This report presents one-year and five-year age-standardised net survival estimates for the 25 NHS England Area Teams, for patients who were diagnosed with a cancer of the oesophagus, stomach, colon, lung, breast (women) or cervix during 1996–2011 and followed up to 31 December 2012 (see Background Notes 1−3). One-year survival estimates are reported for patients diagnosed in 1996, 2001, 2006 and 2011, and five-year survival for those diagnosed in 1996, 2001 and 2006.
The 25 NHS England Area Teams were created on 1 April 2013. For the purpose of these analyses, patients have been assigned to the Area Team that includes their residence when they were diagnosed between 1996 and 2011.
Estimates of one-year and five-year age-standardised net survival (%) are presented for each of the six cancers in tables and charts for each NHS England Area Team, by sex and calendar period. The survival estimates are age-standardised to compensate for differences in the age profile of cancer patients between Area Teams, and for changes in these age profiles over time (see Background Note 5).
One-year survival is above 60% for cancers of the colon, breast and cervix, and five-year survival for these cancers is above 45% (Figures 1A and 1B). For cancers of the oesophagus, stomach and lung, however, one-year survival is below 50% and five-year survival below 20%.
At the national level an upward trend in net survival was observed for all six cancers. The largest improvement in one-year survival among men occurred for cancers of the oesophagus, where survival increased by 19% from 26.7% for those diagnosed in 1996 to 45.4% for those diagnosed in 2011. Five-year survival for men with colon cancer increased by 8% from 45.2% for those diagnosed in 1996 to 53.4 % for those diagnosed in 2006. For women the largest improvement in one-year survival was for cancer of the lung, where survival increased by 13% from 21.9% for those diagnosed in 1996 to 34.7% for those diagnosed in 2011. Five-year survival for women increased the most for those diagnosed with breast cancer, increasing by 9% from 75.2% in 1996 to 84.1% in 2006.
The range in one-year survival between NHS England Area Teams with the highest and lowest survival in 2011 was widest for men diagnosed with stomach cancer at 14.2% and narrowest for women diagnosed with breast cancer at 1.3% (Table 1A). For five-year survival the range between NHS England Area Teams in 2006 was widest for women diagnosed with colon cancer at 12.0% and narrowest for men diagnosed with lung cancer at 3.7% (Table 1B).
These estimates should not be used to rank NHS England Area Teams by their survival, because a change of just 1 or 2% may radically alter the ranking of a given Area Team, especially where the range of estimates is very narrow.
Figure 2 presents a map of the 25 NHS England Area Teams. The geographic patterns of one-year survival (patients diagnosed in 2011) for cancer of the oesophagus, stomach, colon, lung, breast (women) and cervix are mapped in Figures 3A, 4A, 5A, 6A, 7A and 8A respectively. Comparable maps for five-year survival (patients diagnosed in 2006) are mapped in Figures 3B, 4B, 5B, 6B, 7B and 8B respectively.
Reference files presenting results for one-year and five-year net survival by NHS England Area Team are available to download for cancer of the oesophagus (393.5 Kb Excel sheet) , stomach (364.5 Kb Excel sheet) , colon (357.5 Kb Excel sheet) , lung (341.5 Kb Excel sheet) , breast (women) (235 Kb Excel sheet) and cervix (227.5 Kb Excel sheet) .
|ICD-10 Code||Site description||Sex||Year|
|ICD-10 Code||Site description||Sex||Year|
One-year age-standardised net survival improved considerably for patients diagnosed between 1996 and 2011, however survival was still low for patients diagnosed in 2011 and ranged between 38.8% and 49.6% for men and between 33.0% and 42.5% for women. One-year age-standardised net survival doubled in four NHS England Area Teams for men: Durham, Darlington and Tees; Greater Manchester; South Yorkshire and Bassetlaw; and Arden, Herefordshire and Worcestershire. One-year age-standardised net survival doubled in three NHS England Area Teams for women: Cheshire; Warrington and Wirral; Greater Manchester; and Merseyside ( Tables and Figures A1 and A2 (393.5 Kb Excel sheet) ). Five-year age standardised net survival ranged between 9.2% and 15.4% for men and 8.8% and 13.3% for women. Statistically significant improvements in five-year age-standardised net survival between NHS England Area Teams ranged between 4.2% and 9.1% in men and 3.8% and 8.3% in women ( Tables and Figures A3 and A4 (393.5 Kb Excel sheet) ).
One-year age-standardised net survival ranged between 38.8% and 52.9% in men and between 35.0% and 46.3% in women. Statistically significant improvements in one-year age-standardised net survival for men diagnosed in 2011 compared to those diagnosed in 1996 varied between NHS England Area Teams ranging from 6.9% to 19.6% ( Tables and Figures B1 and B2 (364.5 Kb Excel sheet) ). Five-year age-standardised net survival doubled in three NHS England Area teams for men between 1996 and 2006: Cumbria, Northumberland, Tyne and Wear; West Yorkshire; and Bristol, North Somerset, Somerset and South Gloucestershire. Both one and five-year net survival doubled for women in the South Yorkshire and Bassetlaw NHS England Area team. Five-year age-standardised net survival ranged between 13.0% and 21.6% for men and between 13.2% and 21.4% ( Tables and Figures B3 and B4 (364.5 Kb Excel sheet) ).
One-year age-standardised net survival ranged between 72.0% and 79.7% in men and between 68.3% and 79.2% in women. (Tables and Figures C1 and C2). Most NHS England Area Teams saw statistically significant improvements in survival for those diagnosed in 2011 compared to those diagnosed in 1996, these improvements ranged from 8% to 18% for men and 4.4% to 18.5% for women. Five-year age-standardised net survival ranged between 48.9% and 58.7% in men ( Tables and Figures C1 and C2 (357.5 Kb Excel sheet) ), and between 46.2% and 58.2% in women. Many of the NHS England Area Teams also saw statistically significant improvements in five-year survival, ranging from 1.4% to 16.6% for men and 4.1% to 15.8% for women ( Tables and Figures C3 and C4 (357.5 Kb Excel sheet) ).
One-year age-standardised net survival improved between 1996 and 2011, however survival remained low, ranging between 28.3% and 34.6% in men and between 29.6% and 40.7% in women ( Tables and Figures D1 and D2 (341.5 Kb Excel sheet) ). Five-year age-standardised net survival doubled in three NHS England Area Teams for men in the North of England Region: Greater Manchester, Lancashire, and South Yorkshire and Bassetlaw, while survival for women doubled in five NHS England Area Teams: Lancashire; South Yorkshire and Bassetlaw; Bristol, North Somerset, Somerset and South Gloucestershire; Kent and Medway; and Thames Valley. Despite these improvements five-year age-standardised net survival remained under 20% for both men and women. Five-year age-standardised net survival varied between NHS England Area Teams ranging from 5.9% to 9.6% in men and 7.3% to 16.6% in women ( Tables and Figures D3 and D4 (341.5 Kb Excel sheet) ).
One-year age-standardised net survival was very high and above 95%, with a narrow range of only 1.3% between the highest (96.9%) and lowest NHS England Area Team (95.7%). Statistically significant improvements in one-year age-standardised net survival for patients diagnosed in 2011 compared with 1996 ranged from 2.8% to 8.9% ( Table and Figure E1 (235 Kb Excel sheet) ). Five-year age-standardised net survival was above 80% with a range of 4% between the highest (85.6%) and lowest NHS England Area Team (81.6%). Statistically significant improvements in five-year age- standardised net survival for women diagnosed in 1996 compared to women diagnosed in 2006 ranged from 5.7% to 14.5% ( Table and Figure E2 (235 Kb Excel sheet) ).
One-year age-standardised net survival was above 80% across all NHS Area Teams ranging from 81.0% in the lowest to 88.8% in the highest. A number of NHS England Area Teams saw statistically significant improvements in one-year age-standardised net survival for those diagnosed in 2011 compared with those diagnosed in 1996, with these improvements ranging from 4.2% to 12.8% ( Table and Figure F1 (227.5 Kb Excel sheet) ). Five-year age-standardised net survival ranged between 61.5% and 71.1%. Statistically significant improvements in five-year age-standardised net survival were seen in nine NHS England Area Teams, with improvements ranging from 4.5% to 13.5% ( Table and Figure F2 (227.5 Kb Excel sheet) ).
Further information about cancer survival estimates published by the Office for National Statistics (ONS) can be found in the Cancer Survival Quality and Methodology Information paper. Quality and Methodology Information papers are overview notes which pull together key qualitative information on the various dimensions of the quality of statistics as well as providing a summary of the methods used to compile the output. Information about key users of these statistics is also provided.
The Scottish Cancer Registry produces statistics on cancer in Scotland.
Statistics on cancer in Wales are produced by the Welsh Cancer Intelligence and Surveillance Unit.
The Northern Ireland Cancer Registry produces statistics on cancer in Northern Ireland.
Key users of cancer survival estimates include the Department of Health, academics and researchers, cancer charities, cancer registries, other government organisations, researchers within ONS, the media, and the general public. The Department of Health uses cancer survival figures to brief parliamentary ministers, and as part of the evidence base to inform cancer policy and programmes, for example in drives to improve survival rates. Cancer survival estimates will also be used to measure progress against NHS Outcomes Framework indicators. Academics and researchers use the figures to inform their own research. Similarly cancer registries and other government organisations use the figures to carry out individual and collaborative projects to apply subject knowledge to practice. Charities use the data so they can provide reliable and accessible information about cancer to a wide range of groups, including patients and health professionals via health awareness campaigns and cancer information leaflets/web pages. Researchers within ONS use the data to support further research and to publish alongside other National Statistics.
In ‘Improving Outcomes: A Strategy for Cancer’ (January 2011), the Department of Health stated that although improvements have been made in the quality of cancer services in England, a significant gap remains in survival compared with the European average. Survival estimates for cervical, colorectal and breast cancer are some of the lowest among Member States of the Organisation for Economic Co-operation and Development (OECD) (figures for cancer survival in OECD countries are available from the OECD website). The strategy document sets out how the Department of Health aims to improve outcomes for all cancer patients and improve cancer survival, with the aim of saving an additional 5,000 lives every year by 2014/15.
Outcomes strategies set out how the NHS, public health and social care services will contribute to the ambitions for progress agreed with the Secretary of State in each of the high-level outcomes frameworks. The indicator set for the NHS Outcomes Framework 2013 to 2014 – focus on measuring health outcomes include one- and five-year cancer survival indicators for all cancers combined, and for colorectal, breast and lung cancers combined.
Akaike H (1974). New Look at Statistical-Model Identification. Ieee Transactions on Automatic Control AC19: 716-723.
Ashley J (1990). The International Classification of Diseases: the structure and content of the Tenth Revision. Health Trends 22: 135-137.
Cancer Research UK Cancer Survival Group (2004). Life tables for England and Wales by sex, calendar period, region, and deprivation. London School of Hygiene and Tropical Medicine.
Danieli C, Remontet L, Bossard N et al. (2012). Estimating net survival: the importance of allowing for informative censoring. Stat Med 31: 775-786.
Lambert PC, Royston P (2009). Further development of flexible parametric models for survival analysis. SJ 9: 265-290.
NHS England (2012). NHS CB Local Area Teams and Clinical Senates Briefing Pack.
Royston P, Parmar MKB (2002). Flexible parametric proportional-hazards and proportional-odds models for censored survival data, with application to prognostic modelling and estimation of treatment effects. Stat Med 21: 2175-2197.
Statacorp (2013). STATA statistical software. College Station, TX: Stata Corporation.
Ula Nura, Michel P Colemana, Paul Hossackb, Bernard Racheta
a Cancer Research UK Cancer Survival Group, London School of Hygiene and Tropical Medicine
b Cancer and End of Life Care Analysis Team, Office for National Statistics
The National Cancer Registry at the Office for National Statistics and the London School of Hygiene & Tropical Medicine wish to acknowledge the work of the regional cancer registries in England, which provided the raw data for these analyses.
National cancer registration data for England were received from the National Cancer Registry at the Office for National Statistics (ONS), which collates cancer registrations submitted by regional cancer registries in England. The Health and Social Care Information Centre (HSCIC) updates these records with the registration of death or emigration. The data used in these analyses were extracted from the live database at ONS on 2 July 2013 and provided to the Cancer Research UK Cancer Survival Group at the London School of Hygiene and Tropical Medicine on the 4 July 2013.
All adults (15–99 years) who were diagnosed with a first, invasive, primary, malignancy during the period 1996–2011 were eligible for inclusion in the analyses. We excluded patients who were diagnosed with a tumour that was benign (behaviour code 0), in situ (2) or of uncertain behaviour (1). Patients were excluded if their cancer was only registered from a death certificate. Patients with zero recorded survival time were included in the analyses with one day added to their survival. Table 2 shows the number of patients excluded and Table 3 shows the final number of patients in each NHS England Area Team who were included in the analyses.
|ICD-10 code2||Site Description||Eligible for analysis||Exclusions||Patients included|
|NHS England Area Team||Site|
|E1||Cheshire, Warrington and Wirral||2,812||2,704||7,247||12,164||13,927||827|
|E2||Durham, Darlington and Tees||2,319||3,341||7,480||16,084||12,620||1,155|
|E6||Cumbria, Northumberland, Tyne and Wear||3,875||5,882||12,994||27,294||21,550||1,720|
|E7||North Yorkshire and Humber||3,545||3,929||10,032||18,063||18,648||1,597|
|E8||South Yorkshire and Bassetlaw||2,705||4,290||8,174||17,796||15,039||1,182|
|E10||Arden, Herefordshire and Worcestershire||3,103||3,037||9,491||12,974||18,245||1,195|
|E11||Birmingham and the Black Country||4,452||5,963||12,652||22,180||23,508||1,984|
|E12||Derbyshire and Nottinghamshire||4,147||4,616||10,741||19,505||20,667||1,587|
|E15||Hertfordshire and the South Midlands||4,066||4,316||12,613||19,968||27,120||1,547|
|E16||Leicestershire and Lincolnshire||3,527||3,562||9,857||15,134||18,445||1,439|
|E17||Shropshire and Staffordshire||3,367||3,957||9,494||14,243||17,496||1,303|
|E19||Bath, Gloucestershire, Swindon and Wiltshire||2,706||2,435||8,925||10,325||16,827||1,079|
|E20||Bristol, North Somerset, Somerset and South Gloucestershire||2,866||2,670||8,609||11,419||16,344||1,245|
|E21||Devon, Cornwall and Isles of Scilly||3,972||3,615||12,224||15,396||21,498||1,326|
|E22||Kent and Medway||3,383||2,833||8,685||14,796||18,373||1,086|
|E23||Surrey and Sussex||5,376||4,245||16,390||21,461||31,978||1,495|
Net survival in a population of cancer patients is their survival from the cancer of interest in the absence of other causes of death. It was estimated at one and five years after diagnosis for each cancer, sex and year of diagnosis. Net survival was estimated with an excess hazard model in which the all-cause mortality is modelled as the sum of the excess (cancer-related) mortality hazard and the expected (or background) mortality. The background mortality is defined by life tables from the general population. This approach enables population-level cancer survival to be estimated in the absence of detailed data on the cause of death. To obtain an unbiased estimation of net survival, age needs to be carefully modelled to account for the informative censoring associated with age (Danieli et al., 2012).
We used flexible parametric models (Royston and Parmar, 2002) with age and year of diagnosis as main effects and an interaction between age and year of diagnosis. We also examined interactions between year and follow-up time and between age and follow-up time to deal with potential non-proportionality of the excess hazards over time since diagnosis. The Akaike Information Criterion (AIC) (Akaike, 1974) was used to select the best-fitting statistical model using the relative goodness of fit. The publicly available program, stpm2, was used to estimate net survival (Lambert and Royston, 2009). Analyses were performed in Stata 13 (Statacorp, 2013)
Life tables were constructed for the years 1996, 2001, and 2006 using the mid-year population estimates and the mean annual number of deaths in the three years centred on those index years (Cancer Research UK Cancer Survival Group, 2004). Life tables for each year from 1996 to 2005 were created by linear interpolation. The life table for 2005 was used for 2006–11. Background mortality changes with time and varies by sex, age, socio-economic status and region, so life tables were created by single year of age, sex, region and deprivation quintile for each calendar year of death.
The age distribution of cancer patients at diagnosis changes with time and varies between NHS England Area Teams. Since survival also varies with age at diagnosis, robust summary comparisons of survival require control for these differences. The directly standardised overall survival figure for each cancer is a weighted average of the age-specific survival estimates, with standard weights taken from the proportionate distribution by age and sex of patients diagnosed in England and Wales during 1996–99.
Age-standardisation requires a set of survival estimates for each age group. It is not always possible to obtain an estimate for each combination of cancer, age group, sex and calendar year of diagnosis in geographic units with small populations because of the limited number of cases. In this situation, the missing estimate was replaced by the equivalent age-specific estimate for England.
A 95% confidence interval is a measure of the uncertainty around an estimate. It provides a range of values which contains the true population value with a 95% level of confidence.
NHS England was established in April 2013, following the Health and Social Care Act 2012. There are 25 NHS England Area Teams. The role of the area teams includes commissioning of primary care services (such as GP, dental and pharmacy services), supporting and developing Clinical Commissioning Groups, and working with local NHS and public health organisations. The NHS England Area Team boundaries were applied to the whole period 1996–2011, enabling geographic trends to be charted over time (Figure 2). NHS England Area Team populations range from 1.1 to 7.7 million (2011 figures) (NHS England, 2012), making them more suitable for detailed statistical comparison of survival than smaller health geographies such as Clinical Commissioning Groups.
Cancers were defined by codes in the International Classification of Diseases, Tenth Revision (ICD-10) and International Classification of Diseases for Oncology, Second Edition (ICD-O-2) (Ashley, 1990), see Table 2.
Differences between survival estimates for the two periods are taken as the arithmetic difference: for example, 12% is shown as 2% (not 20%) higher than 10%. Survival figures are rounded to one decimal place, but the differences are based on the exact underlying figures.
A list of the names of those given pre-publication access to the statistics and written commentary is available in Pre-release Access List: Cancer Survival by NHS England Area Team: Patients Diagnosed 1996–2011 and Followed up to 2012 . The rules and principles which govern pre-release access are featured within the Pre-release Access to Official Statistics Order 2008.
Special extracts and tabulations of cancer data for England are available to order for a charge (subject to legal frameworks, disclosure control, resources and agreement of costs, where appropriate). Such enquiries should be made to:
Cancer and End of Life Care Analysis Team
Life Events and Population Sources Division
Office for National Statistics
Tel: +44 (0)1633 455704
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|Paul Hossack||+44 (0)1633 455813||Cancer Analysis Teamfirstname.lastname@example.org|