on their life in the future.
Concerning issues of responsibility, 54%
turn to family and friends to look after
them when they are ill and would not
approach the NHS for help and guidance.
In comparison, only 9% would visit their
GP and only 1% would go to hospital.
Questioning comparing individual health to
the perceived health of the community
discovered that 56% of smokers believe
their health is about the same as others in
their local area:
“It would appear that community
and lifestyle references play a
significant role in shaping self-
perception. Those questioned
make observations relating to their
own health based on the people
and lifestyles around them” (Source:
Reaching Out, 2010, pg.19)
Of those questioned, only 40% recognised
any previous health campaigns. Specific
Government campaigns that did resonate
were the FAST stroke campaign (28%)
and the „It‟s 30 For A Reason‟ speeding
campaign (17%). Questioning aimed at
ascertaining the best methods of reaching
the target audience found that 80%
believed that television would be the best
way to make individuals aware of services
that are available locally, with 33%
responding that materials posted through
their door would be the best method.
Worryingly, 46% of those surveyed said
they were not aware of any solutions that
could help to improve their health and
lifestyle. However, when prompted with
potential solutions many were enthusiastic
about using them. In particular, utilising
financial incentives as a means towards a
healthier lifestyle was very well received.
The example of offering individuals
vouchers to redeem against certain
healthy foods such as fruit and vegetables
found that 81% would be likely to use this
service. In addition, free or subsidised
services such as weight loss, fitness, and
swimming classes was a popular option,
particularly for those clinically obese, with
50% saying they would be very likely to
use this service.
Several recommendations are made by
the report aiming at improving the health
and engagement of this under-serviced
population, many of which have the
potential to influence smokers and those
at risk of developing lung cancer:
1. PCTs should take action to identify
those individuals who are not
registered with a GP and seek
ways of encouraging full
registration;
2. PCTs should describe the
prevention services available in
each area tailored to individuals at
different stages of their lives;
3. Health professionals should use
every patient contact as an
opportunity to ask about lifestyle,
directing them to appropriate
prevention services if necessary;
4. As the population group is largely
home-based because of
unemployment, part-time
employment, and long-term
sickness, communications
delivered directly to the home may
prove a productive method of
reaching this audience. In
addition, the found a low level of
educational attainment amongst
this group and so information
should be succinct and easy to
understand;
5. Lifestyle change in response to
financial incentives is another key
route to reach some of the
disengaged audiences;
6. The groups of concern do not
recognise the NHS as a source of
support and their aspirations for
better health for themselves, for
their family, and for their
community may not be high. As
such the most effective solutions
will involve individuals and
communities themselves in service
development, and in some cases
delivery;
7. Data must be collected on the
groups concerned and be used to
inform the Joint Strategic Needs
Assessment (JSNA) and the
provision of appropriate services;
8. Commissioners should adopt a
more collaborative approach to
designing health improvement
programmes, working with the end-
users and the media as well as
public health and communications
colleagues. This co-production
with the end-user will inspire the
belief and drive for behaviour
change to happen. The very act of
involvement creates a value
statement which is important at all
levels;
9. There is no one definite solution,
however for these groups
commissioning focus must be
always on the service user. This
means that commissioners need to
prioritise the development of
joined-up and holistic services with
more social involvement by
primary care;
10. Regional workforce programmes
must ensure the public sector
workforce is fully aware of the
needs of harder to reach groups
and be sufficiently skilled in
responding to them.
 National and local strategies
Cancer Reform Strategy (2007)
The Cancer Reform Strategy builds on the
progress made since the NHS Cancer
Plan in 2000 and sets the direction for
cancer services up to 2012. The Strategy
aims to make NHS cancer services among
the best in the world by 2012.
The Cancer Reform Strategy outlined a
programme of action across ten areas.
Six of these areas of action are aimed at
improving cancer outcomes and four are
designed to ensure delivery.
Actions to improve cancer outcomes:
Drivers for delivery:
Preventing cancer: over half of all
cancer cases could be prevented
by changes to lifestyle such as
quitting smoking, maintaining a
healthy weight, and appropriately
managing alcohol consumption;
Diagnosing cancer earlier: early
diagnosis would have a significant
impact upon cancer survival rates.
This should be done through
enhancing cancer screening,
improving public awareness of
symptoms, and going further on
cancer waits;
Ensuring better treatment: the
Strategy aims to tackle the
shortage of radiotherapy capacity
as well as delays in the NHSs
uptake of new cancer drugs. The
Strategy also plans to encourage
the spread of improved surgical
techniques;
Living with and beyond cancer:
more priority given to information
for patients, face-to-face
communication with health
professionals, and the co-
ordination and continuity of care.
More also needs to be done to
support patients throughout their
survivorship;
Reducing cancer inequalities:
better data collection, research,
and spreading good practice
should help tackle inequalities in
the outcomes and experience of
cancer for different groups;
Delivering care in the appropriate
setting: new service models for
cancer will achieve the quickest
possible diagnosis and reductions
to unnecessary stays in hospital.
Using information to improve
quality and choice: improved
collection and publication of data
on cancer outcomes will improve
service quality and strengthen
commissioning, as well as being a
prerequisite for informed choice for
patients. In addition, more
information is needed on public
awareness of cancer risk factors,
symptoms, and patients‟
experiences of cancer care;
Stronger commissioning: the
Strategy will support
commissioners in the provision of
high quality cancer services which
reflect the needs of the local
population;
Funding world class cancer care:
appropriate funding will be
provided to build world class
cancer services, but
commissioners need to ensure that
money is well spent;
Building for the future: this involves
the construction of a new national
 repository of cancer data,
enhancing research in areas where
gaps in knowledge persist, the
planned provision of a skilled and
flexible cancer workforce, and high
quality facilities and environments
for cancer care.
The latest update was published on 1st
December 2009; Cancer reform strategy:
achieving local implementation – second
annual report.
The Cancer Plan for the North West of
England to 2012 (2008)
The Cancer Plan for the North West was
developed in parallel with the national
Cancer Reform Strategy (CRS) and is in
effect a local response identifying those
actions that need to take place in the
North West.
The Cancer Plan in the North West
complements the Our Life programme in
the North West and the aims identified in
the Darzi review Our NHS Our Future.
To ensure delivery the NHS in the
North West:
Pledge 1: By 2012 the NHS in the
North West will have implemented
the actions identified in this plan;
To help prevent cancer:
Pledge 2: Implement the Regional
Tobacco Control plan;
Pledge 3: Use the „Our Life‟
programme to push for a decrease
in hazardous and harmful alcohol
consumption;
Pledge 4: Networks will support
PCTs with the implementation of
the Human Papilloma Virus (HPV)
vaccination programme to
commence September 2008 and
will ensure that by September
2010 all young women up to the
age of 18 will have been offered
HPV vaccination as part of the
„catch up‟ programme;
Pledge 5: The North West will
strive towards reducing obesity
especially in children and young
people;
Pledge 6: The North West will
campaign for greater regulation of
sun beds to protect children and
young people;
To speed up results following
cervical screening:
Pledge 7: Having been the first
SHA in the country to fully
introduce Liquid Based Cytology
(LBC) screening, we now want to
go further with system redesign of
cytology services and to ensure
that all patients receive their
results within 14 days by 2010. By
March 2011, networks will have
implemented changes arising out
of the North West Review of
cytology services;
To reduce variation in screening
rates:
Pledge 8: Unacceptable variations
in screening uptake will be
investigated and appropriate action
will be taken to target the
population never screened. PCTs
leads will examine the coverage
and uptake rates for all screening
programmes to improve and
maintain uptake by their
populations;
To improve and extend breast
screening services:
Pledge 9: We will review and
enhance capacity within our breast
services to ensure that we meet
the new standards including the
introduction of digital
mammography. Those with a high
familial risk of breast cancer will be
kept under surveillance through the
breast screening service. We will
see greater integration with the
symptomatic breast services. This
will be fully implemented by
December 2012;
To improve and extend bowel
screening services:
Pledge 10: As the bowel screening
programme is made available to
more people we will increase
colonoscopy capacity and ensure
that patients who require this
following their positive FOB (blood
in stool) test will wait no longer
than 2 weeks. From 2010 people
aged between 70-75 years will be
invited for bowel screening;
To improve waiting times for
cancer treatments:
Pledge 11: We will ensure that all
patients in the North West will
meet extended standards for
waiting times. For second or
subsequent surgery and
chemotherapy this will mean that
patients will; wait no longer than 31
days by December 2008. All
women referred by their GP with
breast symptoms will be seen
within two weeks by December
2009. All patients with a
suspected cancer detected through
screening programmes or as
upgraded by their consultant will
be treated within 62 days by
December 2009;
To improve access to radiotherapy:
Pledge 12: Networks will develop
radiotherapy satellite facilities to
meet the expectations within the
CRS and NRAG which will
guarantee that patients have a
maximum travel time of 45 minutes
(by car/ambulance) for the more
common cancers and for those
requiring palliative treatment.
Those patients with cancer or more
complex treatment needs may
need to travel beyond this time.
Networks will identify sites by end
of 2008 with a view to
implementing the first of these by
2010/11. PCTs will commission
any additional capacity that cannot
be met from better utilisation of
existing equipment. Where
radiotherapy is a second or
subsequent treatment, this will be
ensured within 31 days by
December 2010;
To provide greater consistency
across a range of treatments:
Pledge 13: Review treatment
protocols and clinical guidelines to
ensure these are consistent with
best practice and standardised
across the North West. We will
make treatment such as High Dose
Rate Brachytherapy accessible
across the North West. Patients
will be supported wherever
possible to have their radiotherapy
treatment at a location convenient
to them;
To ensure equity of access to
cancer drugs:
Pledge 14: Patients across the
North West will continue to have
access to cancer drugs positively
appraised by NICE. For pre-NICE
drugs and those unlikely to be
considered in the short term by
NICE there will be a common
approach adopted by
commissioners to ensure equity
across the North West. The
opportunity to standardise
treatment protocols will be
explored and a commitment is
given that all patients will be
treated the same regardless of
geographical location by 2012;
To deliver local, consistent and
safe chemotherapy:
Pledge 15: By 2012 chemotherapy
and other systemic therapies will
be delivered as close to home as
possible where this is safe to do
so;
To commission services only from
accredited providers:
Pledge 16: Commissioners will
only commission care from
hospitals specifically designated to
deliver care in accordance with
NICE Improving Outcomes
Guidance by 2012 at the latest;
Pledge 17: Commitment has been
given by all PCTs across the North
West to accelerate the
implementation of the plans where
these have slipped behind national
implementation milestones. In
addition, network organisations
should ensure that peer review
action plans are also auctioned. A
state of readiness report and IOG
remedial action plan (if
appropriate) will be required for
each network by September 2008;
To ensure access to the latest
surgical techniques:
Pledge 18: Network organisations
will ensure that all surgeons can
access training in the latest
surgical techniques. Agreed new
technologies such as laparoscopic
procedures (e.g. for prostate,
gynae, and renal cancers) will be
introduced once these become
more the norm in practice and
PCTs will then only commission
from those providers who can offer
these techniques;
To respond to new guidance for
rare cancers:
Pledge 19: We will balance the
needs of travel distances with the
need to concentrate some services
in fewer locations for the rare
cancers. Clinical guidelines will be
standardised across the North
West centres where there is more
than one using best practice
guidelines and tools;
To be responsive to patients living
with and beyond cancer:
Pledge 20: By listening to what
patients tell us, we will constantly
keep under review their views
through a series of surveys and
through Network Patient
Partnership and other Patient and
Public Involvement arrangements.
We will ensure providers have
robust systems in place to
measure patient satisfaction and
then act upon the findings.
Providers will also ensure that
professionals access the
appropriate education and training,
e.g. communication skills;
Pledge 21: To ensure that all
patients receive care as close to
their home as is possible and that
their stay as an inpatient is kept to
a minimum. Where this cannot be
avoided, we will enhance the
quality of the patient experience,
particularly for those with
advanced disease. Continuity of
care will be ensured through the
transformation and development of
nursing roles such as through
implementation of the Integrated
Cancer Care Programme (ICCP).
This will also ensure that Clinical
Nurse Specialists are used more
effectively and appropriately;
Pledge 22: Patients and Carers will
have access to an appropriate
level of psychological support
throughout and beyond their
cancer journey. Using the
Improving Access to Psychological
Therapies initiative patients will be
referred to an appropriate service
once they are diagnosed;
Pledge 23: Support patients in
making choices around their end of
life including increasing the
numbers of people supported to
die at home and to achieve their
priorities for care;
Pledge 24: To support the agreed
key recommendations of the End
of Life Care clinical pathway group;
To reduce cancer inequalities:
Pledge 25: By the end of 2008 all
networks will have developed
rigorous plans to reduce the health
inequalities experienced by their
population;
Pledge 26: The inequalities in
cancer mortality rates will be
rigorously monitored by the SHA;
To commission and deliver world
class cancer services:
Pledge 27: PCTs in the North West
commit to the Department of
Health World Class
Commissioning programme and
the use of the cancer
commissioning toolkit, through
which standardised care across
the North West can be monitored;
Pledge 28: PCTs will ensure the
ambitions and pledges in this plan
are reflected in their strategic plans
by September 2008.
The Greater Manchester and Cheshire
Cancer Network Prevention, Early
Detection, and Inequalities Strategy
(2010)
Based on the major challenges faced by
the Network of reducing the burden of
cancer across the whole of the Network,
and dramatically improving the situation in
areas that have the worst outcomes, the
Strategy proposes actions to reduce
inequality.
The Strategic Goal of the Strategy:
“A long-term reduction in the
incidence of preventable cancers
and an improvement in the stage
distribution of new cancer cases in
all population groups across the
Greater Manchester and Cheshire
Cancer Network”
This Goal is reinforced with the following
ten Strategic Aims:
1. Reduce the prevalence of
smoking;
 2. Improve the diet of the
population;
3. Reduce the prevalence of
obesity and overweight;
4. Increase the amount of
physical activity;
5. Reduce the excessive
consumption of alcohol;
6. Reduce exposure to specific
causes of cancer;
7. Reduce the spread of
infections that can cause
cancer;
8. Improve communication about
cancer signs and symptoms;
9. Make diagnostic pathways
follow best practice and be
available to all;
10. Improve attendance at cancer
screening, especially in
disadvantaged groups.
End of Life Care Strategy: Promoting
high quality care for all adults at the
end of life (2008)
The Strategy sets out key areas for
improvement when providing people
approaching the end of life with more
choice about where they would like to live
and die. The Strategy covers all adults
with advanced, progressive illness and
care provided in all settings. Contains the
requirement for local end of life care
strategies based on its findings and
recommendations (see below).
Bolton End of Life Care: A strategy for
improving care for people living with
and dying from long-term conditions
2006 – 2011
Sets out a five-year strategy to jointly
develop end of life services throughout
Bolton for people with long-term conditions
in their last six to twelve months of life.
This Strategy will be achieved based on
five clearly defined areas:
Co-ordinated care: a smoother,
faster, and more joined up care
experience will be determined
through better planning and
sharing of information concerning
the needs of patients between
different sections of the health
service and partner organisations;
Better training and education: to be
implemented in all settings where
care is delivered for people at the
end of life;
24 hour access: to a broad range
of community services enabling
patients and their carers to receive
support at the end of life, including
bereavement;
Dignity at the end of life: to strive to
ensure that whatever the cause of
illness, and wherever care is
provided, a dignified and, as far as
possible, pain free death can be
achieved;
Choice: as far as possible in where
the patient would like to be cared
for in the last days of life.
Bolton’s Joint Strategic Needs
Assessment (2008)
The JSNA identified the following areas
relevant to lung cancer as priorities on
which partner agencies should focus in
order to impact on reducing the poor
health and inequalities:
Smoking reduction;
Early symptom recognition of
cancer.
High Quality Care for All – Darzi Review
(2008)
Driving:

Quality at the heart of the NHS;

Raising standards;
Involving clinicians in decision
making at every level in the NHS;
Aspirations within the NHS North
Fostering a pioneering NHS; West’s Healthier Horizons Strategy
Empowering front line staff to lead (2008)
change that improves quality for
patients;
Valuing the work of NHS staff; Focusing on the following seven strategic
enablers:
Help to stay healthy;
Most effective treatments for all; Getting beyond service
Keeping patients as safe as reconfiguration;
possible. Raising our game on safety, quality
and governance;
NHS North West Report of the Next Strengthening leadership and
Stage Review (2008) strategic capacity;
Understanding patients and
tailoring interventions more
Focusing on:
effectively;
Locally led, patients centred and Being innovative;
clinically driven care; Fostering partnerships with
Changes in healthcare and society; meaning;
High quality care for patients and Managing the health system and
the public; the interests of people.
Quality at the heart of everything
we do; NHS Bolton’s Primary Medical Services
Freedom to focus on quality; Commissioning Strategy
High quality work in the NHS; Recommendations
The first NHS Constitution;
Implementation of the vision. This strategy reflects NHS Bolton‟s Triple
Aim principles which are to:

Reflect the needs of the population

served;
Provide high quality patient care;
Provide value for money.

Current activity and services
Lung cancer services concentrate upon
prevention, treatment, and palliative care.
Prevention falls almost exclusively upon
tobacco smoking reduction. This is the
major cause of all lung cancer and gains
here are the only method of effectively
reducing mortality. However, the nature of
carcinogenic exposure is very long-term
and as such benefits will only be
perceived in terms of savings in treatment
costs in around ten years time.
Prevention and caring are central
components of assessing lung cancer
need and planning for the future because
curative treatment lacks effectiveness.
This is because at UK level, less than 10%
of lung cancer patients survive the disease
for at least five years after diagnosis27.
Treatment is dictated by the cell type and
spread of the cancer, and only in early
diagnosed cases where the tumour is
localised in the lung is a cure possible.
Small-cell tumours are more aggressive
but both major types have a poor
prognosis. The result is that the majority
of treatment is intended as palliation and
symptom control.
NHS Bolton must take the weighting of
these components into account when
planning and designing appropriate
services. For curative services there must
be appropriate and systematic
assessment processes that allow those
presenting with reasonable prognoses to
receive necessary and timely diagnosis
and treatment. However, it should be
borne in mind that the bulk of patients will
require palliative services focused on high
quality symptom control and end of life
care. Within this, patients may require
care in the community as well as in an
acute trust (or hospice). While the
majority of resources will be taken by
palliative and terminal care services,
27
Cancer Research UK (2009) CancerStats: Lung cancer
and smoking November 2009, Cancer Research UK,
London.
proper funding must also be available for
preventative strategies and the
progression of new treatments where
possible28.
Prevention
Lifetime risk of lung cancer is the
probability of developing the condition
over the course of a lifetime. In the UK
the lifetime risk of developing lung cancer
has been estimated at a 1 in 14 chance for
men and a 1 in 21 chance for women29.
However, these probabilities are very
strongly correlated with cigarette smoking
and as such this section focuses primarily
on smoking, but also considers radon
exposure and other air pollutants.
Screening
There is no national screening programme
for lung cancer because of the absence of
a reliable testing method that is simple,
economically viable, and not harmful. If
screening becomes possible, as with most
screened diseases it is more cost effective
to screen those at risk rather than the
whole population. For lung cancer this is
almost exclusively smokers.
Screening for lung cancer with a chest X-
ray is unlikely to produce the desired
benefit as X-ray‟s in general are only able
to pick up advanced lung cancer. Rather,
latest research seems to be focused on
spiral CT scans and a particular type of
bronchoscopy in hopes of finding a
suitable method to diagnose lung cancer
earlier.
With the absence of screening there are
three main ways in which lung cancer is
diagnosed in Bolton and nationally:
1. Active case finding;
28
Stevens, A. et al (2004) Health Care Needs
Assessment, Radcliffe Publishing Ltd., Oxford.
29
National Cancer Intelligence Network (2008) Cancer
Incidence by Deprivation England 1995-2004, NCIN,
London.
 2. Presentation of cancer symptoms
at primary care;
3. Serendipitous diagnosis.
Active case finding is a considered and
structured attempt to discover cases of
cancer early, with particular focus on
diagnosis before the patient is aware they
have lung cancer. This may be a formal
part of the diagnosis pathway or an
informal use of the diagnostic skills of
clinicians and other health professionals.
The second method is the presentation of
patients with symptoms of lung cancer at
primary care. Currently, it is difficult for
GPs to establish which individuals have
lung cancer from those with more minor
lung conditions, particularly in smokers.
There are NICE guidelines for GPs to help
in the decision of who to urgently refer to a
specialist, but early diagnosis remains a
problem. The difficulty in diagnosing lung
cancer early affects both screening and
GP referral, resulting in most cases
presenting too late to respond to curative
treatment30. This is why lung cancer has a
very high mortality rate and a very low
survival rate compared to other cancers.
Barriers are also present here against
people presenting with lung cancer
symptoms to their GP. The first of these is
that patients do not often recognize the
early signs of lung cancer as they are not
exclusive to the disease and are quite
common of less severe illnesses. The
second is fear of diagnosis. In the public
perception, as evident from the felt need
section of this assessment, lung cancer is
associated with a forbidding prognosis and
a particularly unpleasant death.
The final method of diagnosis is chance
finding. This is usually the result of an
emergency presentation or referral from
another specialism in secondary care.
The latter is often a result of a chest X-
Ray or other chest examination for other
purposes.
The Greater Manchester and Cheshire
Cancer Network Prevention, Early
30
Cancer Research UK (2010) About Cancer, Cancer
Research UK, London.
Detection and Inequalities Strategy
identifies several important considerations
to affect population level earlier diagnoses
of cancer in the region:
1. Increase awareness of cancer
symptoms among the population,
including health professionals;
2. High risk groups should be
identified and receive tailored
interventions and information;
3. Reduce the fear of cancer, in
particular by focusing on modern
advances and improvements in
survival;
4. Ensure all population groups have
opportunities to discuss health
worries and have easy access to
appropriate diagnostic services;
5. Ensure health professionals follow
correct procedures for cancer
diagnosis.
These recommendations are generic for
all cancers for which screening is not
available.
Smoking
Tobacco smoking is the UKs greatest
cause of early death and preventable
illness and is associated with many
specific cancers, estimated as responsible
for 29% of all cancer deaths in the UK31.
At Bolton level this equates to almost 180
deaths in 2008. However, the most
significant association is with lung cancer;
smoking is responsible for almost 90% of
lung cancer deaths.
The relationship between smoking and
lung cancer is evident in the below graph
produced by Cancer Research UK. The
graph depicts how the incidence of lung
cancer has historically reduced along with
the prevalence of cigarette smoking in
Great Britain.
31
Peto, R. (2006) Mortality from smoking in developed
countries 1950-2000, Oxford University Press, Oxford.
There is a QOF prevalence register for
smoking, but it lacks historical data. The
indicator comprises the percentage of
patients with presence of any or any
combination of the following conditions:
coronary heart disease, stroke or TIA,
hypertension, diabetes, COPD, CKD,
asthma, schizophrenia, bipolar affective
disorder or other psychoses whose notes
record smoking status in the previous 15
months.
There are 66,519 people on the smoking
register in Bolton for 2008/09.
The most reliable source for smoking
prevalence in Bolton is from the Bolton
Health and Lifestyle Survey 2007. The
local trend from the survey supports a
projected decline in future smoking
prevalence. There has been a significant
reduction in the percentage of people who
smoke in the borough since the last
survey in 2001. In 2001, the prevalence of
smoking in adults was almost 30%. In
2007, this had dropped to 23%. This
reduction reflects the amount of work that
NHS Bolton and our partners have put in
place to reduce smoking in the borough.
Importantly, it should be noted, that the
health survey took place during June
2007, one month before the smoke free
legislation was introduced, making it illegal
to smoke in virtually all enclosed public
places and workplaces. We expect the
number of smokers to have fallen further
since the new legislation.
Men in Bolton are more likely to smoke
than women (25.2% of men and 20.9% of
women). The proportion of women
smoking has fallen at a slightly faster rate
than in men (27.3% women smoked in
2001, 31.8% of men smoked in 2001).
The percentage of heavy smokers (20 or
more cigarettes a day) in Bolton has also
fallen since 2001. This has reduced from
8.6% in 2001 to 6.0% in 2007. Men in
Bolton are more likely to be heavy
smokers than women (7.1% men, 4.9%
women).
Comparing smoking in Bolton to national
rates is not straightforward as the most
recent national figures are from 2006 and
the questions used may differ slightly from
those used in the Bolton Health Survey
2007. However, the Health Survey for
England for 2006 found that 24% of males
and 21% females were currently smoking.
The General Household Survey found
smoking prevalence rates in England of
23% for men and 21% for women.
However, it must be noted that both
surveys include people aged from 16
years of age. These figures suggest that
Bolton has a higher prevalence of smoking
in men when compared nationally.
Bolton is shown to be equal to the North
West average for percentage of smokers;
Bolton has 25.74% adults who smoke,
compared to 25.96% for the North West
as a whole. The difference evident
between Liverpool as the highest and
Fylde as the lowest is particularly striking.
The above are synthetic estimates derived
from the Health Survey for England. This
figure differs from the findings of the
Bolton Health and Lifestyle Survey 2007
because of the different period, the small
sample size of the HSE at district level
(sample size is 16,000 for the whole of
England), and the HSE under samples
younger people, people in employment,
ethnic minorities, women, and those who
are healthier but exhibit less healthy
behaviour. Smoking has decreased in
Bolton from the 2001 Bolton Health
Survey to the 2007 survey (current smoker
from 29.5% to 23%; 20+ smoker from
8.6% to 6%).
The chart below shows the percentage of
adults who smoke in each Local Authority
of the North West for the period 2003-
2005.
In order to monitor on an annual basis,
NHS Bolton now works in partnership with
the local authority to include a smoking
question on the annual Place Survey;
early results from the 2008 Place Survey
suggest that smoking has reduced to
approximately 18% since the new smoking
legislation.
The patterns of smoking and heavy
smoking across Bolton closely resemble
the patterns of smoking attributable
mortality and prevalence of lung cancer
seen in Bolton. Smoking is strongly
correlated to deprivation with the poorer
communities still showing the highest
prevalence rates. There is almost a three-
fold difference (12.8-35.3%) between the
lowest and highest smoking rates across
different MSOAs in Bolton. Generally, the
map below shows those areas in the
central and more deprived parts of Bolton
show the highest proportions of smokers.
Most areas show a fall in prevalence since 29% of all adults classified as routine and
2001, with increases seen in only three manual smoke32.
areas. However, the only areas to show a
significant decrease since 2001 are Tonge Bolton is composed of 32 postcode
Moor & Hall i‟th‟ Wood, Leverhulme & sectors. Of these there are 11 with a
Darcy Lever and Westhoughton East. routine and manual penetration greater
than 70%. These are (in order of
Furthermore, the higher proportions of ex- penetration) BL3 6, BL1 3, BL3 5, BL1 2,
smokers are generally seen in areas with BL4 9, BL1 1, BL4 7, BL2 2, BL3 3, BL3 2,
low rates of current smokers. These areas BL4 0. This equates to 28,196
are commonly the less deprived areas, households. These sectors range from
suggesting that people living in these 86.3% routine and manual in the first
areas are able to quit smoking more easily noted to 71.3% in the final (for comparison
than people in more deprived parts of remember that overall in Bolton routine
Bolton. After combining both current and manual household penetration is
smokers and ex-smokers, the lowest 48.3%).
proportions (i.e. areas with more people
who have never smoked) are seen in Table j.
33
areas of higher than average BME Smoking prevalence
population. This is mainly due to the low Lower Upper
prevalence of smoking among South Percent
CL CL
Asian women in Bolton.
Breightmet 33.6 28.9 38.4
Table j. shows smoking prevalence from Crompton 25.0 19.1 30.8
the Bolton Health and Lifestyle Survey Farnworth 32.0 28.4 35.5
2007 by NRS Area. Great Lever 31.0 26.8 35.3
Hall ith Wood 41.6 29.3 53.9
As expected because of deprivation, Halliwell 30.8 26.0 35.5
smoking prevalence is far higher in all the Hulton Lane 32.4 24.4 40.4
NRS areas than it is in Bolton overall. Johnson Fold 40.0 29.6 50.3
Deprivation also affects the ability of a Rumworth 21.6 18.1 25.0
population to quit smoking. From the Tonge with the Haulgh 31.9 26.0 37.8
2001 survey to the 2007 survey there is a Washacre 35.7 27.3 44.0
marked difference in percentage change
of smokers between the most and least BOLTON 23 22.2 23.8
deprived areas of Bolton, as evident in the
below chart.

Smoking prevalence in the most deprived

groups is a particularly important issue in
Bolton. The 2010 PSA target
concentrated on smoking prevalence in
the general population and that of routine
and manual groups. Smoking prevalence
is much higher for this group and as such
they take a disproportionate burden of
lung cancer mortality and incidence. In
Bolton there are estimated to be 118,472
households, of which 57,279 are routine
and manual (48.3%). This means that
almost half of all households in Bolton are
classed as routine and manual; 32
furthermore, national figures estimate that Office of National Statistics (2006) General Household
Survey 2006, ONS, London.
33
NHS Bolton (2007) Bolton Health & Lifestyle Survey
2007, NHS Bolton, Bolton.
In addition to households, there are
estimated to be 1,000 routine and manual
employers in Bolton. Of all 32 postcode
sectors, the ten containing the greatest
number of routine and manual employers
account for 50% of all routine and manual
employers in Bolton. These employers
are situated in sectors BL1 1, BL3 6, BL5
3, BL1 8, BL1 2, BL6 5, BL2 6, BL1 3, BL3
3, BL4 7.
Nationally we know that 70% of routine
and manual smokers want to give up but
are not acting upon this need. The group
has been found to have a very low
awareness of available services despite
being the group requiring greatest support.
The following maps are taken from the
EMO and SmokeFree North West Fact
Find: Routine and Manual Worker
Smokers report for Bolton.
The first map shows the key routine and
manual penetration areas in Bolton with
current pharmacies, GP practices, and
quit groups (LAPs) for smoking cessation.
The second map shows where potential
LAPs are within Bolton for smoking
cessation. There are a potential 17
pharmacies, 24 GP practices, and 40
dentists that could offer LAP services
within the PCT.
Inequalities also persist for smoking
prevalence, especially regarding quit
rates, by ethnicity in Bolton.

The following table shows percentage of

smokers from the Bolton Health and
Lifestyle Survey 2007 by ethnic group.

Table k.
34
Ethnicity: Smoking prevalence

White British 23.9

White Irish 30.3
White other 26.5
Asian Indian 13.7
Asian Pakistani 16.3
Black 11.1
Mixed/Asian Other/Other 23.0

The White ethnic groups have the highest

prevalence of smoking in Bolton, with the
Asian Pakistani group having the highest
prevalence of the BME groups. The lower
smoking prevalence in the South Asian
ethnic groups is primarily due to very low
prevalence in Asian women compared to
men; Asian men display similar levels of
smoking to the White population.

The following map shows the key BME

locations in Bolton with community groups,
mosque‟s, Hindu temples, and other
places of worship identified. These
centres have been acknowledged as
target areas for BME communities.

34
NHS Bolton (2007) Bolton Health & Lifestyle Survey
2007, NHS Bolton, Bolton.
In addition to demographic factors, living
in a house in which cigarette smoking
occurs can increase the risk of lung
cancer - by almost a quarter. It is also
widely acknowledged that children from
smoking families are more likely to smoke
when adults. However, there does seem
to be a crucial age range at which children
begin smoking; less than 1% of 11-12 year
olds smoke, but by 15 years of age this
figure has increased to 20%, typically with
a larger proportion of girls smoking
compared to boys35. The most important
issue for this age group is that although
smoking prevalence in the general
population continues to decline, this is not
the case for adolescent smoking. In
seeking to address this stasis, strategies
must be conscious of the complex
relationship between adolescents and
authority, as well as the confused
messages about cigarettes36. In addition,
an issue that is expected to become
prominent in the future is the branding of
cigarettes with many pressure groups
35
Cancer Research UK (2009) CancerStats: Lung cancer
and smoking November 2009, Cancer Research UK,
London.
36
Stevens, A. et al (2004) Health Care Needs
Assessments, Radcliffe Publishing Ltd., Oxford.
calling for uniform branding and more
severe display limitations.
On a related point, research suggests that
stopping smoking before middle age
eliminates most of the risk of lung cancer
from tobacco37. For this reason the group
prior to middle age is key in targeted
initiatives.
Finally, we must appreciate that being
exposed to second hand smoke can
increase the risk of a non-smoker getting
lung cancer by 24%38.
The World Health Organisation asserts
that tobacco smoke is a carcinogen (a
substance that causes cancer in human
beings) and this places it alongside other
poisonous substances such as asbestos,
radon, and arsenic. In sum, the toxic
substances of second hand smoke contain
over sixty-nine cancer causing chemicals.
It is important to note that there are two
types of tobacco smoke:
37
Cancer Research UK (2009) CancerStats: Lung cancer
and smoking November 2009, Cancer Research UK,
London.
38
Smokefree England (2010)
wwww.smokefreeengland.co.uk
 1. Mainstream smoke: inhaled
through the mouth of the smoker at
the end of the cigarette and later
exhaled;
2. Sidestream smoke: that arising
from the burning tip of the
cigarette.
Second hand smoke consists
predominantly of sidestream smoke, and
although this is inhaled in a diluted form
compared to direct inhalation, sidestream
smoke is almost four times more toxic
than mainstream smoke39.
Today, the impact of second hand smoke
can be expected to be severely reduced
by the introduction of the Smokefree
legislation in July 2007:
“Across the world and in a very
short space of time, smokefree
laws have proved to be highly
effective in protecting people from
the harm of second hand smoke”
(Source: Smokefree England, 2010)
Despite this gain, the effect upon mortality
should be considered limited given that
95% of deaths associated with second
hand smoke are from exposure in the
home40, and as the public places and
workplaces legislation is fully implemented
focus should now be on creating smoke
free homes in Bolton.
Stop Smoking Service
Since the Bolton NHS Stop Smoking
service was established in 1999 it has
helped over 4,500 people quit smoking.
Within this, 7-week intensive quit groups
have helped over 3,000 people quit
smoking in Bolton over the last three
years.
Community quit groups and one-to-one
therapy sessions are also available, as are
services based at the maternity unit,
pharmacies, and GP practices. Also, a
Stop Smoking Specialist is employed at
39
Cancer Research UK (2010) www.canceresearchuk.org
40
Smokefree England (2010)
wwww.smokefreeengland.co.uk
the Royal Bolton Hospital to work with the
hospital, train staff in giving advice and
support to patients who smoke, and to
design new practices and procedures to
make it easier to encourage patients and
visitors to quit.
The North West annual returns for
smoking cessation services across the
country are released by the Information
Centre and show the rate of successful
quitters for specific PCTs. The following
graph shows how Bolton compares for
successful quitters against its target for
2008/09, and how this compares against
the PCTs of the North West. For this
period Bolton PCT saw 1718 successful
quitters. However, this means Bolton has
a successful quitters rate of 827.6 (per
100,000 16+ population) compared to an
Annual Plan target of 1006.9 (per 100,000
16+ population). The chart below shows
the difference in actual numbers to
illustrate the PCTs who achieved their
target.
As evident below from the variance
between number of successful quitters
achieved and planned number of quitters,
Bolton has a higher variance than the
North West as a whole and needed to pick
up an extra 412 successful quitters to
reach its target.
Many of Bolton‟s benchmarked peer PCTs
such as Ashton, Leigh, & Wigan, Halton &
St. Helens, Heywood, Middleton, &
Rochdale, Oldham, Tameside & Glossop,
and Salford all have a lower variance than
Bolton, and these are matched for
demographic and deprivation related
characteristics. (Bury is the only
exception with a higher variance than
Bolton).
Table l.
Successful Quitters who attended NHS Stop Smoking Services: 2008/09 (cumulative)

Annual planned Number of

Number of
number of successful
Successful Percent (%)
successful quitters not
Quitters
quitters achieved

Bolton 1718 2130 -412.0 -19.3

Ashton, Leigh and Wigan 2703 2961 -258.0 -8.7

Blackburn With Darwen 1123 1750 -627.0 -35.8
Blackpool 1295 1265 30.0 2.4
Bury 950 1355 -405.0 -29.9
Central & Eastern Cheshire 2666 2912 -246.0 -8.4
Central Lancashire 3228 3162 66.0 2.1
Cumbria 2771 3049 -278.0 -9.1
East Lancashire 2818 3510 -692.0 -19.7
Halton and St Helens 2637 2200 437.0 19.9
Heywood, Middleton & Rochdale 1820 1813 7.0 0.4
Knowsley 1868 1850 18.0 1.0
Liverpool 4483 4470 13.0 0.3
Manchester 4859 4758 101.0 2.1
North Lancashire 2009 2449 -440.0 -18.0
Oldham 1653 1930 -276.8 -14.3
Salford 1628 1800 -172.0 -9.6
Sefton 2522 2444 78.0 3.2
Stockport 1823 1897 -74.0 -3.9
Tameside and Glossop 1839 1781 58.0 3.3
Trafford 1160 1288 -128.0 -9.9
 Warrington 781 1145 -364.0 -31.8
West Cheshire 1731 1815 -84.0 -4.6
Wirral 2359 2287 72.0 3.1
North West 52444 56021 -3576.8 -6.4

Table m. breaks down the success rate of
quitters and attempters of people using
the service by area within Bolton. A
quitter is a person who has quit, verified
by testing for carbon monoxide levels
and/or self-report. An attempter is a
person who has set a quit date.
For the 2008/09 financial year, 23% of all
successful quitters who came through
smoking cessation services in Bolton were
from the most deprived quintile. Quintiles
2, 3, and 4 are roughly equal to this, while
10% of all successful quitters were from
the least deprived quintile. However,
quintiles 3 and 4 are shown to have the
highest successful quit rate relative to
smoking population (20%). The success
rate is lower for the most deprived (17%)
and quintile 2 (16%).
At geographical level the areas with a
smoking prevalence greater than 30%
(highlighted) all have a relatively low quit
rate. With an average quit rate of 17.9
(per 1000 smoking population) for all
areas, the MSOAs of greatest smoking
prevalence, with the exception of Tonge
Moor & Hall i‟th‟ Wood, all fall below this.
Horwich Town has by far the highest rate
of successful quitters (46.6).

Table m.
Bolton MSOA: Smoking cessation quitters and attempters 1st April 2008 - 31st March 2009

Number Percentage
Set quit date Population Smoking Rate/1000 Rate/1000
Quitters of successful
(attempters) (age 18+) prevalence quitters attempters
smokers attempters

Egerton & Dunscar 8 14 5,733 13.3 765 10.5 18.3 57.1

Turton 14 24 5,972 12.8 767 18.3 31.3 58.3
Sharples 13 25 5,854 16.9 991 13.1 25.2 52.0
Horwich Town 49 65 5,484 19.2 1051 46.6 61.8 75.4
Sweetlove 19 34 5,900 23.4 1382 13.8 24.6 55.9
Harwood 21 24 6,674 14.7 980 21.4 24.5 87.5
Horwich Loco 33 44 5,690 21.2 1204 27.4 36.5 75.0
Smithills N&E 15 23 5,699 19.1 1087 13.8 21.2 65.2
Blackrod 13 20 4,366 20.0 875 14.9 22.9 65.0
Tonge Moor & Hall i'th' Wood 29 59 4,422 35.3 1561 18.6 37.8 49.2
Halliwell Rd 25 44 5,362 26.5 1421 17.6 31.0 56.8
Johnson Fold & Doffcocker 9 19 5,897 22.7 1337 6.7 14.2 47.4
Breightmet N & Withins 28 43 5,362 33.8 1812 15.5 23.7 65.1
Middlebrook & Brazley 25 47 4,396 19.4 855 29.3 55.0 53.2
Victory 23 36 5,873 26.5 1559 14.8 23.1 63.9
Town Centre 23 43 4,648 33.2 1545 14.9 27.8 53.5
Tonge Fold 36 50 6,744 29.7 2006 17.9 24.9 72.0
Heaton 12 32 5,511 19.7 1087 11.0 29.4 37.5
Leverhulme & Darcy Lever 37 56 6,864 22.9 1570 23.6 35.7 66.1
Lostock & Ladybridge 12 21 5,569 14.7 820 14.6 25.6 57.1
Lower Deane & The Willows 28 68 5,424 23.7 1283 21.8 53.0 41.2
Burnden 18 31 5,336 31.6 1689 10.7 18.4 58.1
Daubhill 16 30 5,308 19.8 1053 15.2 28.5 53.3
Little Lever 42 58 7,645 21.8 1670 25.1 34.7 72.4
Lever Edge 17 41 5,169 30.2 1562 10.9 26.2 41.5
Deane & Middle Hulton 22 41 4,717 25.5 1204 18.3 34.1 53.7
Moses Gate 18 22 4,228 28.9 1220 14.8 18.0 81.8
Westhoughton East 14 25 6,735 13.2 889 15.8 28.1 56.0
Townleys 21 32 5,398 23.7 1280 16.4 25.0 65.6
Over Hulton 13 20 4,644 17.0 791 16.4 25.3 65.0
Wingates & Washacre 38 53 6,054 29.3 1773 21.4 29.9 71.7
Central Farnworth 25 38 5,619 28.9 1622 15.4 23.4 65.8
Highfield & New Bury 27 38 5,441 33.4 1818 14.9 20.9 71.1
Central Kearsley 46 71 7,531 23.1 1741 26.4 40.8 64.8
Daisy Hill 18 26 5,520 18.1 1001 18.0 26.0 69.2

The first map below shows the rate per
smoking population of all referrals made to
the smoking cessation service by MSOA
regardless of success.
There is a high rate of referral per smoking
population in the areas of Lower Deane &
The Willows and Middlebrook & Brazley.
A slightly lower rate, but still reasonably
high, is seen in the areas of Deane &
Middle Hulton, Leverhulme & Darcy Lever,
Central Kearsley, Tonge Moor & Hall I‟th‟
Wood, and Turton. Horwich Town has the
highest rate of all referrals. However, with
the exception again of Tonge Moor & Hall
i‟th‟ Wood, none of the areas of greatest
smoking prevalence feature in the highest
rate of referrals per smoking population.
To an extent this translates onto the
second map of successful quitters per
1000 smoking population. The urban
areas around the Town Centre, where the
highest prevalence of smoking exists, are
shown to have a relatively low rate of
successful quitters compared to smoking
population.
There are differences in the method of
referral to smoking cessation services
over this period by deprivation quintile.
The greatest single referral method across
all quintiles is listed as „self‟; self-referral
accounted for over 900 referrals to the
service over this period. For referrals from
the most deprived quintile, 31% were self-
referred compared to 43% for the least
deprived and quintile 4. The second most
significant method of referral for the most
deprived quintile is via PAMU (Princess
Anne Maternity Unit). PAMU is
responsible for 19% of all referrals in the
most deprived quintile, but accounts for
just 6% of all referrals in the least deprived
quintile. Referrals from Royal Bolton
Hospital are consistent at between 9%
and 10% of all referrals across quintiles,
while referrals from GPs do fluctuate by
deprivation quintile, but not greatly,
accounting for between 8% and 13% of all
referrals depending on the quintile.
Interestingly, around 12% of all referrals in
quintiles 1,2, and 5 come via a pharmacy;
this figure drops between 5% and 6% for
quintiles 3 and 4. Youth services referred
2% of the all referrals in the most deprived
quintile, but accounts for none in the least
deprived. Finally, over the year period
discussed, advertising, notice boards, face
to face events, leaflets, and the Quit It
campaign accounted for a very minor
proportion of all referrals.
Beaumont Hospital Breathlessness Clinic
Research has long identified deprivation-
related inequities in effective procedures
for a variety of disease areas. This
section will compare the prevalence of
breathlessness with referrals made to the
Beaumont Hospital Breathlessness Clinic.
The data concerns referrals made by GPs
to the Clinic and so considers inequities a
level beyond that of visiting a GP.
Many patients present at their GP surgery
with breathlessness and would benefit
from rapid investigation and diagnosis. As
such conditions can rapidly deteriorate,
GPs often refer directly to hospital for an
emergency admission. Wherever possible
alternatives are to be sought to prevent
avoidable admission to hospital by
designing services which can provide both
the GP and the patient with the confidence
that the appropriate treatment is being
provided. The Breathlessness Clinic was
commissioned in 2007 to meet this need.
The service is specifically aimed at demographic makeup. For this reason we
patients presenting with mild to moderate would expect more referrals in this cluster.
breathlessness where there has not However, activity overall does not reflect
previously been a diagnosis and where the need of the whole population. The
admission to hospital would be considered following tables compare breathlessness
to remove diagnostic uncertainty; the from the Bolton Health and Lifestyle
service is not designed to meet the needs Survey 2007 to activity from the
of patients who are acutely breathless or Breathlessness Clinic.
breathless at rest or are in need of
immediate hospital admission. A question The Indigo cluster is shown to have the
from the Bolton Health and Lifestyle lowest percent of breathlessness of all the
Survey 2007 aims to identify respondents clusters and yet has the highest rate of
who are breathless when hurrying on level those in need referred to the Clinic. In
ground or walking up a slight hill. This contrast, the Red cluster has the highest
question has been used to compare need percent of breathlessness and the lowest
in Bolton with referrals at the Clinic. The rate of those in need referred to the Clinic.
following shows GP referrals to the
breathless clinic by GP cluster.
Table n. Need Need met
In total, for the period April 2008 to March Percent Number Crude rate Number
breathless breathless (per referred
2009, there were 241 referrals by GPs in 100,000)
Bolton to the Breathlessness Clinic. A
large proportion of referrals were made by Indigo 22 18746 570.8 107
GPs in the Indigo GP peer cluster. The Blue 25 13775 341.2 47
Indigo GP peer cluster is comprised of Green 31 16652 222.2 37
practices with predominantly an Yellow 32 12409 217.6 27
old/normal white population with low Orange 35 11208 160.6 18
deprivation. Red 39 7367 67.9 5

The Indigo cluster has the greatest

number of patients and the eldest
 Table o. Need Need met
Percent breathless Number breathless Crude rate (per Number referred
100,000)
White 26 60413 256.6 155
Asian Indian 35 5492 36.4 2
Asian Pakistani 40 2814 71.1 2
Black 22 753 0.0 0
Mixed/Asian Other/Other 20 1133 441.2 5

Not supplied 85

Ethnicity is less reliable as eighty five
referrals over the period did not supply
their ethnicity. From the survey the Asian
ethnic groups have the highest reported
breathlessness, while the mixed/Asian
other/other and the black groups have the
lowest. The mixed/Asian other/other
group has the highest rate of those in
need referred to the Clinic. In contrast,
the Asian ethnic groups have the lowest
rate of referral. This is shown in table o.
above.
Bearing in mind that the survey had a very
low response rate, the following are
examples of negative feedback from GPs
in Bolton concerning the Clinic:
are repeated which is not ideal for
the patient”.
It is possible referrals may also be
affected by the location of the Clinic,
situated as it is away from the Town
Centre and the areas of greatest
deprivation and surrounded by practices
from the Indigo cluster. This is shown
below.
From the survey conducted, the reasons
are unclear, but what is certain is that
clear differences persist linked to
deprivation for referrals to the
Breathlessness Clinic.

“No feedback and poor

assessment of the only two people
I have referred there”;

“Formal letters not sent soon

enough such that changes
recommended cannot be
implemented when patient visits
GP”;

“Patients always come back with a

mixed diagnosis and multiple
therapy. Unclear how opinion has
been reached”;

“Sometimes results/outcomes not

as quick as ideal. Initial letter or
plan would be useful as patients
often come back to us before all
results available”;

“When patients come back to the

practice, please could we have any
test results, i.e. spirometry
values/echo results. If we have to
refer to secondary care all tests
Smoke Free Homes
Smoke Free Homes in Bolton is an
initiative to reduce the number of homes in
the borough where smoking occurs
indoors. As previously discussed, living in
a house where smoking occurs increases
the risk of lung cancer by almost a quarter.
This is especially important for children,
both to reduce the risk of lung cancer in
later life and to lessen the risk of
becoming adult smokers.
From the Bolton Schools Survey 2005
(Secondary School Information), 51% of
Year 8 and 10 pupils reported that at least
one person regularly smokes at home.
This age group is central to this topic as it
is the one that has yet to show the decline
evident in the all-age smoking prevalence.
The specific objectives of Smoke Free
Homes in Bolton are:
To increase awareness of the
dangers of second hand smoke
and its impact on children‟s health;
To reduce exposure to second
hand smoke – especially amongst
pregnant women, babies, and
children;
To increase dissatisfaction with
smoking behaviour;
To increase the number of people
setting quit dates;
To encourage people to have
smoking restrictions in their home;
To obtain Promises for smoking
Table p. Households signed up to
NRS Smoke Free Homes
restrictions in the home;
To increase awareness of the local
NHS Stop Smoking Services.
These objectives are underlined by the
principles of negotiated goal setting,
contract signing, and positive messages
about the immediate benefits of smoking
restrictions in the home.
In line with Bolton‟s Community Strategy
public health interventions are now
routinely monitored on a quarterly basis.
At time of writing latest data is for quarters
1. and 2. of 2009/10. The performance
measure for Smoke Free Homes is the
number of „smoking‟ households with
children under 17 years of age signed up
to Smoke Free Homes by postcode. At
the end of 2008/09 there were 141
households in total signed up to Smoke
Free Homes, with 42 (30%) of these
including a smoker and child under the
age of 16.
By the end of quarter 2. 2009/10 there are
144 households signed up (table p.), with
53 (37%) of these including a smoker and
child under the age of 16. As discussed
previously, NRS areas have a far higher
smoking prevalence than the general
population of Bolton, and as the most
deprived areas in the borough are also at
greater risk of lung cancer (because of its
association with socioeconomic factors).
For this reason, and in order to combat
health inequalities around these measures
in Bolton, particular emphasis is given in
the Community Strategy to uptake within
NRS areas. In total, 75 (52%) households
in NRS areas have signed up to the
initiative:

Illegal tobacco
Breightmet 6
Crompton 6
Farnworth 0 As tax increases make smoking ever more
Great Lever 30 difficult for those in the more deprived
Halliwell X
Hall ith Wood X
areas of the borough, illegal tobacco is
Hulton Lane X becoming an increasingly important
Johnson Fold X problem.
Rumworth 16
Tonge w t Haulgh 5
Washacre X Price is known to be one of the most
Not NRS or no postcode 69 successful methods of reducing smoking
Total 144 prevalence. The UK tax on cigarettes,
cigars, hand rolled tobacco, and other
tobacco products is the highest in the
European Union. Against this, illegal and
counterfeit cigarettes are cheaper and so
encourage the continuation of smoking in
spite of tax penalties. This is an especially
important issue for deprived communities,
as well as children and young people.
There are three specific types of illegal
tobacco41:
Smuggling: Involves the illegal
transportation, distribution, and
sale of tobacco. This happens
when legitimately produced
tobacco products are diverted to
evade tax (usually in the wholesale
distribution chain). This makes the
products cheaper to the consumer;
Bootlegging: Products are
purchased in a country with low
taxation and illegally brought into
countries with high taxation;
Counterfeiting: The illegal
manufacture and distribution of
tobacco products to avoid tax.
Both counterfeiting and smuggling
are typically part of large scale
organised crime.
Due to the high smoking prevalence and
low income, the North West of England is
an area of great demand for illegal
tobacco. The North of England Tackling
Tobacco for Better Health Plan suggests
six aspects that must be vital to regional
and local work:
1. Development of the role of health
workers through education;
2. Intelligence sharing between
relevant organisations;
3. Mapping informal markets where
products are traded;
4. Marketing and communication to
target key groups and
development of partnerships;
41
SmokeFree North West (2010)
www.smokefreenorthwest.org/
5. Working with businesses to assist
and educate routine and manual
employers;
6. Education of the tobacco retail
sector and pub and club watchers
about illicit tobacco and impact
upon their businesses.
In addition to the above, Tobacco and
Borders: Life Made Cheaper,
recommendations include better
information systems to provide high quality
data on illegal tobacco.
Bolton‟s Community Strategy monitoring
of interventions throughout the borough
now includes an indicator for illegal
tobacco. The intervention concerns
research to understand prevalence of illicit
sales of tobacco in NRS areas. Work
began in the first quarter of 2009/10 to
organise the collection of cigarette packets
in Farnworth and having them analysed to
ascertain the level of the illicit tobacco
problem in Bolton. At last report, 150
packets had been collected and progress
towards implementation is continuing.
Healthy Schools
Healthy Schools is a long-term initiative
aimed at promoting the link between good
health, behaviour, and achievement. The
programme is constructed around four
themes: Healthy Eating, Physical Activity,
Emotional Health and Wellbeing, and
Personal, Social, and Health Education
(PHSE) (including Sex and Relationship
Education and Drug Education). Smoking
cessation is included in PHSE and comes
under Drug Education, which includes
tobacco, alcohol, and volatile substance
abuse. From the Bolton Schools Survey
2005 (Secondary School Information),
42% of Year 8 and 10 pupils reported
trying smoking in the past, while 13% say
they smoke regularly or occasionally.
Furthermore, 75% of this group said that
they would like to quit.
Table q.
Total number of
School type
schools
Nursery (Local authority)
Primary 39 schools FSME
(20%)
Secondary
Special
PRU (Long-term)
The Healthy Schools programme in Bolton
has developed from 6 schools interested
in January 2002 to 123 schools
participating in January 2010. In the past
ten years there has been a great deal of
legislation supporting and recognising the
importance of Healthy Schools (Every
Child Matters, etc.).
The Department for Education and Skills‟
Five Year Strategy for Children and
Learners (2004) stated that every school
should be a healthy school. Furthermore,
Choosing Health: Making Healthy Choices
Easier (2004) included the targets that
50% of all schools should be Healthy
Schools by 2006 and the remainder
working towards this by 2009. In Bolton,
55% of all schools had achieved Healthy
Schools Status by 2007, 65% by 2008,
and 75% by 2009. At present 83% of
Bolton schools have achieved National
Healthy School Status, with over 98% of
Bolton schools participating in the
programme.
In Bolton, primary schools are the only
type of school covered by the programme
that are yet to show full subscription (table
q.).
The Enhanced Healthy Schools model is a
recent development and aims to translate
the Government‟s vision of the 21st
century school (outlined in the Children‟s
Plan ) into practice. This enhanced model
is aimed at schools who have achieved
standard Healthy Schools Status. The
enhanced model is outcome based, which
as well as involving a range school-based
local and national priorities, will also
Number involved Percentage involved
4
4 100%
102;
92 90%
16;
16 7 schools FSME (20%) 100%
5 5 100%
3 3 100%
provide universal and targeted health
interventions. The enhanced model builds
on the 41 criteria governing Healthy
Schools Status and begins with an annual
review to check Healthy Schools continue
to meet the standard criteria. This is to be
followed by a detailed eight-stage process
to further improve the health of schools.
The national expectation is that 10% of all
schools will have reached Stage 4. Part 2.
(needs analysis, identification of priorities,
meaningful outcomes developed, early
success indicators developed, and signed
off by the QUAG (Quality Assurance
Group), by March 2010, and that all
schools will be Enhanced Health Schools
by 2020.
Radon
Radon is categorized as a Class 1
carcinogen and is the second largest
cause of lung cancer in the UK,
responsible for up to 2,000 fatal cancers
each year42. Radon is a naturally
occurring gas, exposure to which
increases the risk of an individual
developing lung cancer. Radon-222 is the
most important isotope in the context of
this needs assessment and comes from
naturally occurring uranium in rocks and
soils. When inhaled, alpha particles and
other decay products can irradiate
sensitive lung cells, increasing the risk of
lung cancer. This risk is increased further,
to almost twenty-five times, for smokers.
Nationally, the highest concentrations of
radon are found in the granite rich south
west peninsula of England, and around
42
Health and Safety Executive (2010) www.hse.gov.uk
the Derbyshire limestone areas. As the
below map illustrates we cannot expect
Bolton to have a high proportion of homes
at or above the radon Action Level (the
point at which the Health Protection
Agency recommends homeowners take
action to reduce the indoor concentration
of radon in their homes).
This map is only an indication of where
naturally occurring radon is likely to be
concentrated. However, levels vary by
each house depending on specific
circumstances; for instance, radon can
originate from building materials, the water
supply, and is reduced by good ventilation
of lower floors and basements.
(Source: Health Protection Agency, www.hpa.org.uk)
Other pollutants/carcinogens In addition to air pollution occupational
exposure to asbestos causes both lung
Air pollution cancer and mesothelioma. Those who
smoke who are also exposed to asbestos
Lung cancer is more prevalent in urban have an extremely high risk of lung
areas compared to rural areas; this is cancer.
primarily due to higher smoking
prevalence, socioeconomic factors, and Asbestos is a generic name for a
occupational hazards. However, there is collection of materials that crystallise into
evidence to suggest that local industrial air thin fibres and bundles. The most
pollution is an independent risk factor for common types of asbestos are white
lung cancer43, but the attributable risk can asbestos (chrysotile), blue asbestos
be expected to be very small. Within air (crocidolite), and brown asbestos
pollution, lung cancer is particularly (amosite). Asbestos is only harmful to
associated with diesel exhaust and health when the fibres become airborne
industrial carcinogens. and are inhaled. Asbestos was previously
mined, but today the greatest risk is posed
The following percentages of views are by asbestos installed in older buildings.
taken from the AGMA Place Survey 2009. For this reason those at greatest risk
The Area Forums of Great Lever, Two today are those working in the
Towns, Rumworth, and Hulton expressed construction, building, and maintenance
the greatest concern for the pollution industries.
levels of their area:
There is a problem with establishing
Table r. prevalence as lung cancer caused by
Bolton area forum: The levels of pollution need improving
44 asbestos is indistinguishable from lung
in my local area
cancer caused by tobacco smoke and
other means. The Health and Safety
Breightmet 8% Executive estimate that around 4,000
Crompton 6% cancer deaths each year in the UK are
Farnworth 9% related to asbestos exposure. Almost half
Great Lever 26% of these can be expected to be asbestos-
Hall'ith' Wood 6% related lung cancers. However, this
Halliwell 9% estimate is very uncertain.
Hulton Lane 9%
Johnson Fold 13% Other
Rumworth 16%
Tonge with the Haulgh 16% Workers with nickel and chromium are at
Washacre 6% higher risk of developing lung cancer as
are those suffering heavy exposure to
non-ferrous metals, nitrogen oxides, silica,
and polycyclic aromatic hydrocarbons45 46.
From the AGMA Place Survey 2009, of
respondents from the white ethnic group Previous cancer treatment
only 10% said the levels of pollution in
their area need improving, compared with If a patient has previously been treated for
nearly double this figure at 18% for BME Hodgkin‟s lymphoma then lung cancer risk
respondents. can be expected to be increased by
between 2.6-7 fold. Furthermore, studies
Asbestos have shown an increased risk of lung

43 45
Stevens, A. et al (2004) Health Care Needs Stevens, A. et al (2004) Health Care Needs
Assessments, Radcliffe Publishing Ltd., Oxford. Assessments, Radcliffe Publishing Ltd., Oxford.
44 46
AGMA (2009) AGMA Place Survey: Bolton, AGMA, Cancer Research UK (2009) CancerStats: Lung cancer
Manchester. and smoking November, Cancer Research UK, London.
cancer following treatment for non-
Hodgkin‟s lymphoma, as well as testicular
cancer, which is linked to radiation to the
chest from previous treatments47 48 49.
In addition, a family history of lung cancer
in a first-degree relative is associated with
a 2-fold increased risk, independent of
smoking50. The association between
family history and lung cancer risk may be
stronger in Black ethnic groups compared
to White51.
Lifestyle factors other than smoking
studies demonstrating this association it
comes with the caveat that further
research is needed in order to clarify the
relationship between physical activity and
risk of lung cancer55.
Common sense and wider epidemiology
imply that this lower risk may be due to the
fact that smokers are less likely to
undertake physical activity. This need not
be a negative association as encouraging
people to undertake more physical activity
may also impact upon smoking
prevalence.

Beyond smoking, there are other Bolton is below the North West average
modifiable lifestyle risk factors that may for physically active adults. This is shown
protect against lung cancer. on the below chart. (Data is for the period
2005/06).
Physical activity
From the Bolton Health and Lifestyle
A meta-analysis52 conducted in 2005 Survey 2007 we know that the central and
found that people undertaking higher more deprived parts of Bolton show the
levels of physical activity compared to the highest proportions of physical
general population have a decreased risk inactivity/sedentary lifestyle. However,
of developing lung cancer. Other studies only Burnden and Lever Edge are
have demonstrated that women who are significantly higher than the average for
current or ex-smokers and take part in a the borough as a whole. These are areas
high level of physical activity have a with higher than average levels of BME
reduced risk of lung cancer53 54. Whilst population. Areas with the highest
Cancer Research UK highlights other proportions of recommended levels of
physical activity include Turton, Johnson
47 Fold & Doffcocker and Central Kearsley.
Lorigan, P. et al (2005) „Lung cancer after treatment for
Hodgkin's lymphoma: a systematic review‟, The Lancet
Oncology, 6(10):773-9. For the 2007 survey, we changed the
48
Mudie, N. et al (2006) „Risk of second malignancy after question on levels of physical activity from
non-Hodgkin's lymphoma: a British Cohort Study‟, Journal
of Clinical Oncology, 24(10):1568-74.
that used in 2001, so comparison to the
49
Travis, L. et al (2005) „Second cancers among 40,576 previous survey is not possible.
testicular cancer patients: focus on long-term survivors‟,
Journal of the National Cancer Institute, 97(18):1354-65.
50
Nitadori, J. et al (2006) „Association between lung
cancer incidence and family history of lung cancer: data
from a large-scale population-based cohort study, the
JPHC study‟, Chest, 130(4):968-75.
51
Cote, M. et al (2005) „Risk of lung cancer among white
and black relatives of individuals with early-onset lung
cancer‟, Journal of the American Medical Association,
293(24):3036-42.
52
Tardon, A. et al (2005) „Leisure-time physical activity
and lung cancer: a meta-analysis‟, Cancer Causes and
Control, 16(4):389-97.
53
Sinner, P. et al (2006) „The association of physical
activity with lung cancer incidence in a cohort of older
women: the Iowa Women's Health Study‟, Cancer
Epidemiology Biomarkers and Prevention, 15(12):2359-
63.
54
Alfano, C. et al (2004) „Physical activity in relation to all-
site and lung cancer incidence and mortality in current and 55
former smokers‟, Cancer Epidemiology Biomarkers and Cancer Research UK (2010)
Prevention, 13(12):2233-41. www.cancerresearchuk.org
Diet
Evidence is mixed concerning the
potential association between dietary
habits and lung cancer risk56. However,
some studies do show that a diet rich in
vegetables is associated with a reduced
risk of lung cancer57 58 59, but others show
this may only apply to smokers60 61.
56
Liu, Y. et al (2004) „Vegetables, fruit consumption and
risk of lung cancer among middle-aged Japanese men
and women: JPHC study‟, Cancer Causes and Control,
15(4):349-57.
57
Galeone, C. et al (2007) „Dietary intake of fruit and
vegetable and lung cancer risk: a case-control study in
Harbin, northeast China‟, Annals of Oncology, 18(2):388-
92.
58
Rylander, R. and G. Axelsson (2006) „Lung cancer risks
in relation to vegetable and fruit consumption and
smoking‟, International Journal of Cancer, 118(3):739-43.
59
Balder, H., Goldbohm, R. and P. van den Brandt (2005)
„Dietary patterns associated with male lung cancer risk in
the Netherlands cohort study‟, Cancer Epidemiology
Biomarkers and Prevention, 14(2):483-90.
60
Holick, C. et al (2002) „Dietary carotenoids, serum beta-
carotene, and retinol and risk of lung cancer in the alpha-
tocopherol, beta-carotene cohort study‟, American Journal
of Epidemiology, 156(6):536-47.
61
Linseisen, J. et al (2007) „Fruit and vegetable
consumption and lung cancer risk: Updated information
from the European Prospective Investigation into Cancer
and Nutrition (EPIC)‟, International Journal of Cancer,
121:1103-1114.
The below chart shows Bolton to be below
the average for the North West for healthy
eating adults, with peaks often being in the
Cumbrian region of the North West. (Data
is for the period 2003/05).
The Bolton Health and Lifestyle Survey
2007 asked people how many portions of
fruit and/or vegetables they eat a day.
Since 2001, the proportion of people
eating five or more portions has risen
significantly from 11.6% to 18.9% of the
adult population of Bolton. This still leaves
Bolton some way behind the national
figure62 of 30%.
The areas in Bolton with the greatest
prevalence of those eating no fruit and
vegetables are the areas of high
deprivation, particularly the Town Centre,
Tonge Moor & Hall i‟th‟ Wood, and
Breightmet and Withins. In contrast, less
deprived areas such as Egerton &
Dunscar, Townleys, and Blackrod have
extremely low levels of no fruit and
vegetable consumption.
62
Department of Health (2006) Health Survey for
England, DoH, London.
No strong relation has been found
between alcohol intake and risk of lung
cancer. The strong association between
alcohol intake and smoking is too
significant a confounding factor for any link
to be established63 64
.

63
Freudenheim, J. et al (2005) „Alcohol consumption and
risk of lung cancer: a pooled analysis of cohort studies‟,
American Journal of Clinical Nutrition, 82(3):657-67.
64
Rohrmann, S. et al (2006) „Ethanol intake and risk of
lung cancer in the European Prospective Investigation into
Cancer and Nutrition (EPIC)‟, American Journal of
Epidemiology, 164(11):1103-14.
 cancer. It should be borne in mind that
Curative this does not represent the number of
patients in Bolton as all trusts receive
patients from other PCTs due to the
In general there are four modalities of specialist nature of cancer treatments.
treatment for lung cancer: However, it does provide an idea of the
type of treatments to which referrals are
Surgery; made in Bolton and surrounding areas
Radiotherapy; compared to England and Wales.
Chemotherapy;
The main acute trusts/hospitals for Bolton
Palliative care. lung cancer patients are Royal Bolton
Hospitals (RMC), The Christie (RBV),
In recent years more than one modality Manchester Royal Infirmary which comes
has often been used to treat an individual under Central Manchester University
patient. For example, surgery followed by Hospitals (RW3), and Wythenshawe
chemotherapy, chemotherapy followed by Hospital which comes under South
radiotherapy, or simultaneous Manchester University Hospitals (RM2).
radiotherapy and palliative care. In addition, Bolton is part of the Greater
Treatment options should be discussed Manchester and Cheshire Cancer Network
with the patient where possible to allow an (N02). In table s. South Manchester has
informed decision to be made65. only recorded 23% of its expected cases
in the audit and so this data is not
Treatments are specific to whether the representative. The Christie does not
cancer is non-small cell or small-cell. For participate fully in the audit as it is a
this reason accurate histological diagnosis tertiary trust.
is critical.

The following details number of cases

recorded for the primary acute trusts for
Bolton PCT regarding treatment of lung
Table s.
National Lung Cancer Audit 2009

Number of Any active Surgery Radiotherapy Small cell cases

cases treatment (%) (%) receiving chemotherapy
(%)

England and Wales 27815 54 10.8 25.3 62.3

RMC 194 49 13.9 33 44.4

RBV 0 0 0 0 0
Main trust sites for
Bolton patients
RM2* 75 81 45.3 21.3 100

RW3 113 53 11.5 34.5 47.6

N02 1597 39 12.9 21.5 43.6

65
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
The Cancer Commissioning Toolkit groups
types of cancers into groups for
presentation purposes. Thoracic cancer
includes lung, tracheal, oesophageal,
mesothelioma, thymomas, chest wall
tumours, and other mediastinal tumours;
the most common of these are lung,
oesophageal, and mesothelioma.
The below chart is based on Health
Episodes Statistics (HES) data and shows
the activity for patients of Bolton PCT
admitted through all methods (all classes
of patient) recorded as cancer type thorax.
National episodes for the thorax cancer
type show a steady and consistent
increase since 1997/98. Trends in this
indicator reflect the influence of changing
cancer incidence, early detection, and
changes to the provision or uptake of
services. There will also be an upward
trend where new and additional forms of
treatment become available. The Bolton
trend is more erratic because of the lower
numbers involved, but since 2003/04 has
roughly followed the pattern of the national
trend. As standardisation of cancer
treatment, care, and outcome is a frequent
message of the lung cancer audit, the
closer Bolton mirrors the national trend the
better we can expect services to be,
especially given that the North West is an
area historically showing wide variation
from the national picture as well as wide
variation within its own borders.
The second chart shows PCTs‟
benchmarked activity by cancer type;
here, thorax. The activity is in FCEs per
100,000 population. The line represents
the activity of all PCTs in England with
Bolton and its statistical peers highlighted.
Compared to its peers Bolton has the
fourth lowest activity for thoracic cancer. If
a PCT has a particularly high incidence of
a cancer type per head of population
compared to England, it would be
expected to have a higher activity, and
vice versa. If a PCT has a low incidence
per 100,000 population of a particular
cancer type but has a high activity, then
this suggests that patient selection and
management should be reviewed. Table t.
allows us to compare incidence previously
given in this assessment (2004/06 is the
latest available incidence figure) with
activity for England, Bolton, and its
statistical peers. Table t. is ranked by
incidence, with all PCTs except Dudley
showing a higher incidence than England;
for this reason England is not an
appropriate comparator. Compared to the
group as a whole, Walsall is perhaps an and around average within the group for
example of a PCT with a relatively low both; thus, this indicator does not reveal
incidence and high activity. Bolton is any serious problems with patient
higher than England for both indicators, selection and management in Bolton.

Table t. Incidence Activity

2004/06 2007/08

Salford 81.28 380.22

Heywood, Middleton, & Rochdale 65.81 239.19

Tameside & Glossop 59.51 309.14

Rotherham 59.34 422.85

Bury 58.89 290.86

Wakefield 58.26 446.51

Ashton, Leigh, & Wigan 57.97 318.17

Oldham 57.12 273.25

Bradford & Airedale 56.74 264.24

Sandwell 56.59 337.32

Halton & St. Helens 55.80 226.52

Bolton 55.71 262.53

Walsall 50.83 384.23

Coventry 50.40 291.22

Kirklees 48.48 245.86

England 45.89 306.34

Dudley 39.33 296.15

The following tables (u. and v.) provide a context by showing what percentage
high level picture of bed use in the Greater share of an organisations‟ bed days are
Manchester and Cheshire Cancer Network utilised for cancer management. The
and Bolton Hospitals Trust for 2007/08. Cancer Commissioning Toolkit found that
By cancer type, the tables show how typically, general medicine is managing
many beds are occupied by a patient with more patients with cancer than are clinical
a cancer diagnosis in a year. It also oncology, medical oncology, or
places the total cancer bed usage into haematology.
Table u.
Greater Manchester and Cheshire Network: 2007/08

Non Elective
Elective Cancer Total Cancer % Share of Cancer % Share of all Bed
Cancer type Cancer Bed
Bed Days Bed Days Bed Days Days
Days
Breast 12394 8182 20576 6.13 0.73
Endocrine System 1692 485 2177 0.65 0.08
Gynaecology 8764 7107 15871 4.73 0.56
Haematology 20670 28946 49616 14.78 1.75
Head & Neck 7552 3923 11475 3.42 0.4
Lower GI 22638 20892 43530 12.96 1.54
Metastases 7662 15279 22941 6.83 0.81
Multiple ICD10 Codes 1785 5816 7601 2.26 0.27
Musculoskeletal 3285 2064 5349 1.59 0.19
Neurology 7035 8513 15548 4.63 0.55
Other Cancer 3109 13775 16884 5.03 0.6
Skin 2280 1354 3634 1.08 0.13
Thorax 9585 31041 40626 12.1 1.43
Upper GI 11688 25430 37118 11.05 1.31
Urology 19042 23672 42714 12.72 1.51

Tablevu.
Bolton Hospitals Trust: 2007/08

Non Elective
Elective Cancer Total Cancer % Share of Cancer % Share of all Bed
Cancer type Cancer Bed
Bed Days Bed Days Bed Days Days
Days
Breast 1066 618 1684 9.77 0.77
Endocrine System 211 100 311 1.8 0.14
Gynaecology 113 411 524 3.04 0.24
Haematology 259 1472 1731 10.05 0.79
Head & Neck 38 278 316 1.83 0.14
Lower GI 1216 1625 2841 16.49 1.3
Metastases 76 883 959 5.57 0.44
Multiple ICD10 Codes 167 523 690 4 0.32
Musculoskeletal 26 38 64 0.37 0.03
Neurology 14 368 382 2.22 0.18
Other Cancer 228 1152 1380 8.01 0.63
Skin 32 61 93 0.54 0.04
Thorax 197 2131 2328 13.51 1.07
Upper GI 425 1476 1901 11.03 0.87
Urology 814 1207 2021 11.73 0.93
In the Greater Manchester and Cheshire
Cancer Network as a whole thoracic
cancers account for 1.43% of all bed days;
12.1% of all cancer bed days. For Bolton
Hospitals Trust the share of all bed days
falls to 1.07%, whilst share of all cancer
bed days increases to 13.51%. Thus,
within the cancer types themselves,
thoracic cancer has the fourth highest
share of all beds days and all cancer bed
days in the Network as a whole, but the
second highest share in Bolton Hospitals
Trust (behind lower GI) for all bed days
and all cancer bed days.
An important factor evident from these
tables is the proportion of all thoracic bed
days that are non-elective. In the Greater
Manchester and Cheshire Cancer Network
76.4% of the total bed days for thoracic
cancer are non-elective. In contrast, for
Bolton Hospitals Trust this figure is 91.5%.
Reasons for this may be that people in
Bolton suffering with cancers in the
thoracic group are less likely than the
Network as a whole to be referred by
appropriate pathways and so must present
as a non-elective admission, or that
comparatively, people stay in Bolton
Hospitals Trust for longer with thoracic
cancers than do those in the Network as a
whole.
Through analysis of excess bed days,
table w. shows the potential savings that a
PCT could make if its providers of services
were treating all patients within the
maximum expected bed days set by the
HRG trim point. Calculations show that in
2007/08 Bolton PCT had 56 excess
elective bed days and 132 excess non-
elective bed days for thoracic cancers,
totalling 188 excess bed days. In Bolton
PCT this accounts for a 5.74% share of
excess costs.

Table w.
Bolton PCT: 2007/08

Cancer type Actual Bed Elective Excess Non Elective Total Excess Total Excess % Share of
Days Bed Days Excess Bed Days Bed Days Costs Excess Costs
Breast 1677 11 171 182 36003 4.84
Endocrine System 351 172 18 190 49718 6.69
Gynaecology 1176 55 37 92 23521 3.16
Haematology 3251 300 309 609 183735 24.71
Head & Neck 860 50 89 139 35202 4.73
Lower GI 2676 57 159 216 48952 6.58
Metastases 1252 73 59 132 26333 3.54
Multiple ICD10 Codes 523 6 57 63 13205 1.78
Musculoskeletal 444 15 55 70 25476 3.43
Neurology 802 62 50 112 28232 3.8
Other Cancer 1392 23 578 601 135954 18.29
Skin 179 22 0 22 5808 0.78
Thorax 3026 56 132 188 42705 5.74
Upper GI 2538 69 128 197 47091 6.33
Urology 2139 73 106 179 41536 5.59
Lung cancer care pathway
The care pathway for people with
suspected lung cancer can begin from any
number of referral routes; this is because
the symptoms of lung cancer and
mesothelioma are relatively non-specific
(more detail below). Nationally, of those
diagnosed with lung cancer no more than
half are directly referred from primary care
to the lung cancer specialist team.
Furthermore, there are frequent delays in
diagnosis. Patients may not recognise
their symptoms as predictive of lung
cancer, especially as a persistent cough is
not normally associated with a serious
illness. A delay furthered as the majority
of symptoms are often normal for a
smoker. For such reasons GPs may not
immediately suspect lung cancer and so
referral may be delayed for further
investigation.
Rapid referral guidelines are available:
NICE Referral Guidelines for Suspected
Cancer 2004.
Management of lung cancer patients is
almost exclusively carried out by specialist
multi-disciplinary teams (MDTs). Both
lung cancer and mesothelioma are
managed by the same specialist clinical
groups.
Establishing a tissue diagnosis is difficult,
often demanding an invasive procedure
(more detail below). The result of this is
that there will always remain a proportion
of patients for whom diagnosis must be
established by clinical or radiographical
means. In addition, there are a proportion
of patients whose illness and/or
comorbidities are too severe to be referred
to secondary care. The specialist nature
of the procedures required to diagnose
and treat lung cancer, mainly surgery,
radiotherapy, and chemotherapy, mean
that patients are frequently managed by a
number of trusts. In Bolton the chief of
these are the Royal Bolton Hospital
(predominantly palliative care), Central
Manchester University Hospitals NHS
Trust (predominantly surgery), South
Manchester University Hospitals NHS
Trust (predominantly chemotherapy), and
Christies Hospital NHS Trust
(predominantly radiotherapy with some
Bolton patients sent for chemotherapy
also).
The diagram below details the lung cancer
care pathway for Bolton patients. The
blue section is the standard pathway and
maximum times set in days for the Greater
Manchester and Cheshire Cancer Network
of which Bolton is a part. (Pathway data
given below is for the 2007 audit period
which was reported in 2009).
Nationally, almost half (47%) of lung
cancer cases are referred to a lung cancer
specialist from a primary care physician.
The remainder are predominantly referred
following an emergency presentation or
from other secondary care specialists. For
Royal Bolton Hospitals Trust this is 39%,
only slightly less than the Greater
Manchester and Cheshire Cancer Network
as a whole (40%). This may be seen as a
gap at primary care that may be improved
upon. We know Bolton has a higher
incidence and mortality rate than England
and Wales from lung cancer (see relevant
previous sections), therefore we would
expect more people to present at primary
care with suspected lung cancer.
However, a higher proportion of people in
Bolton compared to England and Wales
have to wait until they suffer an
emergency admission or enter secondary
care for another illness. It is not clear
whether this is a problem with referral
strategies at primary care in Bolton or
knowledge of symptoms and lack of
presentation in the Bolton population. As
a relatively more deprived population
however, we can expect a lower
proportion of people to present at primary
care in general than is seen nationally, as
socioeconomic deprivation and lack of
presentation are associated to a certain
extent.
Nationally, the median wait date between
referral and date seen (first specialist
appointment) is 6 days (interquartile range
0-11 days). For Royal Bolton Hospitals
Trust this is 2 days (interquartile range 0-
7) and is lower than that for the Greater
Manchester and Cheshire Cancer Network
as a whole (5 days). The interquartile
ranges of these figures cross and so it is
difficult to make any significant
comparative conclusions.
The same is true for wait times between
date first seen and initial treatment.
Nationally, the median wait between date
first seen and initial treatment is 29 days.
This is longer for GP referrals (median 35
days) than for non-GP referrals (median
23 days)66. For Royal Bolton Hospitals
66
The pathway times given in the National Lung Cancer
Audit differ from The Department of Health‟s „Cancer
Waiting Times‟ targets discussed previously in this
assessment.
Trust this is 31 days (28 days for GP
referral), which is lower than the Greater
Manchester and Cheshire Cancer Network
as a whole at 34 days (33 days for GP
referral). The lower figure for Bolton for all
referrals compared to GP referrals differs
from the national trend. The GP referral
route has a longer pathway, but the
unexpected figure may be influenced to an
extent by the lower proportion of all
suspected lung cancer referrals made by
GPs in Bolton compared to England and
Wales.
Diagnosis
As mentioned. diagnosis by a GP is
difficult as many symptoms of lung cancer
are also symptoms of less severe
respiratory diseases and ailments. From
case studies, Beckles et al (2003)
identifies the following symptoms of lung
cancer and their frequency:
Table x. Range of frequency
Symptoms (%)

An important point to notice is that South Cough 8 - 75

Weight loss 0 - 68
Manchester University Hospitals NHS Dyspnoea 3 - 60
Trust has a median waiting time between Chest pain 20 - 49
date first seen and initial treatment of 43.5 Haemoptysis 6 - 35
Bone pain 6 - 25
days. Bolton patients are referred here to
Clubbing 0 - 20
receive chemotherapy. Whilst we cannot Fever 0 - 20
read too much into this as this figure is Weakness 0 - 10
based on referrals from its local population Superior Vena Cava Obstruction 0-4
(SVCO)
as well as referrals from elsewhere, it Dysphagia 0-2
does take a noticeably longer time to Wheezing and stridor 0-2
complete its pathway and so delays may
be encountered here for Bolton patients.
The Central Manchester University In addition, as the average age of
Hospitals NHS Trust, to which Bolton diagnosis is over 70 years, and because
patients are referred for surgery, has a of the association with smoking, lung
comparative pathway time of 24 days. cancer patients have a high incidence of
(No reliable figure can be made for co-morbidities. The most prevalent are
Christies Hospital NHS Trust). Chronic Obstructive Pulmonary Disease
(COPD) and Cardiovascular Disease
Palliative care, not included on the above (CVD). The result is that a large
pathway diagram, will be discussed proportion of patients are unsuitable for
separately later in this section. radical treatment techniques even though
at diagnosis the cancer may be at an
Full care pathways are given in the operable, and ultimately curable, stage.
appendices of this assessment.
The overall fitness of a lung cancer patient
is measured using a scale named the
performance status. The performance
status scales in table y. are taken from
NICE Lung cancer.
Table y.
Performance status scales

WHO (Zubrod) scale Karnofsky scale

0 Asymptomatic 100 Asymptomatic

1 Symptomatic, but ambulatory (able to carry out light 90 Normal activity, minor symptoms
work)

80 Normal activity, some symptoms

2 In bed <50% of day (unable to work but able to live 70 Unable to work, cares for self
at home with some assistance)

60 Occasional assistance with needs

3 In bed >50% of day (unable to care for self) 50 Considerable assistance

40 Disabled, full assistance needed

4 Bedridden 30 Needs some active supportive care

20 Very sick, hospitalisation needed

10 Moribund
0 Dead
Treatment options are contingent upon the
performance status of the patient and
stage at diagnosis. The treatment matrix
pictured above is taken from NICE Lung
Cancer. The diagram is meant only as a
summary of the recommendations made
in the guidance and should be read in
conjunction with the more detailed findings
in the full document. However, for the
present purpose it serves to illustrates
how possible treatments vary according to
stage of lung cancer and performance
status of the patient.

Table z. shows the number of patients

diagnosed at Stage III and IV who go on to
have chemotherapy treatment. The
figures for local trusts cannot be
considered representative and so any
comparison is limited to England and
Wales and the Greater Manchester and
Cheshire Cancer Network (N02).
According to the NICE guidelines, at
Stage IIIa chemotherapy is suitable for
some patients, at Stage IIIb should be the
first choice for eligible patients, and at
Stage IV PS0-1 should also be the first
choice for eligible patients. In England
and Wales chemotherapy is given to those
with Stage III or IV lung cancer who have
a performance status of 0-1 in nearly half
of all cases. For the Greater Manchester
and Cheshire Cancer Network this figure
falls to just over a quarter of all cases.

Therefore, the combination of the non-

specific symptoms, coupled with frequent
low performance status of patients, often
means there is a delay in diagnosis or that
the stage of the cancer at which diagnosis
is made is too advanced for curative
treatment67.

67
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
 Table z.
National Lung Cancer Audit 2009

Number of PS0-1 PS0-1 Stage 3 or 4

NSCLC Stage 3b or having chemotherapy
4 (%)

England and Wales

3,985 47.9

RMC
7 0

RBV
x x
Main trust sites for Bolton patients
RM2*
x x

RW3
8 37.5

N02
202 26.2

The medical diagnosis of lung cancer is the cancer, especially regarding

typically divided between imaging malignancy and morphological features.
practices and efforts at tissue
confirmation. There are several methods Positron Emission Tomography: Unlike X-
currently employed within each area. The Ray‟s and CT scans, Positron Emission
chief of these will be briefly outlined below Tomography can collect functional
(taken from The Diagnosis and Treatment information of cells. F-deoxyglucose
of Lung Cancer by the National (FDG) is usually used for diagnosis of lung
Collaborating Centre for Acute Care, cancer. FDG is a glucose analogue
commissioned by NICE68). labelled with fluorine, which emits
positrons. The majority of malignant
Imaging tumours have an increased glucose
metabolism and so take up more of the
Chest X-Ray: At suspicion of lung cancer FDG than surrounding tissue and so emit
a chest X-Ray is typically the first more positrons, allowing for identification
diagnostic procedure undertaken. and examination. PET scanners offer a
Radiographically, lung cancer appears as range of examinations, and improve
a solitary pulmonary nodule, pulmonary diagnostic accuracy, but are relatively few
mass, pulmonary collapse, mediastinal in number in England.
lymphadenopathy, a pleural effusion, or as
a consolidation. Tissue confirmation

Computerised Tomography (CT): A CT Bronchoscopy: Diagnosis of lung cancer

scan combines X-Ray techniques with
computer technology to produce multiple
images of the inside of the chest. A CT
scan can allow for further examination of
68
National Collaborating Centre for Acute Care (2005)
The Diagnosis and Treatment of Lung Cancer: Methods,
Evidence, and Guidance, National Collaborating Centre
for Acute Care, London.
can be confirmed with a bronchoscopy.
The procedure is invasive and only used
on patients both willing and physically able
to tolerate such invasiveness. Guidelines
for the procedure have been published by
the British Thoracic Society, where it is
recommended that imaging prior to the
procedure will improve its success.
Histocytology is the gold standard in
diagnosis, and a bronchoscopy is accurate
in diagnosing patients with central disease
and with lesions over 2cm in diameter, but
the sensitivity is too low to recommend the
procedure over other available tests for
peripheral disease.
Sputum cytology: Sputum cytology only
occasionally detects lung cancer, but is
the least invasive measure available.
Therefore it is most often used for patients
physically unable or unwilling to undergo
more invasive techniques.
Percutaneous Transthoracic Needle
Aspiration/Biopsy: This technique involves
inserting a small needle percutaneously to
remove fluid or tissue from the lung which
can then be analysed for malignancy. In
order to direct the needle to the affected
area in the lungs fluroroscopy, ultrasound,
or a CT scan is typically used. Evidence
suggests that transthoracic needle
aspiration and biopsy have a good
sensitivity to and specificity for lung cancer
diagnosis. For peripheral disease
especially, it is more accurate than a
bronchoscopy.
Anterior mediastinotomy: A surgical biopsy
technique developed primarily to stage
carcinoma of the left upper lobe of the
lung. The technique is advocated by
NICE when diagnosing primary masses in
the anterosuperior mediastinum,
especially where SVCO may obstruct
needle biopsy.
Thoracoscopy: A thoracoscopy involves
the insertion of an endoscope through the
chest wall. Thoracoscopy is a useful
means of diagnosing indeterminate
solitary pulmonary nodules but results
vary as to its accuracy. The technique
does however have a low complication
rate.
The choice of diagnostic procedure is
determined by symptoms, stage of the
disease, and the fitness of the patient. As
previously mentioned, the first procedure
is often a chest X-Ray, especially where
there is haemoptysis.
The Department of Health published
guidelines in 2000 that have yet to be
superseded, demanding urgent referral for
a chest X-Ray for patients presenting with
haemoptysis. Urgent referral should also
be made for the following conditions that
are unexplained or persistent (defined as
lasting more than three weeks): cough,
chest/shoulder pain, dyspnoea, weight
loss, chest signs, hoarseness, finger
clubbing, features suggestive of
metastasis from lung cancer, persistent
cervical/supraclavicular lymphadenopathy.
All patients with abnormal chest X-Ray‟s
(or chest Computerised Tomography (CT))
should be urgently referred to a chest
physician who is a member of a
multidisciplinary lung cancer team. Chest
X-Ray‟s are abnormal in the majority of
cases of lung cancer, but a normal chest
X-Ray does not rule out lung cancer. For
this reason the Department of Health
guidelines recommend that if a GP is
suspicious of lung cancer but the X-Ray is
normal then the patient should still be
urgently referred to a chest physician who
is part of the multidisciplinary lung cancer
team.
NICE make several recommendations
pertaining to the diagnosis of lung cancer
above those outlined above69:
All patients diagnosed with lung
cancer should be given individually
tailored information (both verbal
and written) relating to all aspects
of their diagnosis, treatment, and
care;
Treatment and care decisions
should be made jointly with the
patient following discussion of
options and plans. Treatment
plans should be individually
tailored and informed by the needs
and wishes of the patient, including
the level of their desire to be
69
National Collaborating Centre for Acute Care (2005)
The Diagnosis and Treatment of Lung Cancer: Methods,
Evidence, and Guidance, National Collaborating Centre
for Acute Care, London.
involved and their capacity to make
decisions;
Copies of radiologists‟ reports
suggestive of lung cancer should
be sent to the multidisciplinary
team where mechanism‟s should
be in place to allow for follow up
enabling the patient‟s GP to have a
management plan in place;
Patients with known or suspected
lung cancer should be offered a
contrast-enhanced chest CT scan
to further diagnose and stage the
disease. This scan should also
include the liver and adrenals;
A chest CT scan should be
performed by an intended
fibreoptic bronchoscopy or any
other biopsy procedure;
A bronchoscopy should be
performed on patients with central
lesions who are willing and
physically fit enough to undergo
the procedure;
From a systematic review NICE
found that sputum cytology is
rarely indicated and so should be
reserved for patients with centrally
placed nodules or masses and
cannot tolerate a bronchoscopy or
other invasive test;
For patients with peripheral lesions
percutaneous transthoracic needle
biopsy is recommended for
diagnosis of lung cancer;
Where other less invasive methods
have failed surgical biopsy should
be performed for diagnosis;
If it can be achieved more easily,
biopsies should be taken from the
metastatic site where there is
evidence of distant metastases;
An F-deoxyglucose positron
emission tomography (FDG-PET)
scan should be carried out to
investigate solitary pulmonary
modules where a biopsy has failed.
This should depend upon nodule
size, nodule position, and CT
characterisation.
As discussed, the difficulty in making an
initial diagnosis of suspected lung cancer
means that some patients may be missed
at primary care or be wrongly referred to
secondary care. The following collection
of graphs shows the percentage of two-
week referrals for suspected lung cancer
that were found to have cancer for Bolton
PCT between quarter 1 2007/08 and
quarter 3 2008/09. This metric is not a
Department of Health standard but is
important as it may be indicative of the
quality of service provided by local
organisations. As evident, Bolton PCT
falls below the lower quartile in four of the
seven quarterly periods for which data is
available. Each chart details every Trust
in England and where Bolton PCT ranks in
comparison for each quarter period. Once
benchmarked, if a Trust falls below the
lower quartile, meaning that a smaller
proportion of patients referred as two-
weeks referrals are diagnosed with lung
cancer, then the Cancer Commissioning
Toolkit suggests that questions may be
asked concerning the interpretation of the
two-week referral NICE Referral
Guidelines by primary care. In addition,
the Toolkit suggests that if this is the case
then local secondary care teams could be
asked to audit the appropriateness of all
two-week referrals received.
However, Bolton PCT scores well on the
converse of the previous metric. This
indicator is the percentage of all lung
cancer cases not referred as a two-week
referral by their GP. Again, this metric
may be indicative of the quality of services
provided locally and the Cancer
Commissioning Toolkit makes the same
suggestions if a Trust is benchmarked in
the upper quartile. Over the same
quarterly period as those above, this is
never the case for Bolton PCT.
The conclusion being that although
primary care within Bolton PCT has often
been found to refer a smaller proportion of
patients that go on to be diagnosed with
lung cancer, the PCT has a consistently coming through other routes that are not
lower percentage of lung cancer patients referred as a two-week referral.
Accurate and timely staging, though often
difficult, is pivotal to the successful
treatment of lung cancer. Following is a
brief overview of staging and potential
treatments.
Non-small cell lung cancer
The lung cancer staging system was
revised in early 2009 to allow for more
accurate prognosis detail of non-small cell
lung cancer.
The TNM staging system for lung cancer
is designed to allow clinicians to
separately assess the tumour (T), nodes
(N), and metastases (M). TNM staging
provides information relating to the likely
outcome of particular treatments.
Tumour (T) stages:
T1a: tumour is limited within the
lung with a diameter less than
2cm;
T1b: tumour is limited within the
lung with a diameter 2-3cm;
T2: tumour is 3-7cm in diameter, or
has grown into the main bronchus
more than 2cm below the division
into each lung, or the tumour has
grown into the visceral pleura, or
the tumour has led to partial lung
collapse. T2 tumours that are 5cm
or less in diameter are classed as
T2a and those larger than 5cm
T2b;
T3: diameter of tumour is greater
than 7cm, or has grown into the
chest wall, the mediastinal pleura,
the diaphragm, the phrenic nerve,
or the pericardium, or the tumour
has led to whole lung collapse, or
there is more than one tumour
nodule in the same lobe of the
lung;
T4: tumour has grown into the
mediastinum, the heart, a major
blood vessel, trachea, the area
where the main airway divides
between the lungs, the
oesophagus, a spinal bone, the
nerve that controls the voicebox, or
there are tumour nodules in more
than one lobe of the same lung.
Node (N) stages:
N0: no cancer in any lymph nodes;
N1: cancer in the lymph nodes
nearest the affected lung;
N2: cancer in lymph nodes in the
mediastinum on the same side as
affected lung, or cancer in lymph
nodes just beneath division of
trachea to each lung;
N3: cancer in lymph nodes on the
opposite side of the chest to
affected lung; or in lymph nodes
above either collar bone, or in
lymph nodes at top of the lung.
Metastases (M) stages:
M0: no signs that the cancer has
spread to another lobe of the lung
or any other part of the body;
M1a: tumours in both lungs, or fluid
around the lung, or heart, that
contains cancer cells (a malignant
pleural effusion or pericardial
effusion);
M1b: lung cancer cells in distant
parts of the body, such as the liver
or bones.
These TNM stages are then grouped into
number stages of lung cancer (table z.).
Table aa.
Stage I Stage II Stage III Stage IV
Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Stage IIIB

T1a or T1b, N0, M0 T2a, N0, M0 T1a, N1, M0 T2b, N1, M0 T1a, N2, M0 Any T, N3, M0 Any T, any N, with
M1a or M1b
T1b, N1, M1 T3, N0, M0 T1b, N2, M0 T4, N2, M0
T2a, N1, M0 T2a, N2, M0 T4, N3, M0
T2b, N0, M0 T2b, N2, M0
T3, N1, M0
T4, N0, M0
T4, N1, M0

In certain cases, for non-small cell lung the UK than it is for other Western
cancer, Stage I, II, and some IIIA are developed countries. Improving the
operable. resection rate is seen as the key goal in
improving survival rates72. As noted, the
Surgery is the main curative treatment for likelihood of surgery is affected by stage at
non-small cell lung cancer in the early presentation and comorbidity as well as
stages. However, early assessment is general health and fitness in the elderly;
vital in order to determine whether the despite this some cancer units in the UK
tumour is operable. Whether or not each reported resection rates of 15-20% in
individual case is operable is influenced by 2007. For the 2007 audit period Bolton
the health of the patient, the size of the Hospitals Trust reports a surgery
tumour, the location of the tumour, percentage of 10.6%. This met the Local
whether there is nodal or distant spread, Action Plan (LAP) target. (Bolton
and if mediastinal disease is present70. Hospitals Trust also attained its LAP target
in 2007 for percentage receiving any
However, radical surgery is appropriate for active treatment and percentage with
only a small proportion (around 20-30%) small cell lung cancer receiving
of all those with non-small cell lung cancer chemotherapy). The resection rate itself
in England. Importantly, this surgery does increased to 13.9% in 2009. In both
positively influence five year survival rates periods Bolton Hospitals Trust
– over 60% for early stage treatments, and demonstrates a higher percentage than
as high as 80% for very early squamous the Greater Manchester and Cheshire
cell carcinomas71. Cancer Network as a whole.

In later stages of the disease Small-cell lung cancer

chemotherapy can extend survival as well
as palliation of local symptoms.
Radiotherapy is also used as a palliative
means that offers an improved quality of
life. More specific interventions such as
radical chemotherapy, adjuvant
chemotherapy, sequential chemotherapy,
and drug combinations such as cisplatin
and a vinca alkaloid, are appropriate for
specific stages of the cancer and the
health of the individual patient.
The proportion of patients undergoing
potentially curative procedures is lower in
70
Souhami R, and J. Tobias (2005) Cancer and its
management (5th edition), Blackwell, Oxford.
71
Souhami R, and J. Tobias (2005) Cancer and its
management (5th edition), Blackwell, Oxford.
The staging system above has only limited
use for small-cell lung cancer. Rather,
small-cell lung cancer staging is typically
classified as either „limited‟ or „extensive‟
disease. This is because small-cell lung
cancer spreads outside the lung very early
on in the diagnosis:
Limited disease: cancer in only one
lung, in close by lymph nodes, or a
pleural effusion is evident;
Extensive disease: cancer has
clearly spread outside the lung
72
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
 within the chest, or to other parts of
the body.
Small-cell lung cancer shows quick
progression and as a systemic condition
surgery is rarely appropriate, however it is
extremely chemosensitive. The typical
treatment for small-cell lung cancer is a
platinum-based multi-drug therapy such as
cisplatin and etoposide. Patients with
extensive disease and other complicating
factors can still achieve increased life
expectancy and palliative affects from
treatment.
Small-cell lung cancer has up to 85%
response rates to combination
chemotherapy. However, this does not
fully translate into survival rates with only
20% of patients typically achieving a two-
year survival73. For the 2007 audit period
Bolton Hospitals Trust recorded 15 cases
of small cell lung cancer, of which 80%
received chemotherapy. This is a greater
proportion than the Greater Manchester
and Cheshire Cancer Network (63%).
However, the proportion for Bolton
Hospitals Trust almost halved in 2009 to
44.4% (from 18 cases), which is similar to
the Network as a whole (43.6%).
and Cheshire Cancer Network at 0.88 in
2007. However, in the 2009 audit this
figure has increased for Bolton Hospitals
Trust to 1.03, with Greater Manchester
and Cheshire Cancer Network increasing
to 0.96. Comparison of hazard ratios
provides a more meaningful comparison of
survival between trusts than does a
comparison of median survival time in
days. The adjusted hazard ratios are
adjusted for sex, age, stage, performance
status, and deprivation. This allows trusts
to be compared as if they had treated the
same casemix of patients in terms of the
adjusted variables74.
Pictured below are hazard ratios for all
trusts in the Greater Manchester and
Cheshire Cancer Network for which data
is relevant (data excludes small cell lung
cancer and mesothelioma).

Table ab. divides lung cancer diagnoses

by non-small cell and small cell. Across
the principal trusts for Bolton patients
there is consistency, both between the
trusts themselves and compared to the
Greater Manchester and Cheshire Cancer
Network and England and Wales.

The difficulties with diagnosis of lung

cancer carry through to outcome. For the
2009 audit Bolton Hospitals Trust
recorded a median survival time of 168
days (the median survival time is the time
at which 50% of patients in a trust were
still alive). This is lower than that for the
Greater Manchester and Cheshire Cancer
Network at 179 days. The total for
England and Wales as a whole was 174
days. Furthermore, Bolton Hospitals Trust
had a casemix adjusted hazard ratio of
0.69, falling below the Greater Manchester

73 74
Souhami R, and J. Tobias (2005) Cancer and its The Information Centre (2009) National Lung Cancer
management (5th edition), Blackwell, Oxford. Audit: Report for the audit period 2007, The IC, London.
 Table ab.
National Lung Cancer Audit 2009

Number of cases Non-small cell (%) Small cell (%)

England and Wales 27815 84 10.5

RMC 194 87 9.3

RBV 0 0 0
Main trust sites for
Bolton patients
RM2* 75 88 6.7

RW3 113 80 18.6

N02 1597 88 8.8

The hazard ratio compares the death rates
between two groups. In the National Lung
Cancer Audit this is a particular
trust/network compared to a baseline
trust/network. A hazard ratio of 1
indicates no difference in death rates
between the two groups. A ratio greater
than 1 indicates the trust/network has a
better survival rate than the baseline trust.
In the Greater Manchester and Cheshire
Cancer Network Bolton Hospitals NHS
Trust has the second lowest ratio for 2007
and the fourth highest, just above 1 at
1.03, for 2009. This however, represents
a significant improvement for Bolton
Hospitals Trust. The trusts immediately
prior and following are trusts that Bolton
refers lung cancer patients to for specialist
treatments; South Manchester as the
lowest has failed to improve, while Central
Manchester has improved since 2007
(though the confidence intervals cross and
so this improvement cannot be said to be
significant).

Changes to thoracic oncology

As a final point, it is important to consider

the medical context around the difficulty in
diagnosing and treating lung cancer
throughout the pathway. There have been
many changes already in the lung cancer
care pathway and its complexity has
increased as a result. Table ac.75 is a
brief breakdown of the major recent
developments with a view to
demonstrating the increasing complexity
of diagnosis, staging, and treatment today.

The Calman-Hine report (1995)76 set out a

strategic framework for creating a network
of cancer care in England and Wales.
Since then thoracic oncology has changed
significantly and its complexity has
increased. From one angle this is a
reflection of the difficulty involved in
successfully diagnosing and treating lung
cancer, but from another it also
demonstrates the increasing complexity of
the pathway and this complexity, coupled
with the fact that many non-specialists are
involved in the lung cancer pathway,
reveals the difficulty faced by approaches
to speed up the diagnosis and treatment
elements of the pathway.

75
Taken from presentation by Peake, M., National Lung
Cancer Clinical Lead, NHS Improvement and National
Cancer Intelligence Network, available on NHS Evidence
(www.library.nhs.uk)
76
The Expert Advisory Group on Cancer to the Chief
Medical Officers of England and Wales (2005) A Policy
Framework For Commissioning Cancer Services,
Department of Health, London.
 Table ac.
Thoracic oncology

Early 1990s (pre Calman-Hine) Today

Chest X-Ray Multi-slice CT

CT scan PET-CT
Bronchoscopy 77
TBNA/EBUS/EUS/US neck
CT guided lung biopsy Thoracoscopy/CT pleural biopsy
Pathology: NSCLC/SCLC? Pathology: NSCLC subtypes/IHC78
‘Basic' surgery Molecular markers
Limited chemotherapy in NSCLC Complex surgical techniques
Radiotherapy - palliative or radical Wider use of chemotherapy
Very few specialist nurses Combination chemo-radiotherapy
No data (no audit) 79
CHART and advanced radiotherapy techniques
No National Cancer Research Network (NCRN) ‘Biological' therapies
Specialist nursing central to care
Audit/peer review
NCRC trial recruitment targets

77
Transbronchial Needle Aspiration (TBNA); Endobronchial Ultrasound (EBUS); Endoscopic ultrasonography (EUS);
Ultrasound neck (US neck).
78
Immunohistochemistry (IHC).
79
Continuous Hyperfractionated Accelerated Ratio Therapy (CHART).
Two-week referrals to Royal Bolton
Hospital
The following makes use of two-week
referral data at the Royal Bolton Hospital
for the calendar years 2005 to 2009,
supplemented by published National Lung
Cancer Audit information where
appropriate.
As discussed previously in this
assessment, Bolton Hospitals Trust met its
„two-week target‟ wait from urgent GP
referral to first outpatient appointment with
suspected cancer for all cases between
Quarter 1 2004/05 and Quarter 2 2009/10.
Table ad. details the total number of two-
week referrals made to the Royal Bolton
between 2005 and 2009, totalling 1,316 in
all (this includes patients referred to the
Trust from outside Bolton). The difficulty
of diagnosis is evident when we consider
that of these 1,316 referrals for suspected
lung cancer only 372 (28%) were actually
diagnosed as lung cancer.
Table ad. Year Number of 2 week referrals
The mean age at referral for the entire
period above is 69.6 years. This age has
varied slightly for each year: 68.8 years in
2005, 69.2 years in 2006, 70.6 years in
2007, 68.0 years in 2008, and 71.3 years
in 2009. This includes patients referred
from outside Bolton. For lung cancer the
younger at which a person is diagnosed
the more likely they are to be viable for
curative treatment, both in terms of their
fitness to undergo invasive procedures
and the stage of their lung cancer.
Following diagnosis, the stage of the lung
cancer must be ascertained to inform
appropriate treatment and management.
For all diagnoses with a stage recorded
between 2005 and 2009 at Royal Bolton
the greatest proportion are made in the
later stages of lung cancer – 41.9% at
Stage III, and 37.9% at Stage IV.
Nationally, patients most often present
with Stage IV lung cancer (metastatic
disease)80.
Table af.
Royal Bolton Hospital: Staging at
diagnosis 2005-2009

2005 253
2006 277 Stage I 15.0%

2007 261 Stage II 5.1%

2008 273 Stage III 41.9%
2009 252 Stage IV 37.9%
Total 1316

The chart below shows the percent at

With the exception of 2005 the percentage
each stage by age group at diagnosis (the
of all two-week referrals to Royal Bolton
35-44 age group is not included as the
diagnosed as lung cancer has varied little, numbers are too low for publication, as is
always being around 30%.
the case for Stage I diagnoses in the older
Table ae.
age groups).
Year Percent diagnose as lung cancer

2005 21%
2006 34%
2007 28%
2008 27%
2009 30%

2005-2009 28%

80
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
Stage III and Stage IV diagnoses
dominate, accounting for over 70% of all
diagnoses in each age group. Though not
portrayed on the above chart, all Stages
(with the exception of Stage II, for which
there are very few diagnoses at all) reflect
the mean age of diagnosis at Royal Bolton
of 69.6 years. This reflects the national
picture where the majority of cases are
diagnosed between 60 and 85 years of
age81. At Bolton Hospitals Trust, age
groups 65-74 and 75-84 feature the
largest number of diagnoses, the majority
of which, as shown above, are diagnosed
at Stages III and IV.
That the majority of lung cancer at
diagnosis in Bolton is found to be in the
later stages III and IV means that the
treatment options available are severely
limited. This has a considerable negative
impact upon the outcome for a diagnosis
of lung cancer for Bolton people, and is a
major contributory factor to the high
mortality rate and low survival rate
following diagnosis.
81
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London.
Inequalities in lung cancer begin with
lifestyle, chiefly smoking, but persist into
diagnosis:
“Deprived groups have an
increased risk of getting cancer
and a lower likelihood of gaining an
early diagnosis” (Greater Manchester
Public Health Practice Unit, 2010, pg.15)
This is partially reflected in two-week
referrals for whom a diagnosis of lung
cancer is made at the Royal Bolton. Here
it is demonstrated that 44% of all patients
from the most deprived quintile in Bolton
are diagnosed in the later stages of lung
cancer (stages III and IV) compared to
37% of Bolton patients overall. (This data
is only for those patients referred for
diagnosis at the Trust who have a Bolton
postcode and so does not include a great
proportion of patients who are diagnosed
here from outside Bolton).
The following concerns only those
referrals to Royal Bolton with a diagnosis
of lung cancer who are also Bolton
residents. The two periods below do not
match exactly, but they are wide enough
for a simple comparison to be made.
Despite the large time scale, the two-week
referral data features a much lower
number of counts and this is reflected in
the confidence intervals for each quintile.
The first chart shows the standardised rate
of two-week referrals to the Royal Bolton
diagnosed with lung cancer over the
period 2005-2009. The confidence
intervals show there to be no significant
difference between the quintiles. In
contrast, the next chart shows
standardised mortality from lung cancer in
Bolton over the period 2002-2008 to be
strongly associated with deprivation
quintile. The difference between the most
deprived and the least deprived in
particular demonstrates a considerable
significant difference. Accepting that
deprivation influences lung cancer
mortality, the ideal would be for these two
charts to roughly demonstrate the same
declining significant pattern across
quintiles.
Given that the mortality rate in the most
deprived quintile in Bolton is so high
compared to the least deprived, it is
reasonable to expect that a significantly
greater proportion of two-week referrals
that are diagnosed with lung cancer
should come from the most deprived
quintile. This is not the case. While there
is clearly a greater proportion of morbidity
in the most deprived quintile, that results
in the higher mortality rate above, this
does not appear to translate significantly
into two-week referrals to the Royal
Bolton.
Very few two-week referrals diagnosed as
lung cancer are for patients registered with
practices within the Red, Orange, and
Yellow GP clusters. These clusters all
have a high level of deprivation (Red –
high; Orange – High; Yellow –
High/Medium). However, these clusters
all have a comparatively young and
ethnically BME and mixed populations.
This demographic make-up can be
expected to skew the referrals we would
expect from people referred from these
practices. Whilst these are the most
deprived practice populations in Bolton,
lung cancer is a disease that primarily
affects older people and smokers (as
noted previously, while smoking
prevalence in South Asian men is similar
to the White population in Bolton, smoking
in South Asian women is extremely low).
In contrast, 28.9% of all two-week referrals
to Royal Bolton are from practices within
the Blue cluster, 27.7% from the Green
cluster, and 24.1% from the Indigo cluster.
These clusters have the largest
populations (Indigo – 81,445; Blue –
56,855; Green – 58,342) compared to
those above (Red – 20,484; Orange –
34,710; Yellow – 36,847), have
predominantly white populations, and
principally normal/old age ranges. These
clusters are however generally less
deprived than the Red, Orange, and
Yellow. There is very little published
literature concerning lung cancer at
primary care. We do know that despite
the high mortality from lung cancer, it is
rare at the level of GP practice. GPs can
expect to encounter a new lung cancer
every eight months; this means that GPs
typically build up very little personal
experience of its diagnosis.
The mean age of two-week referrals
diagnosed as lung cancer at the Royal
Bolton who also have a Bolton postcode is
68 years. This is almost two years
younger than for all two-week referrals
diagnosed as lung cancer at the Royal
Bolton (69.9 years as discussed above).
Differences are evident by gender for
diagnosed Bolton residents with the
average age for women being 67.4 years
compared to 68.7 years for men.
Differences are also apparent by NRS
area where the mean age at referral is
67.8 for those not living in an NRS area
compared to 68.5 for those within an NRS
area, almost one year difference.
However, greater differences are
illustrated when we put these two
together. The first thing to notice (table
ag.) is that female referrals show a 50%
split by NRS and non-NRS area. NRS
areas account for just 32% of the total
population of Bolton, but as the most
deprived areas we would expect higher
smoking prevalence (Bolton‟s NRS areas
taken together have a smoking prevalence
10% higher than Bolton as a whole, and
this has remained static between the 2001
and 2007 health surveys), morbidity, lung
cancer incidence, and co-morbidities. The
pattern is very different for Bolton men
where 70% of all male referrals are from
non-NRS areas. Again, obviously there
are more men in non-NRS areas than
NRS areas, and the percentage split
almost exactly fits the 32% proportion.
However, we know there is higher
mortality from lung cancer in NRS areas;
therefore we would reasonably expect the
percentage split to be skewed beyond
32% because of the greater morbidity in
the NRS population compared to the non-
NRS areas. However, two factors are at
play here that are well known but difficult
to overcome. The first is, following the
quote above from the Greater Manchester
Public Health Practice Unit that the most
deprived (and so those in NRS areas) are
less likely to seek help; the second is an
exacerbation of this as men in general are
less likely to visit primary care compared
to women, a gap that may be widened in
deprived areas in Bolton. At least, this
seems to be the case for two-week lung
referrals diagnosed as lung cancer.
Table ag.
Two-week referrals at Royal Bolton: Bolton residents
Non-NRS
Female 51.3%
Male 70.5%
Persons 61.4%
Further dividing referrals diagnosed with
lung cancer by NRS area produces an
unusual result. Table ah. gives the mean
age at diagnosis for men and women split
by NRS and non-NRS area. The numbers
are relatively small, but this includes every
Bolton resident diagnosed with lung
cancer at the Royal Bolton over a five year
period and so is representative of the
types of people there referred. There is a
switch by gender across the areas. In
Bolton overall, two-week referrals
diagnosed as lung cancer are made for
women at a mean age of 67.4 years and
men at 68.7 years, as mentioned above.
This difference becomes unbalanced at
NRS area level where men are more likely
to be referred younger than women. This
reflects the morbidity in the population
where women live longer and men are
more likely to get lung cancer younger as
they have a higher smoking prevalence.
Smoking levels decrease steadily in
Bolton as you move from the most
deprived quintile through to least deprived
quintile. People in the most deprived
quintile are more than twice as likely to
smoke as those in the least deprived
quintile, and across all groups men are
more likely to smoke than women.
Therefore, table ah. shows the result of
this behaviour in NRS areas.
Table ah.
Two-week referrals at Royal Bolton: Bolton residents (age
in years)
Female Men
NRS 71.6 63.9
Non-NRS 63.3 70.7
Bolton 67.4 68.7
NRS
The reversal for non-NRS areas is difficult
48.7% to explain. Considerations are that the
difference between men and women in
29.5%
terms of smoking prevalence is not as
great in lesser deprived quintiles
compared to the most deprived. Plus,
38.6% lower smoking prevalence overall in the
non-NRS group is likely to produce less of
an effect. We should also consider the
possibility that men in the NRS group are
more likely to be exposed to harmful
working conditions that may affect
incidence. However, smoking is still
higher in men in the non-NRS group than
it is women, and women still live longer in
this group than men. As mentioned,
women are more likely to access primary
care and so we would expect women to be
diagnosed and referred earlier; for
instance, rather than waiting for a chance
finding or an emergency admittance.
Therefore, to a degree the non-NRS age
split also makes sense.
The major issue from all this is the
worryingly late age women in NRS areas
are referred, and the similar picture seen
for men in Non-NRS areas.
Finally, despite covering a five year period
for all Bolton residents referred to the
Royal Bolton the numbers at GP practice
level, and to a lesser extent GP cluster
level, are relatively small. For this reason,
and with reference to the likelihood of a
particular GP having experienced many
lung cancer referrals, it is unwise to focus
on individual practices. The confidence
intervals are extremely wide and this is
why referrals to the Royal Bolton have not
been analysed at practice level in this
assessment. Rather, the data justifies
treating primary care as a whole for this
particular issue, with perhaps greater
emphasis on practices with older, or a
high smoking population. This is a
straightforward reflection of the causes
and aetiology of the disease, but as the
numbers are small at practice level, little
can be expected to be gained from
singling out individual practices.
Primary care: Analysis of significant
event audits (SEA) for cancer diagnosis
in the North of England Cancer
Network82
This section will discuss the findings of
research carried out for the National
Awareness and Early Diagnosis Initiative
(NAEDI): Cancer in Primary Care – an
analysis of significant event audits (SEA)
for diagnosis of lung cancer and cancers
in teenagers and young adults 2008-2009.
82
Mitchell, E., Macleod, U. and G. Rubin (2009) Cancer in
Primary Care: An analysis of significant event audits
(SEA) for diagnosis of lung cancer in teenagers and young
adults 2008-2009, National Awareness and Early
Diagnosis Initiative, London.
The overall aim of the research was to
gain insights into the events surrounding
the diagnostic processes for the two
named cancer groups drawn from a
secondary analysis of significant event
audit (SEA) documents. The research
was carried out in trusts within the North of
England Cancer Network. While not
carried out in the Greater Manchester and
Cheshire Cancer Network, the North of
England Cancer Network is perhaps the
most comparable, and as this is a study
undertaken by NAEDI in response to the
Cancer Reform Strategy the findings
should be considered of high importance
to this assessment and has value to the
goal of improving cancer diagnosis and
referral from primary care.
Insights into the referral process for lung
cancer
The first point of note the research found
was the complexity involved in the process
of diagnosis of lung cancer at primary
care:
“Chest symptoms are common in
general practice, and extremely
common among smokers, who
have a much higher risk of lung
cancer than other population
groups. It is within this context that
GPs have to decide who to treat,
who to investigate, and who to
refer” (Mitchell, E. et al, 2009, pg.15)
Presenting patterns were found to be sub-
divisible into three main categories:
1. Chest symptoms and symptoms
suggestive of malignancy: similar
to the standard given earlier in this
section. Almost three quarters of
all patients involved in the audit
presented with symptoms in this
category;
2. Other symptoms not generally
believed to be suggestive of lung
cancer, the chief of which were
abdominal and epigastric pain,
painful leg, lack of co-ordination of
legs, atrial fibrillation (AF), relatives
 noticed blue lips, weakness left
hand and arm, arm pain, neck
pain, feeling of lump in throat,
routine bloods found to be
abnormal, vague symptoms. A
small number (15%) presented
with symptoms in this category;
3. The remaining diagnoses were
made where the patient did not
present symptoms to a GP, the
chief ways being routine blood
checks, emergency admissions,
seen by Urgent Care Team with
cough and admitted to hospital,
and diagnosed whilst being treated
for a range of other conditions.
This demonstrated to the researchers that
while many patients initially presented with
lung related symptoms the nature of
presentations varied significantly:
“The „text book‟ presentation of
haemoptysis, while reported, was
only the case for a minority of the
patients included in this study.
Much more common was a
combination of symptoms initially
pointing to chest infection; almost
half of the cases presented in the
SEA reports presented this way”
(Mitchell, E. et al, 2009, pg.17)
The study found that the responses made
to presentation by GPs, both to initial
presentation and then to subsequent
consultations, were in keeping with
commonly accepted practice; meaning
that at initial presentation with chest
related symptoms the patient was
examined, examination findings were
noted, antibiotics prescribed, and a chest
X-Ray ordered. In addition, other
responses included venepuncture, referral
to specialist clinic, referral to another
primary care professional, arrangement of
follow up, patients advised to return if no
improvement, and emergency admission.
Co-morbidities were identified as a serious
problem. As is to be expected the majority
of cases were current or ex-smokers, and
many had previously been diagnosed with
COPD, or other smoking related illnesses
such as cardiovascular disease (CVD),
peripheral vascular disease (PVD), and
coronary heart disease (CHD). In addition
a number of reports identified previous
exposure to asbestos or that the patient
was an ex-miner, reflecting the setting of
the audit. However, these co-morbidities
and lifestyle factors are likely to contribute
to the interpretation of symptoms and so
GP response to presentation.
The majority of cases were referred within
one month of presentation. Those taking
longer were assigned to three main
groups:
1. A product of initial chest X-Ray
reports. Referral delayed as initial
chest X-Ray reported as normal or
with findings consistent with benign
disease;
2. Patient mediated factors, the chief
of which were waiting a lengthy
time following first consultation
before re-presenting with ongoing
symptoms, declining referral when
offered by GP, failing to attend
appointment for chest X-Ray,
declining to see GP when
recommended by nurse, and
declining hospital admission. The
reason for these factors are
obviously personal and complex
and the study could provide no
further insight;
3. Complexity of presentation.
Analysis of a number of SEA
reports demonstrated how intricate
some of the cases were and led to
the conclusion that though initial
presentation was chest or
malignancy related, they were so
complex that reaching an earlier
diagnosis would have been
extremely challenging.
There were cases where the researchers
believed there was opportunity for earlier
diagnosis of lung cancer involving chest
symptoms. The number roughly
amounted to one fifth of all referrals taking
longer than one month, and 9% of all
cases presenting with chest symptoms
suggestive of lung cancer. The report
here presents specific case studies and
the main lessons that can be drawn from
the events discussed:
1. It can be difficult to differentiate
new, potentially malignant
symptoms in patients with known
chest disease;
2. It is important to consider the
recent history of presentations,
even if the patient presents with
the symptoms as pertaining to
separate episodes (especially,
COPD exacerbations);
3. It is important to have appropriate
safety-netting and to put in place
follow up plans with patients, even
if they are presenting with their first
recent infective episode;
4. It is important for GPs to maintain
an overall view of presentations
and symptoms, even if specialist
teams are involved;
5. It is important to consider lung
cancer as a differential diagnosis in
patients presenting with shoulder
and neck pain, particularly those in
at-risk groups.
The report found many examples of good
practice in the lung SEA reports and
provides specific exemplary case studies
in lung cancer diagnosis. These are
quoted below.

Exemplar a.

L-06: Patient presented with a history of URTI with increasing cough. Examination revealed
tenderness over the anterior chest wall and right chest signs. The patient was prescribed analgesia
and antibiotics, and given a review appointment with the same GP to check resolution after treatment.
Patient was reviewed two weeks later and reported pain was much better but cough persisted.
Examination showed that there were still signs in the chest. CXR was organised and carried out two
days later. The following day the report was faxed to the surgery. The GP contacted the patient that
day and arranged for them to come into the surgery the same day with a family member, after which a
2WW referral was sent.

This case demonstrates the importance of good safety-netting, as well as good communication
between primary and secondary care, and between the GP and the patient and their family.

Exemplar b.

L-09: Patient presented with a hoarse voice and was treated by the GP. Review was arranged for
eight days later at which time the patient was no better. The patient was referred under the 2WW to
ENT for persistent hoarse voice. CXR was done as part of the work up and showed a suspicious
lesion. The patient was then referred under the 2WW to the chest clinic.

This case demonstrates the importance of good safety-netting, as well as good follow-up by the GP
as part of the referral process.

Exemplar c.

L-14: Patient (50 year old ex-miner) with a known diagnosis of asthma presented with a one month
history of dry cough. There were chest signs on examination and the patient was given a course of
steroids, but because of the duration of cough, a CXR was arranged at that initial consultation. This
showed signs of infection in the right lung. Follow-up was not recommended by the radiologist. The
patient attended again around three weeks later saying that they still had a dry cough and did not feel
quite right. Chest signs were heard corresponding to previous CXR changes; the patient was given
antibiotics but a repeat CXR was ordered to ensure resolution of infection. However, the CXR showed
progressive changes and the patient was immediately referred under the 2WW to the chest clinic.
This case demonstrates the importance of vigilance, good safety-netting, and GP follow-up.

Exemplar d.

L-28: Patient was under the care of the rheumatologists. GP noted that the inflammatory markers had
been rising and the haemoglobin falling, and so wrote to the rheumatology consultant. The patient did
not have any symptoms, but the rheumatology appointment was brought forward and a CXR carried
out at the clinic; this showed a lung mass.

This case demonstrates the importance vigilance by the GP, particularly as these blood tests were
secondary care results being copied to general practice. The communication between primary and
secondary care worked well.

Exemplar e.

L-43: Patient (72 year old) presented to the GP registrar with a three-week history of a productive
cough. In view of smoking history and clinical findings, a CXR was ordered. The same day the
radiologist phoned to say that there were significant changes in the left upper lobe and advised that
the patient should be given antibiotics followed by an interval CXR four weeks later. A week later the
patient returned no better and was offered immediate referral but declined this, instead opting for
another antibiotic. The patient was seen another week later, much improved. They then had the
repeat CXR as planned four weeks after the original one, which was slightly improved but urgent CT
scan was advised and arranged.

This case demonstrates prompt appropriate action by the GP registrar in line with guidance; it also
shows good communication between primary and secondary care.

Exemplar f.

L-68: The patient was noted by the nurse to be thin at COPD review. They were seen the following
month by the nurse, weight loss documented but declined to see the GP. The patient was persuaded
to see the GP around 2 weeks later and a CXR carried out that day was reported as normal.
However, in view of the weight loss the patient was referred urgently to the chest clinic.

This case demonstrates that although the process in primary care did take some time, due mainly to
the patient‟s wishes, it was started by the observation of the nurse, who followed that observation up.
(Source: Mitchell, E. et al, 2009, pg.27-28)

Learning points related to lung cancer
diagnosis
SEAs involve discussion of the event
within a team meeting. This allowed the
discussion and reflection of GPs following
diagnosis of lung cancer to be evaluated
in the research. The learning points were
analysed under five broad themes:
1. Presentation and diagnosis of lung
cancer;
2. System issues and the primary
care/secondary care interface;
3. Patient related factors;
4. Practitioner issues;
5. The role of guidelines.
The study states that some points have
been mentioned by only one or two GPs,
but the researchers have drawn out as
many as possible to document the key
issues raised by practices arising from the
completion of SEAs.
Learning points concerning presentation
and diagnosis of lung cancer focused on
the complexity of atypical symptoms, the
need for vigilance even when symptoms
appear straightforward, and the
usefulness and limitations of CXR as a
diagnostic tool. The chief detailed
learning points identified by practitioners
were:
Lung cancer does not always
present typically and there are no
immediate warning signs or „red
flags‟ on presentation;
Be aware of atypical symptoms
and be prepared to investigate;
Do not always presume the most
common cause for a problem;
Primary care input into
management can only be achieved
if patients present symptomatically;
Initial presentation may be with
secondary signs of malignancy,
and this may obscure the issue
and potentially delay diagnosis;
Co-existing disease can mask
symptoms of malignancy;
The possibility of a serious
diagnosis should be considered in
patients with a known diagnosis,
either those with an existing
respiratory condition (asthma,
COPD) or other concurrent
disease;
Have a heightened suspicion of
lung cancer in patients with
worsening COPD or new or
persistent COPD symptoms;
Malignancy should be considered
as a possibility, even when
symptoms sound innocuous;
Musculoskeletal sounding pain
(neck or shoulder) can be a
presenting symptom for lung
cancer, and should have a low
threshold for CXR request;
There is a need to always remain
suspicious of symptoms in patients
who are smokers;
Lung cancer can occur in patients
who are non-smokers;
Have a high index of suspicion and
a low threshold for investigation
and CXR in patients with persistent
cough (both smokers and non-
smokers);
Reminder of the general signs and
symptoms of malignancy and the
difficulties sometimes involved in
diagnosing malignancy;
CXR reports can sometimes give
false reassurance;
Lung cancer cannot be excluded
even if a CXR is normal;
A normal CXR can become
abnormal over a relatively short
time period;
Awareness to refer people with
continuing symptoms, even if CXR
is negative.
Learning points concerning system issues
and the primary care/secondary care
interface focused on communication and
record keeping:
Effective communication and team
working is key;
Be aware of those patients who
are under the care of several
specialties, as key questions can
be missed even when there is
ongoing and regular
communication;
It would be useful to document
when a patient was referred
urgently if a possible diagnosis of
cancer was discussed;
Difficulties related to the
importance of trying to ensure
continuity within the practice so
that patients with ongoing
symptoms can be reviewed by the
same GP;
The importance of record keeping
to ensure that other colleagues are
aware of patients‟ previous
complaints;
The importance of reviewing recent
medical history (including hospital
and GP appointments) when
seeing a patient;
The importance of ensuring that
test results are passed to the
practitioner who requested the test,
for review;
 The importance of review methods
for follow-up of abnormal tests (i.e.
would a telephone call be more
appropriate than a letter);
Consider reviewing patients
undergoing hospital investigations
and follow-up as this may prevent
delays in the hospital system if GP
can re-refer;
Never be wary of re-referring to
secondary care, even if the patient
has been discharged;
Awareness of the „two-week wait‟
and that it is very beneficial in
ensuring rapid access to
secondary acre;
Be prepared to question
discharges from secondary acre;
The importance of immediate
access to CT scan for sinister
symptoms;
The importance of direct access to
CXR films electronically;
The benefit of rapid reporting of
CXR results (fax was especially
useful).
Learning points in relation to patient
specific factors centre upon co-morbidities
and lifestyle factors:
It is important to have a record of
a patient‟s smoking status and
smoking history;
Although it is often difficult to
influence patient behaviour in
relation to smoking, practitioners
should keep trying;
Consider serious diagnosis in
patients who present only
infrequently or who are not typical
candidates for lung cancer (usual
good health, younger age, non-
smokers);
Be vigilant of warning symptoms
even if these are brought up
coincidentally when the patient
attends for reason or is discussing
another issue;
There is a need for patient
education in relation to
longstanding new or vague
symptoms so that delay can be
reduced;
Patient autonomy during
diagnostic, treatment, and
palliative phases need to be
respected.
Learning points concerning practitioner
issues focused on the need for safety-
netting (the inclusion of back-up
processes to make predictions for and
deal with alternative outcomes following a
working diagnosis and the creation of a
provisional management plan83. The
report quotes Neighbour‟s original safety-
netting concept as being comprised of
asking three specific questions: a) “If I‟m
right, what do I expect to happen?” b)
“How will I know if I‟m wrong?” c) “What
would I do then?”84 Detailed learning
points identified were:
Safety-netting is an important part
of the consultation;
There is a need to give robust
safety-netting advice;
Too much detail around safety-
netting may prevent patients from
re-presenting;
It is important to „link‟
consultations, especially when
continuity is an issue;
Recurrent or non-resolving
complaints should be investigated
further;
Follow-up is important with upper
respiratory tract infections;
Do not assume that results will
automatically be reported or that
they will automatically be reported
to the requesting practitioner;
83
Neighbour, R. (1987) The Inner Consultation, MTO
Press, Lancaster.
84
Neighbour, R. (1987) The Inner Consultation, MTO
Press, Lancaster.
 It is important to follow up patients „Gut instinct‟ and experience are
after negative results; also important;
It is important to prioritise clinical There is a need to remain patient
signs/symptoms rather than centred, and at times to negotiate
negative test results; a referral pathway that is
It is important to be aware of acceptable to the patient.
warning symptoms when
mentioned, even if that is not the Secondary care
focus of the consultation; The data discussed in this section is from
It is important to ask specific the Secondary Uses Service dataset and
questions when patients report concerns all patients with a diagnosis of
improvement on review; lung cancer with a Bolton postcode
Examination is a key part of early regardless of the trust at which they
diagnosis; received treatment.
Serially documenting patient Table ai. shows the total secondary care
weight is valuable; acute trust activity for residents of Bolton
Writing to patients who fail to between 2006/07 and 2008/09 with a
attend appointments is effective; diagnosis of lung cancer. In the
It is important to have up-to-date „Summary: Cancer Commissioning Toolkit‟
section of this assessment the problem of
contact details for patients in case
increasing emergency admissions for
urgent contact is required. cancers was discussed and the desire to
reduce this nationally made apparent.
Learning points concerning the role of Figures for the three yearly periods below
guidelines and existing referral pathways for lung cancer are however relatively
related to cases where guidelines had consistent, showing no increase or
been followed, to cases where the decrease in Bolton.
guideline was not appropriate due to other
associated factors such as symptoms not Table ai. Day Non-
Elective
meeting referral criteria, patient presenting cases elective
elsewhere (Accident and Emergency), and
the patient already being under specialist 2006/07 Count 179 151 139
care. Detailed points were: Bed days 0 630 1627
Average LOS 0.0 4.2 11.7
Raised awareness of the criteria
for urgent „two-week wait‟ referrals 2007/08 Count 112 138 148
Bed days 0 754 1468
for suspected cancer;
Average LOS 0.0 5.5 9.9
Reminder that the NICE guidelines
for COPD suggest CXR as part of 2008/09 Count 109 128 135
initial assessment; Bed days 0 497 1548
NICE guidelines do not always Average LOS 0.0 3.9 11.5
reflect local suspected cancer
referral protocols; The stability of the non-elective cases is
It is not necessary to have a CXR positive given Royal Bolton‟s overall high
emergency admissions; Royal Bolton‟s
result to refer under the „two-week
Accident and Emergency receives
wait‟; 100,000 attendances a year and
Guidelines are useful, but there is significantly more Greater Manchester
still a need for practitioners to be Ambulance Service ambulance arrivals
vigilant and to be suspicious of than any other acute trust in Greater
potentially serious symptoms; Manchester. Compared to Greater
Manchester the Royal Bolton is
consistently amongst the three busiest
trusts in terms of non-elective admissions
(38,000 per year) and has the highest
number of emergency admissions.
Placing the Royal Bolton within this
context, it is perhaps sensible to expect
high non-elective and emergency
admissions for lung cancer from the
Bolton population, but as demonstrated
earlier, Bolton PCT has comparatively
low/average referrals for suspected lung
cancer from routes beyond primary care.
However, this is an important indicator to
monitor for Bolton given the high Accident
and Emergency use in general.
The most frequent interventions
undertaken for those with an ICD-10 code
of C33-C34 are diagnostic, as we would
expect. Most common is „Diagnostic
fibreoptic endoscopic examination of lower
respiratory tract and biopsy of lesion of
lower respiratory tract‟. This intervention
is followed distantly by „Diagnostic
fibreoptic endoscopic examination of lower
respiratory tract and broncho-alveolar
lavage (cell differential)‟. These are
followed distantly by „Biopsy of lesion of
the lung NEC‟ and „Needle biopsy of
lesion of the lung‟. The figures used
above are only for interventions E46-E63
with a diagnosis of lung cancer. However,
taking all interventions undertaken on all
persons with a diagnosis of lung cancer
over the three year period allows
diagnostic and exploratory scans to be
identified. Computed tomography (CT)
scans of the head, chest, and spine are
more common than Magnetic Resonance
Imaging (MRI) scans in the Bolton dataset.
Because of the aggressive nature of lung
cancer the disease rapidly spreads to
other parts of the body and many
interventions are also undertaken to
combat this.
Taking primary cases of all those with a
diagnosis of lung cancer a clear variation
across deprivation quintiles is evident.
This is shown below where the most
deprived quintile has a significantly higher
directly standardised episode rate (per
100,000) compared to the least deprived
quintile of Bolton‟s population. This is to
be expected given that this quintile has a
higher lung cancer mortality rate and
smoking prevalence.
The following considers episodes by GP
practice. The SUS dataset cannot tell us
whether each episode was referred to
secondary care by primary care, or
whether the episodes result from
unscheduled care or other means.
However, in an equitable service we would
expect a higher proportion of people to be
treated in secondary care from the more
deprived sectors of Bolton because of the
strong association between
socioeconomic deprivation and lung
cancer incidence. One person can have,
and is indeed likely to have, more than
one episode of treatment. This has been
taken into account as far as possible by
only taking the first episode of care in the
below calculation. Those practices with
the highest rate of patients who are
treated in secondary care for lung cancer
are mostly fairly evenly spread between
the Red, Orange, Yellow, and Green
clusters. This is what we would expect to
an extent. It does reveal inequalities to a
certain degree as lung cancer is a disease
suffered in old age, but practices in these
clusters have a relatively young population
(Red – young; Orange – young/normal;
Yellow – young/normal; Green –
young/normal/old). However, much of this
difference will have been accounted for in
the age standardisation involved in the
calculation. The Blue and Indigo clusters
have predominantly normal/old
populations and so with no knowledge of
the aetiology of lung cancer we would
expect higher incidence here, but
practices in these clusters are less
deprived and have a far lower smoking
prevalence.
This strong association with smoking
further allows us to identify inequalities.
The following graph plots secondary care
first episodes against smoking prevalence
by GP practice in Bolton. The first thing to
notice is the relative uniformity of smoking
prevalence when compared to secondary
care activity for lung cancer. The greater
smoking prevalence‟s are found in
practices from the Orange and Green
clusters. Secondary care access is more
evenly spread across clusters and so does
not follow the pattern of smoking
prevalence as closely as other disease
areas with a strong association with
smoking. This is representative of the
entire lung cancer care pathway, where
standardisation is urgently needed. The
National Lung Cancer Audit continually
emphasises the differences in access,
correct referral, and treatment between
Cancer Networks. What we see here at
primary care level, while by no means
conclusive, is perhaps an indication of
these wider discrepancies. However, we
must remember that not every smoker
gets lung cancer, and that those in
deprived areas have a lower life
expectancy than their lesser deprived
counterparts and that lung cancer is often
diagnosed in old age may influence the
data. However, it is reasonable to assume
that if fully equitable secondary care
access should match and be as uniform
as smoking prevalence. At the very least,
the wide variation in access between
practice populations is a gap where gains
may potentially be made.
Local Lung Cancer MDT
The Bolton Lung Cancer MDT is a multi-
disciplinary group serving the population
of Bolton and surrounding areas.
The following indicator comes from key
issues from the peer review. Key issues
from peer review include reports on the
establishment of local and specialist MDTs
and their functioning, including appropriate
membership and levels of attendance, and
agreed Network standards and protocols.
Indicators within this also consider
measures relating to the establishment of
an effective Network commissioning group
and forward planning. It is important that
patients and carers are fully informed of
the treatment offered and have an
effective voice in shaping treatment
services. This measure allows the
monitoring of the NHS Cancer Plan
commitment that all patients with cancer
have the right to have their care and
treatment discussed at a multidisciplinary
team meeting. Bolton scores well on this
indicator, with 71% compliance with all
MDT measure for the lung MDT.
MDT working, as specialised in NICE Two week rule
guidance will remain core to the model for
cancer services delivery in the future. The A total of 285 referrals were made for
following summarises the Annual Report suspected lung cancer during 2008/09.
for Royal Bolton Lung Cancer MDT April This is an average of 24 referrals a month,
2008 – March 2009. all of which were seen within fourteen
days.
Previous audits reveal significant
improvements in histological diagnosis, Thirty-one days target
staging, treatment of lung cancer patients,
and MDT discussion, as shown in table aj. Over the period above there were 28
patients diagnosed and treated at Royal
Table aj. Bolton, all of which were treated within 31
Royal Bolton Local Lung Cancer MDT
days from decision to treat to treatment.
The majority of lung cancer patients are
2006 2007 2008
referred out of Royal Bolton for treatment
at another unit.
Total cases 180 211 195
Sixty-two days target
Histological diagnosis (%) 52 70 94
There were 5 patients referred as two-
week rule who were diagnosed and
Anti cancer treatment (%) 23 63 52
treated at the Royal Bolton, all of which
were treated within 31 days from decision
Surgical treatment (%) 5 12 24 to treat to treatment.

MDT discussion (%) 85 96 100

Key achievements

1. Increased numbers of 2 week rule

slots in clinics with resultant
 satisfactory performance
achieving over 95% of patients
seen within two weeks;
2. Two replacement bronchoscopes –
enabling all patients to be offered a
bronchoscopy within two working
days;
3. Increased number of CT scans are
requested by radiologists once an
abnormal chest X-Ray has been
discovered prior to being seen in
thoracic medicine, thus speeding
up the diagnostic process;
4. Now have facilities to perform
transtracheal needle aspiration at
bronchoscopy;
5. Purchased an autoflourescent
bronchoscope which should
facilitate the detection of abnormal
infiltration in mucosa
bronchoscopy and improve
diagnostic yield;
6. Thoracoscopy approved by Trust
and soon to be implemented. This
will improve the management of
pleural effusions and improve
diagnostic tield in lung cancer
reducing the need for referral to
thoracic surgeons outside the
Trust;
7. The provision of an Oncology
Clinic in Thoracic Medicine has
improved patient access
considerably and permits the
provision of LCNS support further
along the patient care pathway;
8. The provision of an inpatient
consultation service for patients
with poor performance status. This
broadens the access of lung
cancer patients to an oncological
opinion and ensures all are
considered for treatment;
9. Commencement of the Sector
MDT has improved the quality of
the MDT discussion with the
presence of an oncologist and a
thoracic surgeon at meetings. This
in ensures a truly multidisciplinary
discussion and helps the group
consider all patients for active
treatment.
Key challenges
1. Need to continue improvements in
data collection and recording in the
Lucada system;
2. Continue to increase referrals for
active treatment of their lung
cancer;
3. Improve recruitment of patients
into clinical trials from the sector;
4. Continue to participate in Network
audit projects;
5. Establish a regular audit process
with particular reference to
recording treatments and outcome
at
data;
6. Improve on attendance at NSSG
meetings;
7. Work on improvements in the
video referencing system to
improve access to good quality
imaging.
Given the findings of this assessment both
the key achievements and the recognition
of the key challenges by the Local Lung
Cancer MDT in its latest Annual Report
are laudable, particularly those focusing
on improvements in diagnosis and active
treatment. These achievements are
reflected in the yearly improvements in
percentage of cases receiving a
histological diagnosis, anti-cancer
treatments, and surgical treatments.
Improving the viability of patients for such
treatments must involve improvements in
the general public‟s recognition and
presentation of the symptoms of lung
cancer, primary care, and secondary care,
but increasing the proportion of patients
receiving these treatments is a nationally
recognised method of increasing survival.
Active treatment
Active treatment is treatment aimed at a
cure.
From the 2009 audit, active anti-cancer
treatment (radiotherapy, chemotherapy,
surgery) is offered to 54% of patients in
England and Wales, which represents an
increase of 3% from the year previous.
However, this figure varies dramatically
between trusts, from less than 10% to
over 80%. For the comparative period,
49% of cases at Bolton Hospitals Trust
received some form of active treatment.
This is higher than the Greater
Manchester and Cheshire Cancer Network
as a whole, where just 39% of cases
overall received active treatment. The
2009 National Lung Cancer Audit states
that active anti-cancer treatment rates
below the national mean of 54% should be
reviewed:
“Cancer Networks and Hospital
Trusts need to examine their
processes for decisions on, and
referral for, cancer treatment, for
example by reviewing their local
treatment policies in light of
national guidance” (NLCA, 2009, pg.5)
Nationally, the percentage of patients
receiving active treatment is greatest for
those with Stage IIIb lung cancer. The
chart below depicts figures from the 2009
audit. At Stage IIIb NICE guidance
(quoted earlier in this assessment)
recommends that chemotherapy should
be first choice for patients able to undergo
active treatment, while some may be
suitable for radical radiotherapy or a
combination of chemotherapy and radical
radiotherapy. Taken overall, the Greater
Manchester and Cheshire Cancer Network
follows the pattern across the Stages of
lung cancer, but with a lower percent of
patients receiving active treatment at each
Stage. Presenting the data this way
eliminates Stage as a factor in the
likelihood that a patient receives active
treatment, thus, the lower percentage may
be a result of later referrals from primary
care, a higher prevalence of co-
morbidities, or the processes and referral
strategies of Trusts within the Network.
The exception is of course treatment for
those presenting with Stage IIa lung
cancer for which 100% of patients in the
Network received active treatment,
however this should be ignored as Stage
IIa accounts for the smallest proportion of
all staged lung cancers, just 0.6% in 2007,
and so the count at Network level will be
very small.
The percentage of those receiving active
treatment follows closely the aetiology of
lung cancer and declines with age. The
Greater Manchester and Cheshire Cancer
Network follows the national pattern, but
again a lower percentage of active
treatment is carried out at each age group.
Of importance is the much wider gap for
the under 65 age group; in comparison the
65 to 80 and the older than 80 years age
groups are much closer to the national
proportion. If we are to be below the
national rates because we are dealing with
more disease and as a result of other
associated factors, if equitable we should
at the very least be consistently below.
The difference may be associated with
socioeconomic deprivation and people
developing lung cancer younger in the
Network than nationally, and having
poorer general health and so more co-
morbidities making them unfit for active
treatment, but this appears a considerable
gap that the Network should work to
address if it is to improve its services for
the local population who develop lung
cancer.
Again, the Greater Manchester and
Cheshire Cancer Network follows the
national pattern for percentage receiving
active treatment by performance status.
The two have almost identical figures for
all performance status levels except
performance status level 1. At this level, a
level at which patients are more likely to
be able to undergo more intensive
treatments, the Network has a far lower
proportion of patients receiving active
treatment. This is a gap that can be
addressed by improving referral
procedures and extant processes for lung
cancer treatment in the individual trusts
working under the auspices of the
Network.
From these charts it is clear that, taking
Stage, age, and even performance status
into account, patients in the Greater
Manchester and Cheshire Cancer Network
are less likely to receive active treatment
than those in other parts of the country.
This reveals the variation in lung cancer
services and contributes to the poorer
outcomes (higher mortality rates and lower
survival rates) regionally.
Specific treatments
As mentioned throughout this assessment
the key part of the pathway in the
successful treatment of lung cancer is
early diagnosis and quick referral to
secondary care. Analysis of treatments
for radiotherapy, chemotherapy, and
surgery by residents of Bolton will not
reveal much as these represent what
happens to patients already diagnosed.
To improve the uptake and the equity of
these services we need to improve upon
and achieve early diagnoses across all
quintiles. However, it is important to
assess the provision and success of these
treatments as a whole for the Bolton
population.
Radiotherapy
Radiotherapy is provided locally principally
through outreach sessions from clinicians
at the Christie Hospital. Radiotherapy can
be given to patients as an active treatment
(radical radiotherapy), or palliative
radiotherapy may be used to control and
relieve symptoms such as breathlessness,
chest pain, cough, and coughing up blood.
Radical radiotherapy is typically given
every week day with a break at weekends
and may last for between three to seven
weeks. Palliative radiotherapy is often
given only once or twice as treatment,
again every weekday with a break at
weekends85.
The Christie does not participate fully in
the 2009 National Lung Cancer Audit as it
is a tertiary trust. This means the Christie
has a high tertiary workload but is not
normally a trust where a patient is first
seen, thus it is inappropriate for
comparison with other trusts (South
Manchester University Hospitals Trust is
also a tertiary trust and so has also been
excluded). However, 33% of all cases
recorded in the 2009 audit by Bolton
Hospitals Trust received radiotherapy.
This is higher than the Greater
Manchester and Cheshire Cancer Network
as a whole (21.5%), and shows the Trust
as the third highest in the Network for this
indicator. In addition, the percentage
receiving radiotherapy at a national level is
25.1%.
Radiotherapy is usually given by directing
high-energy X-Ray‟s at the lung from an
external radiotherapy machine, and this is
known as „external beam radiotherapy‟ (as
85
Macmillan (2010) www.macmillan.org.uk
opposed to internal radiotherapies such as
endobronchial radiotherapy or
brachytherapy). Treatment of external
beam radiotherapy is normally divided into
a number of fractions, usually given on a
daily basis. The National Lung Cancer
Audit found considerable variation in
radiotherapy provision across Cancer
Networks; the need for standardisation of
cancer services, especially for lung
cancer, is a point continually made
throughout the various Audit reports. The
Lung Cancer Commissioning Toolkit
predicts that demand on radiotherapy is
set to increase over the next ten years.
The Toolkit affirms that cancer centres
must have a range of policies and
procedures in place to ensure the
precision of the treatment given whilst also
adhering to standards of safety and
patient care. The following will outline the
key quality measures that relate to The
Christie as outlined in the Manual of
Cancer Services.
The chart above shows the number of
fractions per million population delivered
by all local radiotherapy centres for
2007/08. The NRAG report recommends
that by 2010/11 an interim goal of 40,000
fractions per million population should be
met by radiotherapy services. This goal
recognizes that the workforce and linear
accelerator capacity of radiotherapy
services needs to be expanded to meet
the increased demand expected in the
future.
For the 2007/08 audit period the Christie
Hospital carried out 23,527 fractions per
million. This is an improvement on
2006/07 where 20,542 fractions per million
were carried out. This means that as
illustrated on the the below chart the
Christie is the Radiotherapy Centre
carrying out the seventh lowest fractions
per million; in 2006/07 the Centre was the
third lowest.
Also of interest are the average fractions
per linear accelerator per year. This
performance indicator is based on the
NRAG report which recommends 8,300
fractions per annum averaged across all
linear accelerators in a department by
2010/11.
The chart below shows that for 2007/08
the Christie had 7,547 average fractions
per linear accelerator per year. This is
almost exactly average for all
Radiotherapy Centres in England. For
2006/07 the Christie was slightly below
average, but had a similar figure for this
indicator of 7,260.
The Cancer Reform Strategy identifies key
priorities for improving the treatment of
cancer patients, of which the development
of world class radiotherapy services is a
part. The indicator 3E compliance
measures the performance of radiotherapy
services against measures identified in the
Manual for Cancer Services. These
measures focus on measuring high quality
through clearly defined leadership and
organisational arrangements, adequate
provision of professional staffing and
equipment, minimising delays for
treatment and breaks in treatment, the use
of standardised processes for prescribing
and checking radiotherapy treatments, the
use of standard principles for the delivery
of radiotherapy, and the existence of clear
documentation and quality assurance
processes.
The second chart below shows the localities is 81% (median 84%), and so the
Christie to have 75% compliance with 3E Christie falls just below this.
measures. The mean average for all
Chemotherapy
Chemotherapy is the use of anti-cancer
(cytotoxic) drugs to destroy cancer cells by
disrupting their growth. Most
chemotherapy drugs are injected into the
vein or through a drip, but some are pills
the patient must swallow. Typically, a
patient will receive a combination of two or
three different drugs and have
chemotherapy every three or four weeks.
A patient will usually receive four to six
treatments, and so a typical course can
take three to four months.
A patient with non-small cell lung cancer
may receive chemotherapy before or after
surgery or radiotherapy. In advanced
disease a patient may receive a combined
treatment of radiotherapy and
chemotherapy. Finally, chemotherapy
may be used to control the symptoms of
non-small cell lung cancer.
In the 2009 audit 14.2% of all non-small
cell lung cancer cases (of which there
were 169) at Bolton Hospitals Trust
received chemotherapy. This is just
above average for the Greater Manchester
and Cheshire Cancer Network (12.2%)
(South Manchester has been removed as
a tertiary trust).
From NICE guidance discussed
previously, chemotherapy should be the
first recommended choice for patients
presenting with Stage IIIb or IV non-small
cell lung cancer. Of the non-small cell
lung cancer patients received by Bolton
Hospitals Trust 56.2% were diagnosed at
Stage IIIb or IV and this figure is the
highest in the whole Network. At Bolton
Hospitals Trust, of the 56.2% presenting
with Stage IIIb or IV non-small cell lung
cancer, only 12.6% received
chemotherapy.
The 2009 audit identifies the national
mean for chemotherapy rates for
performance status 0-1 stage IIIb or IV
non-small cell lung cancer as 48%. The
figure for Bolton Hospitals Trust is 27.8%,
which is similar to that for the Network as
a whole (26.2%).The audit recommends
all Trust‟s below the national mean should
be reviewed.
Improving the resection rate for non-small
cell lung cancers is considered the
greatest way of reducing the mortality rate
and increasing the survival rates in these
patients86. Surgery is inappropriate for
small cell lung cancer as this is the most
aggressive form of the disease and
spreads to the rest of the body very
quickly. However, small cell lung cancer
is extremely chemosensitive, and for this
reason it is the main treatment for small
cell lung cancer. Furthermore, as
chemotherapy treats the whole body (as it
travels through the blood stream) it can
treat the cells that have broken away from
the main lung tumour87. From the 2009
audit Bolton Hospitals Trust treated 44.4%
of its small cell lung cancer patients, a
figure similar to the Network as a whole
(43.6%). After Central Manchester (21
cases) Bolton Hospitals Trust recorded the
greatest number of small cell cases in the
Network (18 cases). This is similar to the
2007 audit where Bolton Hospitals Trust
recorded 15 small cell cases, however,
80% of these received chemotherapy.
However, the 2009 figure of 44.4% falls
86
The Information Centre (2009) National Lung Cancer
Audit: Report for the audit period 2007, The IC, London
87
Cancer Research UK (2010)
www.cancerresearchuk.org
below the national mean (62%) and the
audit recommends that chemotherapy
rates for small cell lung cancer falling
below this should be reviewed.
The Cancer Reform Strategy identified key
priorities for improving treatment to
patients. The metric „Compliance with 3C-
1 measures‟ provides an indication of the
performance of chemotherapy services, in
particular the Clinical Chemotherapy
Services, against measures contained
within the Manual for Cancer Services.
The metric considers governance
arrangements for the chemotherapy
service, the local chemotherapy group,
guidelines and protocols, patient centred
care, safe delivery of chemotherapy, safe
workload arrangements, 24 hour
telephone advice, staff training, and
service improvement.
Percentage compliance with 3C-1
measures concerns clinical chemotherapy,
3C-2 the oncology pharmacy service, and
3C-3 IT chemotherapy.
As a locality, Bolton has 58% compliance
with 3C-1 measures. For comparison,
average compliance for all localities is
73%, and compliance for the whole
Greater Manchester and Cheshire Cancer
Network is 67%.
As a locality, Bolton has 82% compliance
with 3C-2 measures. For comparison,
average compliance for all localities is
81% (median 91%), and compliance for
the whole Greater Manchester and
Cheshire Cancer Network is 78%.
For 3C-3 measures Bolton has a
compliance of 0% as it has zero counts for
usage concerning this metric (IT
chemotherapy).
All charts and data discussed previously in
this section are from the Cancer
Commissioning Toolkit88.
Surgery
The majority of lung cancer cases
requiring surgery in Bolton are referred to
the Manchester Royal Infirmary at Central
Manchester University Hospitals NHS
88
Cancer Commissioning Toolkit (2010)
www.cancertoolkit.co.uk
Trust. The National Lung Cancer Audit
records cases by the Trust at which they
were first seen. (South Manchester has
been excluded as a tertiary trust).
From the 2009 audit, 12.9% of all lung
cancer cases within the Greater
Manchester and Cheshire Cancer Network
receive surgery. There is great variation
within the Network; Bolton Hospitals Trust
is around this average with 13.9%
receiving surgery, Central Manchester is
the lowest with only 11.5% receiving
surgery, whilst East Cheshire NHS Trust
achieved resection rates over 45%.
However, East Cheshire receives a
relatively small amount of cases (53
compared to 194 for Bolton Hospitals
Trust and 113 for Central Manchester,
whilst Wrightington, Wigan, and Leigh,
and Pennine Acute Hospitals Trust‟s both
recorded over 300 cases in 2009). The
surgical resection rate in England and
Wales is 11%. The audit recommends
that all trusts below the national mean
should be reviewed. The main Trust‟s of
greatest importance to the population of
Bolton and the Network as a whole all
achieve the national mean.
Surgery is mostly appropriate for non-
small cell lung cancer. In the Greater
Manchester and Cheshire Cancer Network
only 10.9% of all non-small cell lung
cancer cases receive surgery. For Bolton
Hospitals Trust this figure is 8.9%. Again,
this is about average for most Trust‟s
within the Network, with East Cheshire
achieving 40%. (Again, in comparison
East Cheshire receives relatively few
cases of non-small cell lung cancer).
Odds ratios represent a more considered
and comparable measure of resection
rates across Trust‟s. The odds ratio
shows those having surgery in a specific
Trust/Network relative to the whole
Lucada population, adjusted for
composition of population in terms of age,
sex, socioeconomic status, and stage. An
odds ratio less than one suggests that the
outcome for patients in the Trust/Network
is less likely than the population average
and the converse for odd ratios above
one. This is not a statistically significant
observation if the confidence intervals
span one (identified on the below chart by
the red line). East Cheshire has been
excluded from the chart as it has an
extreme odds ratio (13.4) comparative to
the group.
As evident, all Trust‟s around one also
have confidence intervals that span one
and so no firm conclusions can be drawn.
Mesothelioma audit: Greater where many of the tests used to diagnose
Manchester and Cheshire Cancer lung disease prove negative89.
Network
Bolton participated in the Greater
Mesothelioma is a relatively rare cancer Manchester and Cheshire Cancer Network
and it is difficult for GPs to effectively Mesothelioma audit.
diagnose suspected cancer as symptoms
may often be similar to much more minor Outcomes
conditions. NICE guidelines state that
GPs should refer patients for an urgent Majority (86%) of GP referrals
chest X-Ray if they have been exposed to seen in two weeks, but
asbestos in the past and have chest pain, subsequent delays in diagnosis
difficulty breathing, or unexplained
were evident;
symptoms lasting more than three weeks
such as shoulder pain, cough, or weight Very low diagnostic value of
loss. Where a chest X-Ray shows pleural fluid cytology;
anything abnormal the patient will be Delays for patients having open
referred to a specialist (according to the surgical biopsies after non-
two-week rule this is expected to be within diagnostic Abrams/percutaneous
two weeks of the original GP visit).
biopsy;
In addition to a chest X-Ray, diagnosis Performance of Greater
tests for mesothelioma may also include a Manchester and Cheshire Cancer
CT scan, a thorcoscopy, a laparocoscopy Network cohort higher than
with a biopsy, or involve fluid drainage national Lucada data;
from around the lungs. This is because of MDT discussion for 58% of
the difficulty in diagnosing mesothelioma
patients;

89
Cancer Research UK (2010)
www.cancerresearchuk.org
 Low referrals to palliative care
consultants;
Audit found that 66% of patients
were recorded as being seen by a
Specialist Nurse.
Recommendations made following the
audit
Patients over 50 years of age with
pleural effusion and history of
asbestos exposure should be
treated as „two-week wait‟ patients
with expedited CT and diagnostic
tests;
Need improved access to
diagnostic biopsy services
(especially thoracoscopy);
All patients PS-2 or less, who may
be suitable for treatment, should
be discussed by SMDT;
Need for improved/earlier referral
to Specialist Nurses and palliative
care consultants;
Patient survey required.
Future work
From the above, earlier presentation of
symptoms and earlier diagnoses are key
to improving outcomes for lung cancer in
Bolton.
The National Cancer Action Team and the
Royal College of General Practitioners
undertook a primary care cancer audit in
the Greater Midlands Cancer Network in
March 2010. This also involved analysis
of SEAs and a current local version may
again prove useful.
Finally, Doncaster PCT have successfully
undertaken a social marketing project to
improve early presentation and diagnosis
of lung cancer in primary care and
increase uptake of X-Rays for patients
presenting with a persistent cough. This
project also targeted the families of the
key risk group identified (men over the age
of 50 in the most deprived areas of
Doncaster). Furthermore, Doncaster PCT
conducted an X-Ray audit of the local
acute trust and used this as one measure
of the success of the programme. This
work is provided here as Appendix d. as it
is a relatively brief document and contains
other useful information relevant to this
assessment.
These examples of good practice point the
way towards future work that has the
potential to improving early diagnosis of
lung cancer at primary care in Bolton. In
the absence of local work, the findings
from other areas discussed and
referenced here serve as a proxy as what
works and the problems encountered in
primary care.

Several important pieces of work have

been referenced above in determining
actions to better increase uptake of
services in those most at risk and to
identify what works in better
training/equipping GPs and other health
professionals in diagnosing lung cancer.

The most significant of these was the

Significant Event Audit (SEA) analysis of
lung cancer in primary care undertaken in
the North of England Cancer Network. A
similar audit undertaken in the Greater
Manchester and Cheshire Cancer Network
will increase the local evidence base on
what works in primary care; however, the
results may not differ dramatically from
those discussed.

Mortality in hospital90
Activity definitions:
Episode: The continuous period during which a
patient is under the care of one consultant
team.
Spell: One or more episodes linked into a
period of continuous care at a single provider
from date of admission to date of discharge.
Superspell: First spell from a group of spells
linked together by transfer.
Expected deaths: The expected number of
deaths when casemix adjusted.
Relative risk: The observed number of deaths
as a percentage of the expected number of
deaths.
The following details mortality (in hospital)
for the diagnosis group “Cancer of
bronchus, lung” during the period from
April 2005 to January 2010 for patients
within Bolton PCT (except where stated).
Over this period there were 1,868 spells
and 1,829 superspells for “Cancer of
bronchus, lung”. This activity resulted in
208 deaths from an expected 210.2
deaths. As such the relative risk is 98.9
(86.0 and 113.3 being the respective
confidence intervals).
“Cancer of the bronchus, lung” is the
“Neoplasm‟s” diagnosis group that
accounts for the greatest number of
hospital deaths. Table ak. shows the
breakdown of all 889 neoplasm deaths
over the period (excluding cancers with
deaths less than five). Despite the high
number of lung cancer deaths and spells,
diagnosis groups “Leukaemia‟s” and
“Multiple Myeloma” are the only two with a
significantly high relative risk, though the
respective confidence intervals are wide.
Over time there have been few significant
variations in the number of deaths
resulting from the lung cancer activity, and
90
Data is taken from The Real Time Monitoring Tool from
Dr. Foster (see bibliographic references)
though the number of deaths is low in
some quarters compared to others, and
this is reflected in the relative risks, no
change is consistent or significant and as
such over this period there has been little
cause for concern. Lung cancer mortality
is relatively consistent in its outcome at
Bolton PCT level (table al.).
Analysed by provider (table am.), the
relative risk is very low for Others and The
Christie, but is high for the Royal Bolton.
However, comparatively, this is likely due
to the number and purpose of these
providers when treating lung cancer. The
Royal Bolton is a major provider of
palliative and end of life care for lung
cancer patients and so we would expect a
high level of mortality here compared to
tertiary trusts like the Christie. However,
this is accounted for in the below table
where expected deaths are included in the
relative risk calculation. Therefore, taken
in isolation from the other providers, the
conclusion must be that the relative risk of
dying from “Cancer of bronchus, lung” is
higher than it should be for Royal Bolton
Hospital over this period. There are
27.9% more deaths than should be
expected over the entire period.
Table an. shows a drill down of all Royal
Bolton Hospital activity from the above by
calendar year from April 1996 to January
2010 (thus, 1996 and 2010 are not
representative). The years 2003, 2005,
and 2006 are those years having the
greatest negative impact upon the
mortality overall at the Royal Bolton, with
relative risks of 160.0, 161.7, and 146.8
respectively. However, for the last three
years of data (2007, 2008, and 2009) the
numbers of deaths and the associated
relative risks at the Trust have declined,
especially in the past two years.
Table ao. shows there to be no significant
difference in admissions and outcome by
Ward within Bolton. This picture carries
over into mortality by deprivation quintile
(in hospital).
In addition, there are no GP practices in
Bolton where there have been significantly
more lung cancer hospital deaths than
expected for casemix.
The majority of spells and superspells for
lung cancer (85.3%) occur under the care
of one consultant team. The below chart
analyses relative risk for diagnosis group
“Cancer of bronchus, lung” by how many
teams cared for patients during each spell.
Though not shown clearly on the chart,
there is statistical significance for mortality
in those spells where the patients were
under the care of two different consultant
teams. The number of deaths in those
being cared for by three different
consultant teams is relatively small, and
so the main conclusion to draw here is the
increased risk of mortality (in hospital) for
lung cancer patients in Bolton when under
the care of two different consultant teams,
though this may be representative of a
greater need in those under the care of
two consultants.
longer than one month. This picture can
be demonstrative of the condition at which
patients arrive at hospital. A high number
staying longer than one month may
indicate that these patients are admitted to
die. For this reason this is an important
indicator and value can be gained from its
future monitoring.
Table aq. shows mortality by length of
stay. There is little statistical difference,
but this analysis does show that the
greatest number of deaths occurs in the
medium to long length of stays, again
suggesting patients were admitted
primarily to die.

Table ap. shows mortality (in hospital) by

how many trust moves were involved in
the pathway of care. Where one trust only
is involved then the spells should match
the superspells, as evident below. There
are few trust moves for the majority of lung
cancer patients who die in hospital and
there is no statistical significance between
the number of moves in the pathway
where the outcome is death in hospital.
Given that the majority of active treatment
for lung cancer is provided at tertiary trusts
and other specialist sites we would
perhaps expect more spells within
superspells; this may point to patients
being admitted primarily for palliative and
end of life care.

Overall, the length of stay for all Bolton

PCT patients for lung cancer is lower than
would be expected when casemix
adjusted. However, the longer length of
stay bands 14-20 days, 21-27 days, and
28+ days, show a far higher length of stay
than would be expected when adjusted for
casemix. This may indicate inadequate
places for suitable discharge, such as
palliative care places. The total
percentage of all length of stays greater
than 14 days is 10.8%, with 3.2% staying
Table ak.
Bolton PCT: All mortality (in hospital) Cancer (April 2005 to January 2010)

Percent
Percent Percent
Diagnosis group Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)

ALL 22751 22576 100.0% 889 3.9% 871.7 3.9% 102.0 95.4 108.9

Cancer of bronchus, lung 1868 1829 8.1% 208 11.4% 210.2 11.5% 98.9 86.0 113.3
Secondary malignancies 1089 1073 4.8% 86 8.0% 85.8 8.0% 100.2 80.2 123.8
Malignant neoplasm without
248 242 1.1% 76 31.4% 61.8 25.5% 123.0 96.9 153.9
specification of site
Cancer of colon 730 730 3.2% 56 7.7% 61.7 8.5% 90.7 68.5 117.8
Cancer of oesophagus 822 815 3.6% 48 5.9% 47.0 5.8% 102.1 75.3 135.4
Cancer of pancreas 278 272 1.2% 44 16.2% 41.4 15.2% 106.3 77.2 142.7
Leukaemia‟s 1937 1925 8.5% 37 1.9% 25.8 1.3% 143.1 100.8 197.3
Non-Hodgkin's lymphoma 1191 1181 5.2% 34 2.9% 35.3 3.0% 96.3 66.7 134.6
Cancer of stomach 556 552 2.4% 34 6.2% 36.9 6.7% 92.1 63.8 128.8
Cancer of rectum and anus 555 553 2.4% 27 4.9% 25.5 4.6% 105.7 69.6 153.8
Cancer of prostate 326 325 1.4% 24 7.4% 19.6 6.0% 122.4 78.4 182.2
Cancer of breast 1483 1483 6.6% 22 1.5% 26.6 1.8% 82.6 51.7 125.0
Neoplasms of unspecified
nature or uncertain 925 919 4.1% 20 2.2% 12.4 1.4% 160.9 98.3 248.6
behaviour
Cancer of brain and nervous
474 451 2.0% 19 4.2% 20.7 4.6% 91.7 55.2 143.3
system
Cancer of ovary 381 373 1.7% 19 5.1% 20.7 5.5% 92.0 55.3 143.6
Cancer of liver and
112 111 0.5% 19 17.1% 17.4 15.6% 109.5 65.9 171.0
intrahepatic bile duct
Multiple myeloma 497 495 2.2% 17 3.4% 9.6 1.9% 177.4 103.3 284.1
Cancer of head and neck 488 483 2.1% 16 3.3% 15.5 3.2% 103.5 59.1 168.1
Cancer of bladder 1043 1043 4.6% 14 1.3% 20.7 2.0% 67.5 36.9 113.2

Cancer of other GI organs, 126 122 0.5% 12 9.8% 9.5 7.8% 126.6 65.3 221.2
peritoneum
Cancer of kidney and renal
213 210 0.9% 11 5.2% 14.2 6.7% 77.7 38.7 139.0
pelvis
Cancer, other and
173 169 0.7% 9 5.3% 7.3 4.3% 122.9 56.1 233.3
unspecified primary
Cancer, other respiratory
186 186 0.8% 8 4.3% 10.4 5.6% 76.6 33.0 150.9
and intrathoracic
Cancer of uterus 211 211 0.9% 6 2.8% 7.3 3.4% 82.6 30.2 179.8
 Table al.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)

Percent of Percent Percent

Trend (Quarter) Spells Superspells Deaths Expected RR Low High
all (%) (%) (%)

ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0

2005-Q2 90 89 4.9% 12 13.5% 10.6 11.9% 113.2 58.4 197.8

2005-Q3 94 94 5.1% 9 9.6% 12.2 13.0% 73.9 33.7 140.3
2005-Q4 119 117 6.4% 15 12.8% 13.2 11.3% 113.2 63.3 186.8
2006-Q1 96 96 5.2% 13 13.5% 13.6 14.2% 95.4 50.7 163.1
2006-Q2 114 111 6.1% 14 12.6% 11.8 10.6% 119.1 65.0 199.8
2006-Q3 105 102 5.6% 16 15.7% 10.1 9.9% 158.2 90.4 256.9
2006-Q4 128 126 6.9% 12 9.5% 11.0 8.7% 109.3 56.4 191.0
2007-Q1 116 116 6.3% 11 9.5% 11.2 9.7% 97.8 48.8 175.1
2007-Q2 136 132 7.2% 14 10.6% 15.1 11.5% 92.6 50.6 155.4
2007-Q3 113 109 5.9% 16 14.7% 14.7 13.5% 108.6 62.0 176.4
2007-Q4 68 65 3.5% 6 9.2% 7.1 10.9% 85.0 31.0 185
2008-Q1 83 83 4.5% 13 15.7% 11.2 13.5% 115.9 61.7 198.2
2008-Q2 93 92 5.0% 6 6.5% 9.2 10.1% 64.9 23.7 141.2
2008-Q3 88 87 4.7% 9 10.3% 11.5 13.2% 78.3 35.7 148.6
2008-Q4 82 80 4.4% 6 7.5% 8.3 10.4% 72.4 26.4 157.5
2009-Q1 77 73 4.0% 8 11.0% 7.2 9.9% 111.2 47.9 219.2
2009-Q2 88 88 4.8% 12 13.6% 12.2 13.8% 98.5 50.9 172.1
2009-Q3 78 76 4.1% 12 15.8% 9.5 12.4% 126.9 65.5 221.7
2009-Q4 74 72 X% <5 X% 8.0 X% X X X
2010-Q1 26 26 X% <5 X% <5 X% X X X

Table am.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)

Percent
Percent Percent
Provider Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)

ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0

Others 739 723 39.4% 18 2.5% 38.8 5.4% 46.4 27.5 73.4

Royal Bolton Hospital 715 705 38.4% 175 24.8% 136.9 19.4% 127.9 109.6 148.3
NHS Foundation Trust

The Christie NHS 292 285 15.5% 10 3.5% 26.2 9.2% 38.2 18.3 70.3
Foundation Trust

Central Manchester
101 100 X% <5 X% <5 X% X X X
University Hospitals
NHS Foundation Trust

Salford Royal NHS 15 15 X% <5 X% <5 X% X X X

Foundation Trust

Wrightington, Wigan and

6 6 X% <5 X% <5 X% X X X
Leigh NHS Foundation
Trust
Table an.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 1996 to January 2010),
Royal Bolton Hospital

Percent
Percent Percent
Trend (Year) Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)

ALL 2205 2196 100.0% 557 25.4% 462.5 21.1% 120.4 110.6 130.9

1996 97 97 4.4% 30 30.9% 23.1 23.8% 129.9 87.6 185.4

1997 173 171 7.8% 43 25.1% 39.6 23.2% 108.5 78.5 146.2
1998 187 186 8.5% 46 24.7% 44.5 23.9% 103.4 75.7 137.9
1999 198 198 9.0% 35 17.7% 36.5 18.4% 95.8 66.8 133.3
2000 181 181 8.2% 42 23.2% 35.2 19.4% 119.4 86.1 161.4
2001 181 181 8.2% 38 21.0% 39.1 21.6% 97.2 68.8 133.4
2002 192 191 8.7% 43 22.5% 35.0 18.3% 122.9 89.0 165.6
2003 165 163 7.4% 59 36.2% 36.9 22.6% 160.0 121.8 206.3
2004 94 94 4.3% 30 31.9% 26.5 28.2% 113.2 76.4 161.7
2005 94 93 4.2% 42 45.2% 26.0 27.9% 161.7 116.5 218.6
2006 155 155 7.1% 45 29.0% 30.7 19.8% 146.8 107.0 196.4
2007 177 176 8.0% 39 22.2% 30.0 17.0% 130.2 92.6 178.0
2008 150 150 6.8% 30 20.0% 26.6 17.7% 112.8 76.1 161.0
2009 148 147 6.7% 32 21.8% 29.7 20.2% 107.7 73.6 152.0
2010 13 13 X% <5 X% <5 X% X X X
Table ao.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)

Percent
Percent Percent
Ward (Census) Spells Superspells of all Deaths Expected RR Low High
(%) (%)
(%)

ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0

Astley Bridge (00BLFA) 141 135 7.4% 14 10.4% 14.7 10.9% 95.0 51.9 159.5
Kearsley (00BLFR) 122 120 6.5% 15 12.5% 16.1 13.4% 93.3 52.2 153.8
Breightmet (00BLFD) 114 114 6.2% 11 9.6% 10.7 9.4% 103.2 51.4 184.6
Deane-Cum-Heaton (00BLFJ) 111 108 5.9% 12 11.1% 13.1 12.2% 91.3 47.1 159.5
Horwich (00BLFP) 107 103 5.6% 11 10.7% 9.8 9.5% 112.7 56.2 201.6
Westhoughton (00BLFW) 100 100 5.5% 11 11.0% 7.6 7.6% 143.9 71.8 257.6
Central (00BLFG) 95 93 5.1% 10 10.8% 10.8 11.6% 92.3 44.2 169.8
Smithills (00BLFT) 90 89 4.9% 9 10.1% 8.8 9.9% 101.8 46.4 193.2
Tonge (00BLFU) 90 89 4.9% 5 5.6% 10.4 11.7% 48.1 15.5 112.2
Blackrod (00BLFB) 89 89 4.9% 10 11.2% 8.6 9.7% 115.9 55.5 213.2
Burnden (00BLFF) 89 86 4.7% 7 8.1% 7.9 9.2% 88.5 35.4 182.3
Derby (00BLFK) 88 85 4.6% 8 9.4% 10.0 11.8% 79.8 34.4 157.3
Farnworth (00BLFL) 88 86 4.7% 13 15.1% 10.6 12.3% 122.6 65.2 209.6
Harper Green (00BLFN) 80 78 4.3% 9 11.5% 14.9 19.1% 60.3 27.5 114.4
Hulton Park (00BLFQ) 78 78 4.3% 11 14.1% 8.2 10.5% 134.6 67.1 240.9
Little Lever (00BLFS) 77 76 4.1% 12 15.8% 8.8 11.6% 136.1 70.2 237.7
Bradshaw (00BLFC) 73 73 4.0% 8 11.0% 7.5 10.3% 106.0 45.6 208.9
Daubhill (00BLFH) 68 66 3.6% 15 22.7% 11.9 18.0% 126.0 70.5 207.9
Halliwell (00BLFM) 64 63 3.4% 8 12.7% 8.3 13.2% 96.5 41.5 190.1
Bromley Cross (00BLFE) 60 60 3.3% 6 10.0% 6.9 11.4% 87.4 31.9 190.3
Table ap.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)

Percent
Spells in Percent Percent
Spells Superspells of all Deaths Expected RR Low High
superspell (%) (%)
(%)

ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0

1 1776 1776 96.8% 197 11.1% 195.9 11.0% 100.6 87.0 115.6
2 70 46 2.5% 12 26.1% 12.1 26.2% 99.4 51.3 173.7
3 21 11 X% X X% X X% X X X
4 X X X% X X% X X% X X X

Table aq.
Bolton PCT: All mortality (in hospital) Cancer of bronchus, lung (April 2005 to January 2010)

Percent
Length of Percent Percent
Spells Superspells of all Deaths Expected RR Low High
stay (%) (%)
(%)

ALL 1868 1834 100.0% 211 11.5% 211.8 11.5% 99.6 86.7 114.0

DC 620 619 33.8% 0 0.0% 0.0 0.0% - 0.0 0.0

0 Days 172 171 9.3% 19 11.1% 19.6 11.4% 97.1 58.4 151.6
1-6 Days 639 621 33.9% 70 11.3% 82.6 13.3% 84.7 66.0 107.0
7-13 Days 236 229 12.5% 65 28.4% 54.5 23.8% 119.3 92.1 152.0
14-20 Days 85 81 4.4% 26 32.1% 22.0 27.2% 117.9 77.0 172.8
21-27 Days 56 53 2.9% 15 28.3% 14.6 27.5% 102.9 57.5 169.7
28+ Days 60 60 3.3% 16 26.7% 18.4 30.7% 86.9 49.6 141.1

End of life care
Given the low survival rate of lung cancer
patients, palliative and end of life care are
very important.
In general in Bolton the Primary Care
Team and GPs lead the provision of end
of life care, whilst a range of other
services are provided by the Primary Care
Trust itself and its partners. Bolton
Hospice provides specialist care services,
predominantly to cancer sufferers. In
addition there are several community and
hospital based Macmillan Clinical Nurse
Specialists in Palliative Care who provide
specialist care for cancer patients at the
end of life.
Palliative treatment for lung cancer
typically consists of well managed pain
relief, palliative radiotherapy, and
supplemental oxygen therapy. In patients
with obstructive lesions other procedures
such as brachytherapy, bronchoscopic
laser therapy, or the placing of surgical
stents may allow for improved control of
symptoms. Counselling services are also
vital and are provided by specialist cancer
nurses, such as Macmillan Nurses.
End of life treatment is a very personal
aspect of a patients care and needs may
be different for each patient depending
upon physical symptoms and pain
management, social situation, emotional
problems, spiritual issues, and family
and/or carer issues. The combination of
these factors results in a very complex
stage of the lung cancer care pathway.
“End of life care involves active,
compassionate approach that
treats, comforts, and supports any
individual with a progressive life
threatening condition and who is in
the last six to twelve months of life”
(Bolton PCT, End of Life Care Strategy, 2007,
pg.5)
Bolton PCTs end of life care strategy aims
to underpin the above statement with
evidence-based practice originating in the
three key tools for end of life care:
1. Gold Standards Framework;
2. Liverpool Care Pathway;
3. Preferred Place of Care.
Furthermore, the strategy was informed by
a consultation on end of life care;
feedback from this consultation is provided
in the strategy itself but is also in the
appendix of this assessment for reference
(appendix b.).
Gold Standards Framework
The Gold Standards Framework is a
system allowing patients approaching the
end of life to be identified, their care needs
assessed, and a plan of care with all
relevant agencies put into place. The key
aspects of the framework are the
optimisation of the continuity of care, an
emphasis of teamwork, the need for
advanced planning, effective symptom
control, as well as patient, carer, and
professional support. The framework was
initially designed for use in primary care
but can be employed in care homes and
for all disease groups.
The following is taken from the Bolton
PCT End of Life Care Strategy and
provides a local lung cancer case study
whose care was appropriately managed in
line with the Gold Standards Framework
and so represents an exemplar of best
practice.
Local case study: Care Co-ordination, using the Gold Standards Framework in
General Practice

“David developed lung cancer in his late 50s. He was treated initially with surgery that
unfortunately was unsuccessful. Secondary cancers developed and David needed palliative
chemotherapy and radiotherapy. Despite this treatment he still had some symptoms that
were managed in conjunction with the Bolton Hospice Team. Another complication for him
was the development of diabetes as a result of some of his treatment. Despite these quite
complex problems, in the last 6 months of his life, David was managed at home (his and his
family‟s expressed wish) where he died peacefully surrounded by his family.

Gold Standards Framework meant that the practice had a system in place for identifying
people in David‟s position. This allowed a key health professional to be identified and be the
first port of call for David or his family. David was consulted about his care at all times, and
his wishes regarding where he would like to receive care and spend his last days were
sought. At this stage he had time to discuss his wishes with his family and the team were
able to plan for his needs and anticipate potential problems. His care was discussed within
the team regularly; this meant that good continuity was obtained even when his main contact
was unavailable.

The GPs had actively sought education regarding symptom control and so had the skills to
deal with his complex problems and knew where and when to seek help. In the end phase of
his illness, David‟s problems were anticipated so if they arose medicines and equipment
were already available in his home. The Gold Standards Framework meant that there was a
good relationship between the district nurses and the practice team and all worked together
in a co-ordinated way to provide the best standard of seamless care. After David‟s death his
family was able to continue to seek support from the practice, recognising that care needs
for family and carers extend beyond the death to include the period of bereavement.”

(Source: Bolton PCT, End of Life Care Strategy, 2007, pg.12)

Key to this aspect of the strategy is active
case management. Active case
management is a service targeting
patients with complex health needs and
who use health services frequently with
support from a health professional to
manage their own health better. As
identified in the strategy, increasing the
number of patients in Bolton who receive
active case management will greatly
improve quality of end of life care in Bolton
in line with the Gold Standards
Framework.
Pathway are a strong emphasis upon
communication with the patient and their
family, anticipatory planning including
psychosocial and spiritual needs, effective
symptom control, and continuing care
following death.
The following is taken from the Bolton
PCT End of Life Care Strategy but is an
example of best practice for lung cancer
palliative care in line with the Liverpool
Care Pathway from a national report.

Liverpool Care Pathway

The Liverpool Care Pathway for the Dying

Patient is designed to translate the best of
hospice care into care for patients in
hospital and other settings. The Pathway
is used to deliver care for people during
their last hours of life once it is known they
are dying. The key aspects of the
Case Study: Example from national report

“Emily had been diagnosed with advanced heart failure and lung cancer and although she
had repeated admissions to hospital with similar symptoms, she was significantly weaker on
this occasion and did not respond to the usual interventions. The Specialist Palliative Care
team was asked to get involved in her symptom management.

Although her pain and breathlessness settled with appropriate support and medication, she
remained weak and fatigued and she felt she was too frightened to be nursed at home. The
option of a care home placement was discussed and it was explained that support would be
available at the end of life through the Liverpool Care Pathway.

Emily was transferred to the care home within two weeks. She died three months later.

A few days prior to Emily‟s death, the staff in the care home were able to recognise that
Emily was deteriorating. In discussion with the family, it was agreed that she should not be
admitted to hospital and the LCP was initiated. An assessment of Emily‟s needs was
undertaken which included psychological, social, spiritual and physical aspects, and included
stopping oral medication and prescribing medication by other routes for symptoms such as
pain, breathlessness, nausea and vomiting. Her daughter said, „I think the culture of the
care home was excellent and the Liverpool Care Pathway helped the staff to help my mum
and me. I will miss her terribly but I know her care was the best it could be and that helps.‟

Benefits of using Liverpool Care Pathway in this situation: The LCP provided a structure
within which excellent care could be given in the final days of life without readmission to
hospital. This meant that disruption was avoided for the resident and the LCP gave the care
team confidence to manage the situation.”

(Source: Bolton PCT, End of Life Care Strategy, 2007, pg.22)

The Strategy identifies a reduction of the
number of deaths in the Royal Bolton
Hospital who are residents of a care home
as key to implementing the Liverpool Care
Pathway.
show the importance of the Preferred
Place of Care Plan in the provision of end
of life care.

Preferred Place of Care

The Preferred Place of Care Plan is a

document retained by the patient when
receiving care in different places. It allows
the patient to document their opinions and
thoughts concerning their care and the
choices they would like to make, including
the setting in which they would prefer to
die. Information can also be recorded
about the family of the patient to enable
new care staff to learn who‟s who and
what matters most to the patient.

The following is taken from Bolton PCTs

End of Life Care Strategy and does not
concern lung cancer specifically, and is
taken from a national report, but it does
Case Study: Example from national document

“Derek was 62 and had been in a care home for three months. He was admitted following a
stroke from which he never fully recovered. He was also suffering from dementia. His wife
Betty had visited every day but had been looking increasingly tired. Derek had his own
business but passed this on to his two sons when he started having difficulties due to
dementia. Visits from their sons were rare as they lived in the South.

Derek had another chest infection for which the doctor prescribed antibiotics. One day Betty
asked to discuss Derek‟s care; she cried as she spoke about her concerns. She asked that
next time Derek developed a chest infection it should not be treated. She did not want him to
be transferred to hospital, as he was last time, as this was traumatic and Derek‟s dementia
seemed to worsen after this. Derek was very comfortable in the home and it was easier for
Betty to visit. She felt that nature should take its course. She said that she had not discussed
this with her sons but felt that after being married to Derek for so long, she knew him best
and that previously when in good health he had talked of not wanting to end his days in
dependence. She added that he would have hated to be like this and for their sons to
witness his demise.

The benefits of using PPC in this situation:

The Preferred Place of Care provides a mechanism to facilitate discussions between the
individual and their families earlier in the process of care. It records an individual‟s
preferences and can initiate establishment of advance directives if the person wants to
decline medical treatment. The PPC process includes the opportunity to regularly review
options and to ensure that the difficult discussions about end of life care are recorded and
available to all of the teams involved in the delivery of an individual‟s care.”

(Source: Bolton PCT, End of Life Care Strategy, 2007, pg.25)

The implementation of the Preferred Place
of Care Plan is a key aspect in increasing
the number of people in Bolton who, in
agreement with their carers, wish to be
supported to die at home. For all deaths,
the baseline figure is identified in the
strategy as 16% (2004) with the aim to
increase this figure to 50% by April 2011.
The latest available figure is for 2006/08
and is 18.7%. The comparative figure for
both England as a whole and the North
West is 19.5%. Deaths at home due to
lung cancer is discussed below.
Deaths at home
Having an indicator measuring the
percentage of deaths at home due to lung
cancer is important if we remember lung
cancer services have three main aspects.
The first is prevention, which is almost
exclusively the reduction of cigarette
smoking as the disease would practically
be eliminated if no one smoked. The
second aspect is curative. Most lung
cancer is incurable, but services and
research concentrate mostly on
developing different treatment
modalities91. The caring aspect is where
deaths at home are important. In order to
improve palliative care for cancer patients
at the terminal stages of life, more patients
should be allowed the choice of dying at
home.
End of life care is an important issue for a
disease that is often terminal; from
previous sections we know that only 7% of
lung cancer patients in Bolton can expect
to still be alive five years after diagnosis.
The Department of Health has identified a
„mismatch‟ between people‟s preferences
for where they would prefer to die and
their actual place of death. Findings that
motivated the Department of Health‟s End
91
Stevens, A. et al (2004) Health Care Needs
Assessments, Radcliffe Publishing Ltd., Oxford.
of Life Care Strategy92 reveal that most
people would probably like to die at home,
but nationally, acute hospitals account for
58% of all deaths. Furthermore, the Care
Quality Commission found that 54% of all
complaints in acute hospitals relate to care
of the dying/bereavement93. Table ar.
shows the percentage of all lung cancer
deaths that occur at home. Bolton is
below both the national and regional
averages, as well as many of its statistical
peers.

We cannot compare the percentage of

deaths at home due to lung cancer with
other diseases or even other cancers
because of the effect of casemix.
Basically, the specific cause of death, the
acuteness of onset, and the type of
palliative care and symptom control
needed all have implications upon those
wishing to die at home being able to do
so.

However, the Department of Health define

the purpose of this indicator as being:

“to improve palliative care and

service planning for patients in the
terminal stages of life, allowing
more of them the choice of dying at
home.” (Source: nchod)

In light of this purpose it is worth

monitoring the trend of the percentage of
lung cancer deaths that occur at home in
Bolton. This is shown below where
increases are evident in the latest periods.
A consistently increasing trend into the
future is the desired outcome for this
indicator as a measure of the palliative
care of lung cancer and how well that care
is planned and managed.

92
Department of Health (2008) End of Life Care Strategy:
promoting high quality care for all adults at the end of life,
DoH, London.
93
Care Quality Commission (2010) www.cqc.org.uk
Table ar.
Deaths at home from lung cancer, persons

2006/08 95% Confidence

OBS Percent
Lower Upper

England 22779 27.3 27.0 27.7

North West 3922 28.1 27.4 28.8

Bolton 130 25.8 22.2 29.8

Heywood, Middleton, & Rochdale 101 24.6 20.7 29

Tameside & Glossop 137 28.0 24.2 32.2
Oldham 103 22.7 19.1 26.8
Coventry 145 30.8 26.8 35.1
Walsall 155 32.6 28.5 36.9
Ashton, Leigh, & Wigan 136 22.6 19.5 26.1
Bury 97 26.3 22.0 31.0
Dudley 134 27.6 23.8 31.7
Kirklees 204 29.2 25.9 32.7
Bradford & Airedale 257 30.3 27.3 33.4
Salford 139 23.8 20.6 27.5
Halton & St. Helens 213 35.6 31.9 39.5
Wakefield 175 24.8 21.8 28.1
Rotherham 154 28.6 24.9 32.5
Sandwell 132 23.7 20.4 27.5
Palliative care at Royal Bolton Hospital initially seen as a two-week referral at the
Royal Bolton and diagnosed with lung
The provision of palliative care is divided cancer went on to receive end of life care
into two categories: at the trust.

1. General care: care provided in As can be expected from palliative care

primary care by GPs, district data the greatest proportion of patients are
nurses, and other allied health in the later stages of lung cancer and the
average age at diagnosis is above 70
professionals;
years.
2. Specialist care: care provided by
consultants in palliative medicine, Table as.
nurse specialists such as Royal Bolton Hospital: Staging, palliative care

Macmillan Nurses and other allied

health professionals. Typically, Stage I 11.5%
people with unresolved symptoms Stage II 6.1%
or complex psychosocial end of life Stage III 37.9%
issues access these specialist Stage IV 44.6%
services.
Table at.
Royal Bolton undertakes the majority of Age at diagnosis
specialist palliative care for Bolton‟s lung
cancer patients; however, specific
treatments which may be used palliatively, 2005 71.2
such as chemotherapy, are carried out at 2006 71.1
the appropriate trust.
2007 70.7

End of life care is an area vital to assess 2008 70.5

the needs of the population as these are 2009 72.4
frequently the people unsuitable for further
active treatment. Age and stage are
The average age of all patients is around
particularly important here as we need to
71 years and the age group 71-80 account
reduce the number of people in younger
for 34% of all end of life care lung cancer
age groups, that is, those younger than
patients. What is worrying given that we
the average age at diagnosis of 69.9 know the average age at diagnosis for
years, who require end of life care. If
two-week referral is 69.9 years, is that the
these patients present earlier in their
second largest proportion are those aged
disease trajectory then they are more
61-70, who account for 29% of all end of
likely to be suited for procedures aimed at
life care lung cancer patients at the Royal
a „cure‟, and so not require end of life care
Bolton. The average age at diagnosis
at such a relatively young age.
within the 61-70 age group is 66 years.
This is three years younger than average
All records
and if this proportion accessing end of life
care and not receiving active treatment is
This data concerns all patients (including
growing it will negatively impact upon
those from outside Bolton) treated at
mortality and life expectancy statistics, as
Royal Bolton for end of life care between
well the resection rate and other active
1st January 2005 and 31st December 2009.
treatments such as radiotherapy and
chemotherapy. However, the number
The 2007 National Lung Cancer Audit
given end of life care at the Royal Bolton
records that 29.1% of cases at Bolton
from this age group is consistent over the
Hospitals Trust received palliative care.
years analysed, with roughly 60 cases per
Over the period above, 25% of patients
year (always around the same
proportionally). This proportion should
reduce if patients are diagnosed earlier
and present with earlier stages of cancer
where more active treatment options are
available. That this has not changed over
the five years previous demonstrates the
difficulty of this task locally.
Bolton residents
The dataset shows an increasing number
of lung cancer patients from Bolton
accessing end of life care at Royal Bolton.
Around twenty cases a year up to 2007,
this doubled in 2008, and stood at 70
cases in 2009.
The great majority of these are from the
lesser deprived and less ethnically mixed
practices in Bolton, with the Green, Blue,
and Indigo GP clusters accounting for
77% of all Bolton resident end of life care
patients. However, the makeup of these
patients, though accessing the lesser
deprived practices, do show a declining
rate across quintiles from the most to the
least deprived, as we would expect.
However, in general, current smokers are
fifteen times more likely to die from lung
cancer than lifelong non-smokers94.
Quintiles divide the population of Bolton
into roughly equal segments (around
52,000 in each quintile). From the Bolton
Health and Lifestyle Survey 2007 we know
there are over 10,000 more smokers in the
most deprived quintile than in the least
deprived. As smokers are fifteen times
more likely to die from lung cancer, if
equitable, the proportion accessing end of
life care in each quintile should show a
steep decline. The following chart shows
the proportion of Bolton resident
accessing end of life care at Royal Bolton
alongside smoking prevalence by quintile.
Smoking prevalence demonstrates a far
steeper gradient across quintiles than
access to palliative care does. Whilst
accepting that non-smokers can develop
lung cancer, and that not all smokers
develop lung cancer, it is by far the most
significant cause and prevalence here
should translate into a similar picture for
access to appropriate end of life care.
The patients in the more deprived quintiles
who do not receive end of life care must
arrive somewhere when their condition
94
Cancer Research UK (2010)
www.cancerresearchuk.org
worsens, and often this is likely to be as
an emergency admission.
Though a rough comparison, it is
important to note that a greater proportion
of people receive end of life care for lung
cancer in the least deprived quintile than
smoke. If equitable this should perhaps
also be the case in the more deprived
quintiles. Again, this picture demonstrates
that the more deprived sections of Bolton
society are more likely to get lung cancer
and less likely to access appropriate
services. This is an uneven picture and
represents a gap that should be
addressed.
National Lung Cancer Audit: Points of
focus for the future
The National Lung Cancer Audit is an
attempt to assess the extent to which
differences in survival can be explained by
regional variations in the configuration of
services, the management of policies
(including diagnosis, staging, and
treatment), the standard of specialist
treatment (for example the availability of
oncologists and specialist surgeons), as
well as casemix factors such as
socioeconomic deprivation, stage at
presentation, co-morbidity, and
performance status. As the Audit has
continued and its data become more
complete and robust, it has been able to
monitor measures of process and
outcomes of care.
The first conclusion from the audits so far
undertaken is that England and Wales
demonstrate wide variation in lung cancer
treatment, management, performance,
and outcomes across trusts and networks.
It has been established that casemix does
not appear to explain the whole of this
variation.
Key findings: 2009 audit period
For England and Wales histological
confirmation of the cancer diagnosis is
made in 72% of cases, but with a wide
variation of between 25% and 85%. This
is the 2009 published figure and is an
improvement on the 68% of the year
previous but is still below the 75% target
which is considered a benchmark for
acceptable practice (a target of 100% is
not appropriate as there will always be
some patients who are unfit for a biopsy
procedure). Bolton Hospitals NHS Trust is
above the England and Wales average, as
well as the average for the Greater
Manchester and Cheshire Network
(58.8%) with 73.2% for histological
diagnosis.
The overall unadjusted proportion of lung
cancer patients in England and Wales
receiving surgery is 11%, varying between
5% and 25%. Bolton Hospitals NHS Trust
has a figure of 13.9% for this indicator,
which is also higher than the Greater
Manchester and Cheshire Network
(12.9%). As mentioned previously,
increasing the resection rate is seen as a
vital method of increasing survival rates
from lung cancer overall. Therefore, this
is a very important indicator to monitor in
Bolton, which from previous sections of
this assessment has demonstrated a high
mortality rate and low survival rate.
Active anti-cancer treatment (surgery,
chemotherapy, or radiotherapy) is offered
to 54% of patients in England and Wales.
This figure varies between trusts and
networks from less than 10% to over 80%.
Bolton Hospitals NHS Trust shows 49% of
patients received active treatment in 2009.
This is lower than the national average but
higher than that for the Greater
Manchester and Cheshire Network (39%).
Audit data shows that in many cases
national guidance is not being followed.
Examples given are that nationally only
76% of patients have a CT scan prior to
bronchoscopy and only 48% of patients
with advanced non-small cell lung cancer
who are of good performance status
receive chemotherapy. Bolton Hospitals
NHS Trust falls below these averages for
both indicators. Nationally, other
measures of good performance such as
the proportion of patients seeing lung
cancer specialist nurses (51%) and the
proportion of patients with small cell lung
cancer receiving chemotherapy (62%) are
reported as “unacceptably low”. Bolton
Hospitals NHS Trust has a higher
percentage than the national figure for
patients seeing lung cancer specialist
nurses (68%); this figure is also higher
than that for the Greater Manchester and
Cheshire Network at 56.4%. However, the
percentage of patients with small cell lung
cancer receiving chemotherapy is lower
than the national average at 44.4%; this
figure is similar to that of the Greater
Manchester and Cheshire Network, which
stands at 43.6%.
The National Lung Cancer Audit 2009
records 169 cases of non-small cell lung
cancer for Bolton Hospitals Trust, of which
8.9% received surgery. Within this count
36 had Stage IIIb or IV non-small cell lung
cancer with performance status 0-1, of
which 27.8 received chemotherapy. The
number of histologically confirmed non-
small cell lung cancer patients is recorded
as 117, of which 10.3% had surgery.
Finally, the audit records 18 cases of small
cell lung cancer, of which (as mentioned
previously) 44.4% received chemotherapy.
All figures discussed from the audit come
with caveats around data completeness.
In addition, it must be borne in mind that
results do not take into account the
casemix of patients. In due course these
figures will be adjusted for casemix by the
Information Centre, however this is
unlikely to significantly affect the relative
performance of organisations.
The National Lung Cancer Audit 2009
makes several recommendations based
on its findings:
1. All trusts should ensure they
participate in the national audit
2. Data on all patients diagnosed with
either lung cancer or mesothelioma
are submitted to the audit
3. All relevant data fields are
completed for each patient
4. Actual completeness of at least
80% should be achieved for key
data fields including stage and
performance status, and
completeness of 95% should be
achieved for MDT
 RMC 2009 figures: Stage
completeness 75.8%; performance RMC 2009 figure: 27.8%
status completeness 93.3%; MDT
completeness: 57.2%
13. Where CT scan prior to
bronchoscopy rates are lower than
5. Over 95% of patients submitted to
90%, the results should be
the audit are discussed at a
reviewed
Multidisciplinary Team Meeting

RMC 2009 figure: 2.6%

RMC 2009 figure: 53.6%
14. Trusts who have exceeded these
6. The Histological/Cytological
targets in 2008 should work to
Confirmation Rate is at least 75%
maintain their high standards and
exceed them where appropriate.
RMC 2009 figure: 73.2%

7. Over 80% of patients are seen by

a lung cancer specialist nurse

RMC 2009 figure: 68%

8. Over 80% of patients have a lung

cancer specialist nurse present at
time of diagnosis

RMC 2009 figure: 22.7%

9. Surgical resection rates below the

national mean of 11% should be
reviewed

RMC 2009 figure: 13.9%

10. Active anti-cancer treatment rates

below the national mean of 54%
should be reviewed

RMC 2009 figure: 49%

11. Chemotherapy rates for small cell

lung cancer below the national
mean of 62% should be reviewed

RMC 2009 figure: 44.4%

12. Chemotherapy rates for

performance status 0-1 stage
IIIB/IV NSCLC lung cancer below
the national mean of 48% should
be reviewed
 Programme budgeting The relative size of the „bubble‟ represents
the proportion of total expenditure spent
on the programme in Bolton. The total
NHS Bolton undertook an analysis of expenditure per 100,000 population is also
programme budgeting data to inform shown for each programme.
interventions to deliver health outcomes
identified in the Strategic Plan 2009-2014.
The main results that impact upon lung
cancer are summarised here.

The PCT spends slightly less per head of

population on cancers and tumours when
compared to other similar PCTs; however,
performance is similar to or better than
others:

“This indicates that we should

consider increasing efficiency and
spending. Interventions within the
Strategic Plan to increases
spending and efficiency focus on
cancer prevention, early symptom
recognition, cancer information
services, one stop cancer
diagnostics, and provision of
therapy services closer to home”
(NHS Bolton, 2010, pg.151)

This is shown on the following graphs

which plot expenditure against various
outcome indicators. In each case the
programme budget category „Cancers and
tumours‟ has been coloured yellow.

The horizontal axis of each chart shows

the percentage that NHS Bolton‟s 2006/07
expenditure per 100,000 of unified
weighted population exceeds the average
for its Department of Health PCT cluster
„Centres with Industry‟. A positive position
on the horizontal axis indicates a relatively
high expenditure compared to other PCTs
within the group, while a negative position
represents the opposite.

The vertical axis shows the percentage by

which the outcome indicator differs from
the average for the PCT cluster. A
positive percentage indicates a higher rate
(such as the mortality rate in the first
graph) compared to the cluster group, and
a negative placing again shows the
opposite.
The above shows how considerable an
outlier the „Maternal‟ programme budget
category is in Bolton (with a very high
expenditure and poor performance
compared to the PCT cluster group). This
is removed from the following graphs to
better reveal the differences between the
other categories.
On the chart below, NHS Bolton is shown
to spend slightly less than the PCT cluster
group and have a relative mortality rate
around average for the cluster. Thus,
based on the mortality rate alone, the
Strategic Plan 2009-2014 confirms this
justifies considering increasing spending
and efficiency to improve the outcome.
The chart above compares spending with
years of life lost due to each condition.
NHS Bolton is shown to spend slightly less
than the PCT cluster on „Cancers and
tumours‟ but performs better concerning
years of life lost due to cancer. The
Strategic Plan 2009-2014 concludes that
based on years of life lost due to cancer
alone, spending need not change.
The chart below compares spending with
the prevalence of each condition. NHS
Bolton spends slightly less than the PCT
cluster and has a prevalence similar to
other PCTs in the cluster group. The
Strategic Plan 2009-2014 states that this
supports the consideration to increase
spending and efficiency.
 tackle inequalities” (Source: The IC,
Geodemographic segmentation Health Service Journal, 2009).

With this in mind, this assessment

“Geodemographics is the employs geodemographic segmentation to
description of people according to improve our understanding of the
the area in which they live, derived characteristics of those people in Bolton
from the study of spatial who are at greatest risk of respiratory
information. Census data, disease. The following shows an overview
consumer data, and social of the geodemographic make-up of Bolton
attitudinal data are common forms as defined by P²: People and Places96.
of spatial information used to
create a geodemographic
classification” (Source: Beacon Dodsworth,
2009).

The World Class Commissioning process

makes clear the need for PCTs to
understand the differences between
populations we need to target95:

“PCTs of all sizes have a large

range of population groups within
their patches, often with wide
variation in life expectancy. The
PCTs that did best on competency
5 recognised that blanket solutions
do not make financial sense or

95
Health Service Journal (2009) Information for
improvement, The IC, London.
96
Beacon Dodsworth (2009) P²: People and Places:
Understanding people by where they live, Beacon
Dodsworth, York.
The P² tool seeks to understand people in to predominantly white areas.
Bolton by where they live, with a view to
informing strategies that target specific The below map shows lung cancer
local areas. There are two mortality by small areas within Bolton over
geodemographic classifications that do not the period 2002 to 2008.
appear in Bolton at all; these are „B:
Country Orchards‟ and „E: Qualified
Metropolitans‟. The grey area in the
northern part of Moses Gate represents
„U: Unclassified‟. P² describes such
areas: “At each tier of „P² People and
Places‟, there is an unclassified cluster
which describes people whose
characteristics are too unique for them to
fall comfortably into the standard
categories. Those who are unclassified
make up 1.26% of the UK population”97.

Lung cancer prevalence increases along

the P² classifications. The only
interruption to this pattern in Bolton is the
Multicultural Centres group. This can be
expected to be a product of a lower
smoking prevalence in Bolton‟s South
Asian community (the majority of Bolton‟s
multicultural population) when compared

97
Beacon Dodsworth (2009) P²: People and Places:
Understanding people by where they live, Beacon
Dodsworth, York.
The average for Bolton as a whole over
this period is 48.86 (per 100,000). The
areas with the highest mortality rates (per
100,000) from lung cancer are:
1. Breightmet N & Withins (79.62);
2. Deane & Middle Hulton (77.16);
3. Halliwell Road (76.96);
4. Lever Edge (71.09);
5. Sweetlove (70.37);
6. Burnden (67.39);
7. Tonge Moor & Hall i‟th‟ Wood
(67.21);
8. Town Centre (66.58).
These key areas are identified on the
below geodemographical analysis and will
be discussed in turn. (The Town Centre is
not featured as it is almost entirely „M:
Urban Challenge‟, as is clear on the
previous P² map of Bolton).
Breightmet N & Withins
K: Weathered Communities. Most of this
Tree are past retirement age with many
being older than 75 and living alone.
Weathered Communities mainly have
small homes that they rent from the local
council or a housing association. These
properties are mostly flats, semi-detached,
or terraced houses. Some are without
central heating. Many members of this
Tree are retired and unemployment is
high, with many having been out of work
for a while. Previous occupations were
mainly in construction and it is common for
no adults in the household to work. Of
those still working, qualifications are few
and most jobs are of a routine nature or
are skilled or semi-skilled. Employment
with utility or manufacturing companies is
popular. Since many are retired, earnings
are in the bottom two income bands.
Weathered Communities rarely have a car
and they get around mainly by bus and
some on foot. These people tend to read
tabloid newspapers and have little interest
in politics. Many listen to commercial
radio, although internet usage is low.
They take few holidays and eat out
infrequently. Weathered Communities
tend not to have a credit card and
generally shop at ASDA, Aldi, Lidl,
Morrisons, and Somerfield. With an older
population and some below standard living
conditions, many Weathered Communities
have poor general health. Smoking is
common and exercise levels are low and
falling.
L: Disadvantaged Households. This is a
young Tree composed mostly of young
parent families who are aged 16 to 34 and
have young children. The proportion of
married couples is low, with many families
being cohabiting couples or lone-parents.
Most people live in terraced houses, flats,
or semi-detached houses which they rent
from the council or a housing association.
Often these properties have no central
heating. Most homes are small and many
are overcrowded, sometimes severely so.
There are also a number of vacant
properties, particularly terraced houses
and flats. There is a high rate of
unemployment amongst members of this
Tree, with around half not having worked
for several years. In many cases no adult
members of the household work. They
are largely unqualified and those who do
work usually have routine, semi-skilled, or
unskilled occupations. Incomes have
remained the same or risen slightly with
most having earnings in the lowest income
band and some in the third quartile. Most
Disadvantaged Households have no car.
Those who work tend to travel by bus or
on foot, with distances travelled generally
being short. These people have no
interest in politics and read tabloid
newspapers. They rarely take holidays
but frequently listen to commercial radio.
Internet usage is low. Members of this
Tree hardly ever eat out. Very few people
in this group have a credit card and they
mainly shop at ASDA, but also at Aldi and
Lidl. They rarely have any savings.
Disadvantaged Households have the
highest proportion of smokers out of all the
Trees, being one and a half times the
national average. They take little
exercise, although this is a habit that is
increasing. There are many very deprived
households; as a result, even though they
are a relatively young group, there is a
high level of ill health with long-term illness
being common.
J: Urban Producers. This Tree has a high
proportion of lone-parent families. Many
households are couples aged 25 to 34
who are unmarried and have children.
There are also some people aged 16 to 24
with children. The majority of this group
live in terraced houses that are rented,
mainly from the local council. Most
properties are medium-sized and some
have no central heating. The
unemployment rate is above average and
some of those over fifty have not worked
for several years. Urban Producers have
few qualifications and most have routine,
unskilled, semi-skilled, or skilled jobs in
manufacturing. It is common for only the
man in the household to work. Earnings
fall into the lowest income band, although
this is improving with the number in the
third quartile increasing. Most Urban
Producers do not have a car and many
live near enough to their work to walk
there, whilst others travel by bus. These
people have no interest in politics and
read tabloid newspapers. Most do not
take regular holidays and they are
infrequent users of the internet. Eating out
has become increasingly rare. Urban
Producers are less likely to have a credit
card and shopping is mainly at ASDA, with
Aldi and Lidl being popular and some
visiting Morrisons and Somerfield. Many
people in this Tree smoke and few take
regular exercise, with numbers falling for
the latter. Coupled with a relatively high
number of deprived households, this
results in many people being in poor
health.
Deane & Middle Hulton
M: Urban Challenge. Most homes are
small and cramped and most rented from
the council or a housing association.
Many are overcrowded and some have
shared facilities. Long-term
unemployment is common and many
people are retired. Unemployment affects
both men and women; those who do work
mainly have routine occupations due to
lack of qualifications. Others may have
unskilled or semi-skilled manual jobs in
manufacturing companies. Earnings are
in the lowest income band but are
increasing. Urban Challenge do not have
cars and those who work get there by bus
and some live near enough to walk. The
proportion of people in this group who eat
out is the lowest of all the Trees and is
decreasing. They mainly read tabloid
newspapers and some have an interest in
politics. Internet usage is the lowest of all
groups. These people mainly shop at
ASDA, but may also go to Morrisons,
Somerfield, Aldi, and Lidl. Few have
investments. Smoking is above average
and exercise is uncommon, although is
increasing slightly. Long-term illness is
common amongst the working population
and this may be due to high levels of
deprivation across the entire Tree.
K: Weathered Communities. See above.
J: Urban Producers. See above.
D: Rooted Households. This Tree is
generally an older group but does contain
a wide range of age groups and generally
originates from the UK. Most households
are buying or have paid for their homes.
Unemployment is low with many having
skilled jobs, frequently in the
manufacturing industry. This is not a
highly qualified Tree. This Tree has little
interest in politics, mainly read black top
newspapers, and use the internet. Rooted
Households shop at various
supermarkets, particularly Tesco.
Smoking is uncommon and the majority
are in good health with low deprivation
levels and health prospects are generally
positive.
(Deane & Middle Hulton is a large MSOA,
the southern part of which is Rooted
Households; it‟s northern part shares
borders with Heaton, Lower Deane & The
Willows, and Lever Edge, and it these
northern parts which contain the more
deprived areas classified as Urban
Challenge and Weathered Communities
above).
Halliwell Road
M: Urban Challenge. See above.
I: Multicultural Centres. This Tree consists
mainly of families, some of which are
large, who originate from India, Pakistan,
and Bangladesh (in Bolton). There is a
combination of young parents with
children and older parents with teenagers.
The majority are Muslims (in Bolton) and
although the parents were born outside
the UK, their children have been born
here. These people mainly live in terraced
housing and flats with the majority of the
rest living in bedsit accommodation.
Properties tend to be small and many do
not have central heating. They tend to
rent with many residents occupying
housing association or council properties.
The unemployment rate is twice the
national average. Of those who are
unemployed, half are long-term
unemployed. Those who work are mainly
in semi-skilled or unskilled manual jobs
rather than professional positions. They
tend not to have qualifications and their
earnings, although rising, are in the
bottom bracket. Car ownership is low and
the majority use public transport. They
mainly travel to work by train or bus, with a
few working from home or commuting by
car. These people mainly read tabloid
newspapers, but some also read
broadsheets. They regularly listen to
commercial radio and are not inclined to
take regular holidays or eat out. Internet
usage is high and growing. Aldi, Lidl, and
Sainsbury‟s are the most popular
supermarkets for regular shopping in this
Tree. They are unlikely to use credit
cards. Although mainly a young
population, many live in households that
are particularly deprived and so may
cause health problems in the future. They
are unlikely to exercise and their illness
levels are above average.
K: Weathered Communities. See above.
Lever Edge
I: Multicultural Centres. See above.
L: Disadvantaged Households. See
above.
Sweetlove
K: Weathered Communities. See above.
J: Urban Producers. See above.
I: Multicultural Centres. See above.
G: Suburban Stability. This Tree covers a
wide range of age groups, from young
families with children up to those of 75
years old. Many of the parents are
unmarried. They generally live in semi-
detached or terraced houses that they are
buying, or in some cases have bought. A
few privately rent their home. These are
mainly medium-sized properties and some
have no central heating. These people
are not highly qualified and mainly have
routine or skilled manual jobs, but some
are semi-skilled or unskilled. Many work
in manufacturing and unemployment is
below average. Most have earnings in the
third quartile with some in the bottom
band, although incomes are increasing.
Suburban Stability households generally
have one car, which is small or medium-
sized. They often travel to work in the car,
although some walk or travel by bus.
Commercial radio is listened to frequently
and tabloids are the newspaper of choice,
although some read black tops. This Tree
has little interest in politics and internet
usage is below average. Credit card
usage is just below average, whilst
Suburban Stability have no strong
shopping preferences, with ASDA being
the favourite but others also visited.
Smoking is just above average but only
one fifth take regular exercise. There are
no major long-term illness problems and
there is only a small amount of
deprivation.
Burnden
I: Multicultural Centres. See above.
K: Weathered Communities. See above.
H: New Starters. This Tree consists
mainly of young people aged 16 to 34 with
no children. There are a lot of students
and people living alone. Some older
households, aged 35 to 54, do have
children but few of the couples are
married, choosing to cohabit instead.
There is also a mix of people from
multicultural backgrounds. New Starters
tend to live in small flats and bedsits that
are privately rented with some renting
through a housing association. Many of
the properties have shared facilities and
no central heating. Some are
overcrowded, often severely so. Since
many of this group are students, this is not
their main home and there are a lot of
unoccupied flats and terraced houses.
Many of these people do not work,
although a good proportion of the
unemployed are students. This Tree is
highly qualified and people tend to work in
offices. Earnings are stable with many in
the lowest income band and some in the
third quartile. Most New Starters do not
have a car and many live near their work
or place of study and walk there whilst
others go by bus. New Starters are very
interested in politics and read broadsheet
newspapers. They are not inclined to take
holidays but are likely to use the internet.
Eating out has fallen to a very low level.
Most supermarket shopping is done at Aldi
or Lidl, with some also going to
Sainsbury‟s. New Starters are likely to
smoke but the level of exercise is low and
decreasing. There are poor living
conditions and high levels of deprivation in
some households. For the rest, there is
little long-term illness.
Tonge Moor & Hall i‟th‟ Wood
L: Disadvantaged Households. See
above.
K: Weathered Communities. See above.
Town Centre
M: Urban Challenge. See above.
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 Glossary

Benchmarking: A method of comparing processes and outcomes against particular

standards.

BME: Black and minority ethnic.

Cancer Network: A system within the NHS to organise the integrated care of cancer
patients across a region. NHS Bolton comes under the Greater Manchester and Cheshire
Cancer Network.

Casemix: A means of classifying patients for comparing quality of care.

Confidence interval: In statistics a confidence interval is an interval estimate of a

population parameter. Instead of estimating the parameter by a single value, an interval
likely to include the parameter is given. A 95% confidence interval is such that if the
sampling were repeated numerous times, then 95% of the time the population parameter
(i.e. the mean) will fall within the upper and lower limits of the confidence interval.

Crude rate: The condition count divided by the population.

Cytology: The study of cells.

Directly Standardised Rate (DSR): The directly standardised rate (DSR) is the rate
expected in a standard population if the age-specific rates of the study population had
applied.
DSR =
n
Σ Condition count i
i=1 Population i * ESP i

(i represents the 1 to n population groups, and ESPi is the European Standard population for
age band i)

Health Profiler: Small area database with various indicators to identify health inequalities
across the North West.

HES: Hospital Episode Statistics is a data warehouse containing details of all admissions to
NHS hospitals in England.

HSE: Health Survey for England. A series of annual surveys beginning in 1991
commissioned by the Department of Health and designed to provide regular information on
various aspects of the nation‟s health.

Histology: The study of tissues.

ICD-10 codes: The International Statistical Classification of Diseases and Related Health
Problems 10th Revision is a coding of diseases, symptoms, social circumstances, and
external causes of disease or injury, as classified by the World Health Organisation.
IMD: The Index of Multiple Deprivation combines a number of indicators, chosen to cover a
wide range of economic, social and housing issues, into a single deprivation score for small
areas in England.

Incidence: The rate at which new cases appear in the population over a given period of
time.

Interquartile range: The range of a variable excluding the highest and lowest quarter of the
recorded values.

MSOA: Middle Super Output Area. ONS designed small areas within Bolton.

MSOA code MSOA name

E02000984 Egerton & Dunscar

E02000985 Turton
E02000986 Sharples
E02000987 Horwich Town
E02000988 Sweetlove
E02000989 Harwood
E02000990 Horwich Loco
E02000991 Smithills N&E
E02000992 Blackrod
E02000993 Tonge Moor & Hall i'th' Wood
E02000994 Halliwell Rd
E02000995 Johnson Fold & Doffcocker
E02000996 Breightmet N & Withins
E02000997 Middlebrook & Brazley
E02000998 Victory
E02000999 Town Centre
E02001000 Tonge Fold
E02001001 Heaton
E02001002 Leverhulme & Darcy Lever
E02001003 Lostock & Ladybridge
E02001004 Lower Deane & The Willows
E02001005 Burnden
E02001006 Daubhill
E02001007 Little Lever
E02001008 Lever Edge
E02001009 Deane & Middle Hulton
E02001010 Moses Gate
E02001011 Westhoughton East
E02001012 Townleys
E02001013 Over Hulton
E02001014 Wingates & Washacre
E02001015 Central Farnworth
E02001016 Highfield & New Bury
E02001017 Central Kearsley
E02001018 Daisy Hill

NCHOD: National Centre for Health Outcomes Development.

NOMIS: A service by ONS providing detailed and up-to-date UK labour market statistics
from official sources.

NRS areas: Neighborhood Renewal Strategy Areas are the 25% most deprived boroughs in
Bolton.

NWPHO: North West Public Health Observatory.

ONS: Office for National Statistics.

People and Places: A geodemographic classification that uses Census and lifestyle data to
classify people by where they live.

Practice cluster list:

Prevalence: The proportion of individuals in a population who have the outcome at a
specific instant.

Public Health Mortality File: Database containing information about deaths within different
health authority boundaries.

QOF: The Quality and Outcomes Framework is used for prevalence data. QOF is the
annual reward and incentive programme detailing GP practice achievement results. QOF is
a voluntary process for all surgeries in England. QOF is measured by QMAS, a national IT
system developed by NHS Connecting for Health (CfH).

Standardisation: Standardised rates are statistically constructed summary rates that

account for the differences between populations with respect to other variables such as age,
sex, and ethnicity.

Standardised Mortality Ratio (SMR): A method of indirect standardisation involving the

application of standard rates for each age group in the standard population to the population
age groups under study.

SMR =
Observed condition count *100
Expected condition count

(Expected condition count = n

Σ Crude rate of standard population i * Local population i
i=1

i is 1 to n age bands under consideration)

Surgical resection: An operation to remove abnormal tissues or organs.

Synthetic estimate: Synthetic estimates are not estimated counts of the number of people
or prevalence of a behaviour, e.g. smoking. Rather, they are estimates based on a model
and represent the expected prevalence of a behaviour given the demographic and social
characteristics of that area.
 Appendices

Appendix a.

Benchmarking Peer Groups for Bolton

The Institute of Public Finance Nearest Neighbour Model (cipfastats.net) has been used to
select peers for Bolton.

The model is local authority based; however it is more recent than clusters based solely on
Census 2001 data and arrives at more specific peers than traditional ONS groups (for
instance, „Centres of industry‟).

This report displays the nearest neighbours for Bolton based on the selected indicators
listed below:

Metropolitan Districts
Population
% of population aged 0 to 17
% of population aged 75 to 84
% of population aged 85 plus
Output area base population density
Output area based sparsity
Taxbase per head of population
% unemployment
% daytime net inflow
Retail premises per 1,000 population
Housing benefit caseload (weighted)
% of people born outside UK and Ireland
% of households with less than 4 rooms
% of households in social rented accommodation
% of persons in lower NS-SEC (social) groups
Standardised mortality for all persons
Authorities with coast protection expenditure
Non-Domestic rateable value per head of population
% of properties in Bands A to D
% of properties in Bands E to H
Area cost adjustment (other services block)
% Ethic Minority
Indices of Multiple Deprivation
Based on these indicators the model arrives at the following „nearest neighbours‟:

Statistical
Pos. Neighbour Authorities
Distance

1. Rochdale 0.0276

2. Tameside 0.0375

3. Oldham 0.0441

4. Coventry 0.0956

5. Walsall 0.0995

6. Wigan 0.1007

7. Bury 0.101

8. Dudley 0.114

9. Kirklees 0.1323

10. Bradford 0.1518

11. Salford 0.1554

12. St Helens 0.1566

13. Wakefield 0.1651

14. Rotherham 0.1823

15. Sandwell 0.1896

 Appendix b.

The following is taken from the Bolton PCT End of Life Care Strategy.

Feedback from End Of Life (EOL) Consultation: August 2006 to January 2007

1. The key initial findings are that we ensure that integration between health and social care
is a priority to ensure responsive joint working and robust co-ordination of care. That the
standard of care is agreed amongst all stakeholders and that this is delivered seamlessly
from the patient and carers perspective. End of life care should be planned in a proactive
manner, be person centred, responsive and sustainable to be effective. End of life care
should be seen as a priority and investment should be robust and sustainable based on
realistic costings. The delivery of the strategy needs to be realistic and workable to be
successful. It should be inclusive and involve all partners and stakeholders such as for
example, PPI, voluntary sector, Benefits advice and Housing. Consideration also should be
given to the relationship between Private health insurance and healthcare and that general
awareness is taken into account of the potential impact of other services by changes in
provision. The design of new services should involve partners from secondary care to
ensure the development of an integrated model and to ensure that we don‟t underestimate
the challenge of delivering 24/7 care.

2. We need to ensure that EOL care is truly person centred rather than target driven and that
the education and support needs for families and carers is given priority and that more
carers and people from BME groups are involved in the future commissioning planning and
implementation.

3. A significant element of feedback from the consultation concerned carers. This related to
issues around identifying hidden carers, GPs developing their registers of carers to enable
support to be given when needed. There were issues raised about carers having key
workers as first contacts and also the need to facilitate carer breaks through respite care.
Any support needs to be available over a 24 hour period to be effective and that there
should be a range of support for carers. It is also important that carers are involved in
discussions about care whether directly or from a strategic planning perspective and that
their views are respected.

4. More commitment needs to be given to the spiritual care of people at EOL and not
skimmed over as appears at present. This is reflected in the following feedback:

It was felt that the document did not reflect that anyone has been consulted on spiritual care.
It would be inadvisable for a non-spiritual professional to conduct assessments without
extensive training. Parish priests and Religious Leaders generally do not have skills in this
area of work, and may not be appropriate anyway. There is a considerable difference
between normal pastoral visiting and support of the sick, and the liaison with other health
professionals in the extended care of the terminally ill. Using voluntary workers from the
community raises also the problem of communication. Health workers could not share
confidential, but essential information about the progress of the illness or the services
provided to voluntary visitors. Similarly, there would be no formal referral mechanism, or
ongoing return of information from the Religious Leader to the health professionals. The
possibility of 24-hour callouts for spiritual care would not be sustainable by Religious
Leaders on a voluntary basis. Spiritual support should also be available to members of the
various disciplines who have input to these patients/clients. There seems to be no evidence
that spiritual care is provided at any level in the PCT. It is suggested that the PCT consider
funding a whole-time chaplain who would provide that service and expertise and that this
person has a wide expertise in multi-denominational and multi-faith issues and requirements.
The Chaplaincy Dept. at Bolton Hospitals NHS Trust would be willing to assist the PCT in
exploring and developing spiritual care.

5. The education and training for all staff and carers was seen as an essential and that the
success of the strategy will rest on this being implemented broadly. In particular, good
communication and awareness raising and education to promote strategy implementation
was seen as essential. As was the need to ensure carers were recognised as having
relevant knowledge and skills, which needs to be supported practically in the home by
support and education. In relation to staff, it was felt that an audit of existing background
knowledge of long term conditions should be undertaken as well as ensuring that all staff
involved in assessments have good communication skills. Staff feedback related to the need
to have a range of training for all grades, from very practical skills to more academic levels
and that this study time must be protected. There should be a mentorship system for staff
and that training should be developed on a multi-agency basis with adequate and sustained
financial support. The basic education for nurses should include palliative care at end of life.

6. Communication was seen as the other key requirement with emphasis on the use of Gold
Standards Framework etc. across primary care and the links to single assessment process.
The need to have robust information and IT systems that communicate with each other was
also highlighted.

7. From a practical perspective the fundamentals within the draft strategy remain unchanged
following consultation. This hopefully indicates we are approaching end of life in the right
way. Some of the feedback relates to very operational issues such as:

Develop processes and care pathways

Advanced directives
Equipment services collection fragmented
Death certification process
Sensitivity towards clinical staff
Diagnosing last 6-12 months who and how
Breaking bad news
Avoid marginalising people
Avoid defensive medicine

Other general comments were:

Don‟t forget children‟s EOL needs

Obtain more detailed and accurate data on figures
Supporting care homes in deciding who needs to be in hospital and who can remain
in home
Preferred place of care vs mental capacity issues
Community beds- ensure not care on the cheap.

November 2006.
 Appendix c.

This appendix details the principal evidence base for this needs assessment.

1. Various bodies were established as part of the Cancer Reform Strategy to help
reduce cancer inequalities:
The National Cancer Equality Initiative (NCEI): to develop policy and research
proposals for tackling cancer inequalities;
The National Cancer Intelligence Network (NCIN): to improve the collection
and co-ordination of data on cancer patients;
The National Awareness and Early Diagnosis Initiative (NAEDI): to co-
ordinate activities and interventions, including those at a local level, aimed at
raising public awareness of the early signs and symptoms of cancer and
encourage people to seek help sooner;
The National Cancer Survivorship Initiative (NCSI): to improve the care and
support provided for people living with or after a cancer diagnosis.

2. The Manual of Cancer Services Standards – Lung Cancer Measures, NHS National
Cancer Action Team (2004)

3. „Improving Outcomes Guidance‟ for lung cancer, Department of Health (1998)

4. Healthier Horizons Strategy, NHS North West (2008)

5. Report of the Next Stage Review, NHS North West (2008)

6. High Quality Care for All, Department of Health (2008)

7. Our Health, Our Care, Our Say, Department of Health (2006)

8. Our NHS, Our Future: NHS Next Stage Review, Department of Health (2007)

9. The Cancer Plan, Department of Health (2000)

10. Cancer Reform Strategy, Department of Health (2007)

11. The NHS cancer plan and the new NHS: Providing a patient-centred service,
Department of Health, (2004)

12. NHS Cancer Care in England and Wales. National Service Framework Assessments
No.1., Commission for Health Improvement (2001)

13. Cancer ten years on: improvements across the whole care pathway, Department of
Health (2007)

14. Gold Standards Framework www.goldstandardsframework.nhs.uk

15. Liverpool Care Pathway for the Dying Patient www.lcp-mariecurie.org.uk

16. Preferred Place of Care www.cancerlancashire.org.uk/ppc

17. Improving access to medicines for NHS patients, Richards, M. (2008)

18. NICE Cancer Referral Guidelines, NICE (2005)

19. NICE Lung Cancer Diagnosis and Treatment Guidelines, NICE (2005)

20. NICE PH10 Smoking cessation services: guidance, NICE (2008)

21. Forever cool: the influence of smoking imagery on young people, British Medical
Journal (2008)

22. Cancer is our number one fear but most don‟t understand how many cases can be
prevented, Cancer Research UK, (2007)

23. Public Priorities for Health in Britain, MORI for Cancer Backup (2003)
 Appendix d.

This appendix shows the report of a social marketing initiative undertaken by Doncaster PCT
which aimed to increase early detection of lung cancer at primary care. The report is
publicly available from the National Social Marketing Centre (http://www.nsmcentre.org.uk/).