Docstoc

Lung Cancer in the North West

Document Sample
Lung Cancer in the North West Powered By Docstoc
					Lung Cancer in the North West




              Holger Möller, Lorraine Shack and Anthony Moran


                               Hosted by the Christie Hospital NHS Foundation Trust
2
Lung cancer in the
North West

Holger Möller, Lorraine Shack, Anthony Moran




Published by:
North West Cancer Intelligence Service (NWCIS)
Liverpool office:
2nd Floor
Muspratt Building
Liverpool
L69 3GB
Manchester office:
Centre for Cancer Epidemiology
Kinnaird Road
Withington
Manchester
M20 4QL

www.nwcis.nhs.uk

September 2008                                   1
Acknowledgements • Many thanks to Gavin Flatt, David Lemon, Catherine O’Hara and Becky Taylor
                             for contributing to this report.
Table of contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
    1.1 Lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
    1.2 Government policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
    1.3 Smoking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
    1.4 The burden of active and passive smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
    1.5 The smoking ban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
    1.6 Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
    1.7 Demograhics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2. Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
    2.1 Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
    2.2 Geographic variations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
    2.3 Age specific trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
    3.2 Geographic variations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
    3.3 Performance against the national cancer target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
    3.4 Age specific analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4. Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5. Histological type and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
    5.1 Histological types of lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
    5.2 Lung cancer treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6. Estimating the number of deaths attributable to active and passive smoking in the North West . . . . . . 42
    6.1 Active smoking attributable cancer deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
    6.2 Passive smoking attributable deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7. Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

List of figures
Figure 1.1:           Logic model of expected outcomes associated with smoke-free legislation in
                      Scotland (source: Haw et al 2006). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 1.2:           Population distribution in the North West, 2005 (source: ONS). . . . . . . . . . . . . . . . . . . . . . . 7
Figure 1.3:           Population predictions for 2014 and 2024 by age for the North West
                      (source: ONS, 2006). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 2.1:           Trends in lung cancer incidence rates (ASR per 100,000) by sex and cancer network in the
                      North West 1985 to 2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2.2:           Joinpoint analysis of trends in lung cancer incidence rates (ASR per 100,000) in women
                      in the North West 1986-2004 (three year rolling averages). . . . . . . . . . . . . . . . . . . . . . . . . 10


                                                                                                                                                                   i
     Figure 2.3:    Joinpoint analysis of trends in lung cancer incidence rates (ASR per 100,000) in
                    men in the North West 1986-2004 (three year rolling averages). . . . . . . . . . . . . . . . . . . . . 10
     Figure 2.4:    Funnel plot of age standardised (per 100,000) lung cancer incidence rates in women
                    by local authorities in the North West compared to the England average, 2003-05. . . . . . . 12
     Figure 2.5:    Change (%) in age-standardised lung cancer incidence rates for women by local
                    authorities from 1995-97 to 2003-05, North West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
     Figure 2.6:    Funnel plot of age standardised (per 100,000) lung cancer incidence rates in men by
                    local authorities in the North West compared to the England average, 2003-05. . . . . . . . . 14
     Figure 2.7:    Change (%) in age-standardised lung cancer incidence rates for men by local
                    authorities from 1995-97 to 2003-05, North West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
     Figure 2.8:    Lung cancer incidence (number and rates per 100,000) by age and sex, North West,
                    2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
     Figure 2.9:    Age-specific lung cancer incidence trends (rate per 100,000), by sex and cancer
                    network, Northwest, 1985-2005. Note that each chart uses different scale . . . . . . . . . . . . 18
     Figure 3.1:    Trends in lung cancer mortality (ASR per 100,000) by sex and cancer network
                    in the North 1985 to 2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
     Figure 3.2:    Joinpoint analysis of trends in lung cancer mortality rates (ASR per 100,000) in
                    men in the North West 1986-2004 (three year rolling averages). . . . . . . . . . . . . . . . . . . . . 21
     Figure 3.3:    Joinpoint analysis of trends in lung cancer mortality rates (ASR per 100,000) in
                    women in the North West 1986-2004 (three year rolling averages). . . . . . . . . . . . . . . . . . . 21
     Figure 3.4:    Funnel plot of age standardised (per 100,000) lung cancer mortality rates in women
                    by local authorities in the North West compared to the England average, 2003-2005. . . . . 23
     Figure 3.5:    Change (%) in age-standardised lung cancer mortality rates for women by
                    local authorities from 1995-97 to 2003-05, North West. . . . . . . . . . . . . . . . . . . . . . . . . . . 24
     Figure 3.6:    Funnel plot of age standardised (per 100,000) lung cancer mortality rates in men by
                    local authorities in the North West compared to the England average, 2003-2005. . . . . . . 25
     Figure 3.7:    Change (%) in age-standardised lung cancer mortality rates for men by local
                    authorities from 1995-97 to 2003-05, North West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
     Figure 3.8:    Change (%) in age-standardised lung cancer mortality rates in patients under 75
                    years from 1995-97 to 2003-05, by local authority in the North West . . . . . . . . . . . . . . . . 28
     Figure 3.9:    Change (%) in the gap for mortality between the national average for those
                    under 75 years from 1995-97 to 2003-05 by local authority, North West. . . . . . . . . . . . . . 29
     Figure 3.10:   Lung cancer mortality (number and rates per 100,000) by age and sex,
                    North West, 2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
     Figure 3.11:   Age-specific lung cancer mortality trends (rate per 100,000), by sex and cancer
                    network, Northwest, 1985-2005. Note that each chart uses different scale . . . . . . . . . . . . 31
     Figure 4.1:    Relative survival (%) for patients diagnosed 1989-1991 to 2004-2005 in the North West. . 34
     Figure 4.2:    Five and one year relative survival (%) by age at diagnosis in the North
                    West, (based on 2004-05 data for one year survival and 1998-00 data for
                    five year survival analysis). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
     Figure 5.1:    Distribution (%) of histological types of lung cancer by cancer network,
                    North West, 2003-05. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
     Figure 5.2:    Distribution (%) of histological types of lung cancer by age at diagnosis,
                    North West, 2003-05. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37



ii
Figure 5.3:    Lung cancer treatment by cancer network, North West, 2003-2005. . . . . . . . . . . . . . . . . . 38
Figure 5.4:    Lung cancer treatment by histological type in all cancer networks in the North West,
               2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Figure 5.5:    Treatment (%) for lung cancer patients under and over age 75 at diagnosis in all
               cancer networks in the North West 2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Figure 5.6:    Difference (%) in lung cancer treatment (over 75 year olds compared to under
               75 year olds) by cancer network, North West 2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . 40
Figure 5.7:    Lung cancer treatment by deprivation quintile (1= least deprived and 5 = most deprived)
               in all cancer networks in the North West, 2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Figure 7.1:    Estimated average annual percentage of successful smoking quitters treated in
               the NHS smoking cessation service 2003-04 to 2006-07. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Figure 7.2:    Difference in smoking prevalence estimates from two different models; the data
               is sorted by ONS synthetic estimates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Figure 7.3:    Synthetic estimate of smoking prevalence (01-03) and average estimated rate
               of successful quitters at 52 weeks 2003-2007, per 100,000 population aged over 16. . . . . 50
Figure 7.4:    Estimated average annual percentage of smoking quitters (03-04 to 06-07)
               by IMD score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Figure A2.1:   Change (%) in age-standardised lung cancer incidence rates in patients
               under 75 years at diagnosis from 1995-97 to 2003-05, by local authority
               in the North West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Figure A2.2:   Change (%) in the gap in incidence between the national average in patients
               under 75 years at diagnosis from 1995-97 to 2003-05 by local authority in
               the North West. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57


List of tables:
Table 2.1:     Annual percentage change in lung cancer incidence rates in women for the time segments
               identified in the joinpoint analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 2.2:     Annual percentage change in lung cancer incidence rates in men for the time segments
               identified in the joinpoint analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 2.3:     Change (%) in age-specific and all ages lung cancer incidence rates (per 100,000), by sex,
               1994-96 to 2003-05. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 3.1:     Annual percentage change in lung cancer mortality rates in men for the time segments
               identified in the joinpoint analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 3.2:     Annual percentage change in lung cancer mortality rates in women for the time segments
               identified in the joinpoint analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 3.3:     Change (%) in age-specific and all ages lung cancer mortality rates (per 100,000), by sex,
               1995-95 to 2003-05. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Table 4.1:     One and five year survival in patients diagnosed in cancer networks and the North West. . . . 35
Table 5.1:     Treatment for lung cancer patients, North West 2003-2005. . . . . . . . . . . . . . . . . . . . . . . . . . 38
Table 6.1:     Smoking attributable mortality for cancers in the North West; 2005 mortality data.. . . . . . . . 43
Table 6.2:     Estimated annual number of deaths attributable to passive smoking in non smokers in the
               North West of England. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45




                                                                                                                                                        iii
iv
Foreword
I welcome this report on lung cancer in the North West. While
emphasising that lung cancer is still a major health problem
in our region, it highlights trends and developments that
suggest optimism for the future, not only for lung cancer
but for other smoking–related diseases.
First the bad news - lung cancer is the most common cause
of death from cancer in both men and women in the North
West. It is also much more common in urban areas with high
levels of deprivation, and survival rates remain low. Work
undertaken by the Roy Castle Lung Cancer Foundation
suggests that a lack of symptom awareness hampers early
diagnosis of lung cancer with symptoms being ignored until
the disease is advanced.
Better news is that incidence rates have dropped considerably
in men and though still rising somewhat in women, trends in
younger women suggest that this may soon be reversed.
Encouragement is also provided by evidence that the smoking
ban will save hundreds and possibly thousands of lives, not
only by decreasing exposure to passive smoking but also by
leading to a large drop in the number of smokers.
The large number of people giving up smoking as a result
of attending NHS stop smoking services is also good news.
A North West wide programme has been set up specifically
to drive down adult smoking prevalence and to create a
tobacco free future for our children, breaking the cycle of
smoking-related health inequalities.
Additionally, the Roy Castle Lung Cancer Foundation is
working to address the issue of symptom awareness through
activities to support Lung Cancer Awareness Month annually
each November and the innovative workplace health
promotion initiative ‘Look after your lungs’ which aims to
raise awareness of lung cancer symptoms and to promote
healthier life-style choices to reduce lung cancer risk.
In summary, this report shows us how far we have come and
where we need to make further progress to achieve the goal
of making lung cancer - what it was less than a century ago
– a rare disease.




Dr Ruth Hussey OBE,
Regional Director of Public Health & Medical Director
NHS North West




                                                                1
2
Executive Summary
Incidence and mortality
The most important results for the North West are:
■ Lung cancer is the most common cause of death from cancer in both men and women, with 2,550 men
  and 1,953 women dying from this disease in 2005.
■ Mortality and incidence rates vary greatly within the region with deprived urban areas such as Liverpool,
  Manchester and Knowsley having at least twice the rates of more affluent rural areas.
■ Mortality rates are dropping but not as fast in many deprived areas as in the country as a whole.
■ Incidence rates for men have dropped by 2.4% per year from 1986 to 2004 but have risen in women by
  1.1% per year over the same period.
■ Incidence rates in every age group are dropping in men. In women rates are still rising markedly in women
  over 75 years and stabilising in those aged 55-64, with rates falling in the 30-54 and 65-74 age groups; this
  pattern varies by cancer network.

Survival and treatment
Most patients with lung cancer have a poor prognosis with fewer than one in ten alive five years after diagnosis;
the main reason being that most tumours have spread too far for the patient to be cured. In the North West:
■ The five year survival rate is 7.5% for men and 8.3% for women.
■ The five year survival rate for patients covered by the Merseyside and Cheshire Cancer Network (MCCN) at
  9.8% is higher than for the Greater Manchester and Cheshire Cancer Network (7.2%) and the Lancashire
  and South Cumbria Cancer Network (6.7%).
■ The proportion of patients in MCCN reported as undergoing surgery was higher than for the other two
  networks.
■ More work is needed to confirm these results and to find out the reasons for these important differences.

Prevention
The best way to prevent lung cancer is for fewer people to start smoking and more smokers to quit. The most
important findings for the North West are:
■ About 7,000 deaths from cancer each year are attributed to smoking.
■ The number of people dying from passive smoking is probably more than 500 each year; over 300 due to
  exposure at home and more than 200 at work, suggesting that the smoking ban should save at least 200
  lives a year, as it covers more than smoking at work.
■ About 8,000 people give up smoking each year after attending NHS smoking cessation clinics in the North
  West (estimated number at 52 week follow up). As most of these live in deprived areas, this may help to
  reduce health inequalities.
■ It has recently been reported that the percentage of people in England who smoke has decreased by 4.3%
  in the nine months following the introduction of the smoking ban, suggesting that the numbers of lives it
  will save may be more than previously thought.




                                                                                                                   3
    1. Introduction
    This report evaluates trends in lung cancer in the North West of England with particular focus on the
    epidemiology and treatment of lung cancer, and future impact of the smoking ban. The report builds upon
    and expands on previously published work on lung cancer in Cheshire and Merseyside1, and covers the whole
    of the North West.
    We particularly focused on the age-specific analysis of incidence and mortality trends, as these may, especially
    in younger age groups, give an indication of the success of smoking cessation measures and of future rates2,3.
    Regional variations exist in relation to smoking and thus lung cancer incidence and mortality. In addition to
    analysing incidence and mortality trends, we evaluated variations in survival, treatment and histological types
    to further understand geographic differences. With the strong link between smoking and lung cancer we
    felt that the report would be incomplete without looking at the effects of smoking. We estimated how the
    smoking ban may influence future mortality rates in the North West and included a section on NHS smoking
    cessation data.

    1.1 Lung cancer
    At the beginning of the 20th century lung cancer was a rare disease in the UK but is now the second most
    common cancer and the most common cancer cause of death. The link between lung cancer and smoking
    was first established in 19504,5,6,7,8 with 80-90% of all lung cancer cases caused by smoking. Lung cancer has
    also been linked to passive smoking, radon exposure, air pollution and occupational exposures. Occupational
    exposures include uranium, arsenic, certain petroleum products and asbestos, the last of which also causes
    mesothelioma, a cancer of the pleura.
    The latency period between smoking uptake and lung cancer is at least 20 years9. Due to the strong association
    between lung cancer and smoking, incidence and mortality trends reflect historical smoking patterns, which
    vary by gender and age. Smoking prevalence decreased rapidly during the 1970s and 1980s and has decreased
    at a slower rate since, to 22% prevalence (23% male; 21% female) in 200610. Lung cancer incidence and
    mortality in England was almost two times higher in men than women during 2000-05, reflecting the higher
    historical smoking levels in men.
    Lung cancer incidence and mortality rates vary within England with both being higher in more deprived areas9
    and can be linked with higher smoking rates in more deprived areas11. The North East and North West have the
    highest lung cancer incidence and mortality rates in England, and the South East and South West the lowest.
    Lung cancer rates also vary widely within regions, mainly due to smoking patterns.
    Lung cancer has a poor prognosis. In England and Wales only 20% and 6-7% of patients diagnosed between
    1998-2001 were alive at one and five years after diagnosis, respectively12.
    Lung cancer is classified into two main types, (i) small cell and (ii) non-small cell, based on cell characteristics
    and response to treatment. Approximately 80% of lung cancer tumours are non small cell; these in turn
    are classified into three main subtypes: a) squamous cell carcinoma, b) adenocarcinoma and c) large cell
    carcinoma. Small cell carcinomas grow faster on average than non-small cell tumours but are more responsive
    to chemotherapy and irradiation. A meta-analysis of the effect of smoking on pathological types of lung
    cancer found a stronger association with squamous cell and small cell carcinoma than large cell carcinoma
    and adenocarcinoma13.

    1.2 Government policy
    Cancer is a priority area particularly in relation to the national target to increase life expectancy and reduce the
    gap in health inequalities14. The 2001 life expectancy target focused on spearhead health authorities by aiming
    to reduce the gap between the quintile of areas with the lowest life expectancy at birth and the population
    as a whole by 10% by 201015. The target for cancer is to reduce mortality rates by at least 20% in under 75
    year olds by 2010 (measured from the 1995-1997 baseline) with a reduction in the inequalities gap of at least
    6%15.
    To tackle lung cancer and other smoking related diseases the government set a target (PSA08) to reduce

4
smoking rates in England to 21% by 2010, with a reduction in the smoking prevalence in routine and manual
groups to 26% or less. This target is supported by the initiation of NHS stop smoking services.

1.3 Smoking
Smoking prevalence in England decreased from 45% in 1974 (51% male; 41% female) to 22% (23% male;
21% female) in 200610. Whereas smoking prevalence declined by 10% in the eight years from 1974 to 1982
it took another 22 years to decrease a further 13% to 22% in 2006. Smoking prevalence decreases with age
with only 12% of people aged 60 smoking. In England those aged 20 to 24 had the highest smoking rate
during 2006, with 33% of men and 29% of women estimated to smoke10.
Smoking prevalence is higher in more deprived areas16 and manual occupational groups (30%) compared to
professional workers (15%). Smokers in manual groups were also found to have higher tobacco consumption
than smokers in managerial and professional groups (on average 15 compared to 12 cigarettes per day)10.
Problems around smoking prevalence data and smoking cessation data will be looked at in more detail in
chapter seven.
Smoking prevalence in the North West in 2006 was 25% (23% in women, 26% in men), amongst the highest
in England. Within the North West smoking rates varied by local authority with the highest rates in Liverpool
(34.3%), Knowsley (34.2%) and Manchester (33.8%) and lowest in Fylde (16.5%), Macclesfield (16.9%) and
Ribble Valley (17.9%) during 2003-200517.

1.4 The burden of active and passive smoking
The negative health effects of smoking are well established and the overall contribution of smoking to morbidity
and mortality as well as the economic costs of smoking has been quantified18,19,20,21,22,23,24,25,26. In addition to
cancer, smoking is also associated with bronchitis, emphysema, chronic obstructive pulmonary disease, stroke
and coronary heart disease (CHD) and approximately 50% of lifelong smokers will die of smoking. One major
study of British doctors estimated 75% of smokers would die of a related illness27. It is estimated that between
1990 and 1999 smoking killed 21 million people in all developed countries worldwide, of which 5 to 6 million
would have occurred in Europe28.
Passive smoking, also referred to as environmental tobacco smoke (ETS) or second hand smoke, has mainly
been linked with lung cancer, CHD, stroke and respiratory diseases. The excess risk* of lung cancer and CHD
associated with passive smoking through domestic and workplace exposure are estimated to be around
25% and 25-30%, respectively29,30. Studies also suggest an increased risk of stroke and respiratory disease
associated with passive smoking18,20,21,23,31,32. The risk of CHD from passive smoking compared to active smoking
is disproportional high, being about half that of an active smoker. In comparison the risk of lung cancer in
active smokers is 15-20 times that of a non-smoker, with individuals exposed to passive smoking having a 1.25
fold risk29,33,34.
Passive smoking has also been linked with sudden infant death, pneumonia and bronchitis, asthma, middle
ear disease in children and may also adversely affect the unborn child18.


1.5 The smoking ban
The smoking ban is a major breakthrough in limiting passive smoking and may encourage people to stop
smoking or not even start. As a consequence the ban should reduce tobacco related morbidity and mortality.
The key question is: How will the smoking ban affect the health status of the population in the short and long
term? The immediate outcome will be a significant reduction in the exposure of the public to second hand
smoke. In the longer term changes in behaviour, smoking culture and a reduction in smoking prevalence and
tobacco consumption can be expected35 (Figure 1.1).
Limited evidence of the health effects of smoking bans is currently available, as smoking bans have only been
in place for the past 2-3 years (except for California which has been smoke free since 1998) and the lag time
from exposure to lung cancer is over 20 years. Some evidence is available on the more immediate health


* The additional risk of illness due to the risk factor, in this case the additional risk of lung cancer and CHD due to environmental tobacco smoke


                                                                                                                                                      5
    effects of smoking bans with many studies finding a reduction in hospital admissions for acute myocardial
    infarction36,37,38,39. Occupational studies of the effects of the smoking ban on service industry workers found
    significant improvements in performance in pulmonary function tests, a decrease in respiratory symptoms and
    general improvements in respiratory health40,41,42,43. The effect of smoking bans on smoking prevalence and
    tobacco consumption is less clear. It requires time and cost intensive surveys and it is difficult to establish a
    causal relationship between smoking bans and smoking behaviour.
    A review of the possible health and economic outcomes of smoking bans suggested an association between
    smoking bans and a reduction of the number of cigarettes smoked by continuing smokers, increased quit
    attempts and reduced smoking prevalence. Modelling the health impacts of a smoking ban in public places in
    Scotland showed substantial positive health outcomes, reduced costs to health service due to tobacco related
    illnesses and increased productivity from absenteeism due to a reduction in passive smoking alone19.


     Figure 1.1: Logic model of expected outcomes associated with smoke-free legislation in Scotland
     (source: Haw et al 2006).35

                                                                  Expected Outcomes
                                Short term 0-12 months         Intermediate >2-12 months                    Long term >12 months

                                                                 Reduction in exposure to ETS                  Reduced ETS exposure



                                  Increasing awareness of         Increasing compliance with                 Sustained compliance with
        Implementation of        health risks of ETS, change         smoke-free legislation                    smoke-free legislation
       smoke-free legislation     in attitudes towards ETS
                                           exposure

                                                                Increasing support for legislation and        Sustained cultural change
                                                                     change in smoking cultures
          Enforcement of
            smoke-free
             legislation
                                                                          Reduction in smoking prevalence and tobacco mortality


                                                                           Reduction in tobacco related morbidity and mortality



                                                                                                            Reduction in costs to health
                                                                                                          service of tobacco related illness


                                                                 Variable economic impact on
                                                                                                           Reduction in health inequalities
                                                                       hospitality sector




    1.6 Geography
    The North West Government Office Region (GOR) includes three complete cancer networks; Lancashire and
    South Cumbria Cancer Network (LSCCN), Greater Manchester and Cheshire Cancer Network (GMCCN) and
    Merseyside and Cheshire Cancer Network (MCCN), plus part of the Northern Cancer Network. This report
    covers all of the North West (except for the section on histological type and treatment, which only covers the
    three cancer networks in the North West). The Northern Network is not analysed separately as only part of it
    is covered by the North West Cancer Intelligence Service (NWCIS).




6
There are 24 Primary Care Trusts (PCTs) in the North West of England (as of 2006) and they are mostly
coterminous with local authority boundaries. A large proportion of local authorities (23 of the 43) in the North
West are classified as spearhead local authorities. Spearhead local authorities are in the bottom fifth nationally
for three or more of the following five indicators:
■ Male life expectancy at birth
■ Female life expectancy at birth
■ Cancer mortality rate in under 75s
■ Cardiovascular disease mortality rate in under 75s
■ Index of multiple deprivation (IMD)
The socioeconomic and health status of the population varies greatly between and within the local authorities
in the North West. The local authorities of Congleton, Ribble Valley and Macclesfield rank among the most
affluent areas in England while Liverpool, Manchester and Knowsley are three of the most deprived local
authorities in England.

1.7 Demographics
The population in the North West in 2005 was estimated to be 6.8 million with 51.2% female44. The population
pyramid in the North West has a typical northern European shape with a declining birth rate and long life
expectancy. The number of women is higher, particularly in the older age groups reflecting their longer life
expectancy (Figure 1.2).
Over the next ten years the proportion of people over 60 in the North West is predicted to increase by 3.2% in
men and 2.1% in women (Figure 1.3) due to an increase in life expectancy and the ageing of baby boomers45.
The predicted change in the proportion of older people varies between local authorities in the North West.
For example, the proportion of older people is predicted to decrease by 2.1% in women and 0.9% in men
in Liverpool compared to an increase of 6.2% in men and women in Congleton over the next ten years.
This change in population structure will affect the number of expected cancer cases as higher cancer risk is
associated with increasing age.


 Figure 1.2: Population distribution in the North West, 2005 (source: ONS).44




                                                                                                                   7
    Figure 1.3: Population predictions for 2014 and 2024 by age for the North West (source: ONS,
    2006).45




8
2. Incidence
In the North West there were 3,039 men and 2,403 women diagnosed with lung cancer during 2005 of which
GMCCN registered the most cases (n=2,292) followed by MCCN (n=1,829) and LSCCN (n=1,099). Lung
cancer incidence in the North West decreased in men between 1985 and 2005 while incidence in women
increased slightly (Figure 2.1). Over the past 20 years MCCN has consistently had the highest incidence and
mortality rates for both men and women, followed by GMCCN and LSCCN, respectively.

2.1 Trends
Trends in age-standardised rates (ASR) between 1986 and 2004 were analysed for the three cancer networks
and the North West by joinpoint regression analysis46 which highlights significant changes in cancer trends (see
methods in Appendix).

 Figure 2.1: Trends in lung cancer incidence rates (ASR per 100,000) by sex and cancer
 network in the North West 1985 to 2005.

                       160
                                                                                                                    North West men
                                                                                                                    LSCCN men
                                                                                                                    GMCCN men
                       140
                                                                                                                    MCCN men
                                                                                                                    North West women
                                                                                                                    LSCCN women
                       120                                                                                          GMCCN women
                                                                                                                    MCCN women


                       100
     ASR per 100,000




                        80



                        60



                        40



                        20



                         0
                             1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005




For the North West lung cancer incidence in women increased on average by 1.1% per year between 1986 and
2004, with a more rapid increase of 1.4% between 1986 and 1997 and a slower increase of 0.5% between
1997 and 2004 (Figure 2.2). Incidence increased in all networks over the full period; increasing fastest in
LSCCN (2.1% per year) and slowest in MCCN and GMCCN (both, 0.8% per year). MCCN and LSCCN showed
a slowdown in incidence for more recent years with an annual increase of 0.3% for MCCN from 1994 to
2004 and of 1% for LSCCN from 1997 to 2004. From 2002 onwards incidence rates in GMCCN increased at
3.6% per year; however this trend is based on three data points only so should be evaluated in the future to
determine if it continues (Table 2.1).




                                                                                                                                        9
     Figure 2.2: Joinpoint analysis of trends in lung cancer incidence rates (ASR per 100,000) in
     women in the North West 1986-2004 (three year rolling averages).




     Figure 2.3: Joinpoint analysis of trends in lung cancer incidence rates (ASR per 100,000) in
     men in the North West 1986-2004 (three year rolling averages).




10
For men lung cancer rates decreased between 1986 and 2004 for all networks and in the North West overall
(Figure 2.3), the largest reductions being in GMCCN and MCCN, with a 2.7% and 2.6% decrease per year,
respectively. In the North West incidence rates decreased more rapidly between 1995 and 2004 (3% per
annum) than in the earlier period (1986 to 1995 at 2% per year). After 1994 incidence decreased rapidly at
3.2% per year in MCCN (Table 2.2).
The different trends in men and women reflect differences in historical smoking patterns. Lung cancer incidence
in women continues to increase in the North West albeit at a slower rate, while incidence in men has been
decreasing for many years. The difference in incidence between MCCN, the network with the highest rates
in men and women, and the other two cancer networks in the North West is narrowing. This is due to the
rates in women increasing more slowly and rates in men decreasing more quickly than in the other two cancer
networks in the North West. The age specific analysis in section 2.3 gives a more detailed picture on which age
groups contribute the largest burden and also whether rates in women are expected to decline in the future.


   Table 2.1: Annual percentage change in lung cancer incidence rates in women for the time
   segments identified in the joinpoint analysis.

     Place                                 Segment (years)                       Annual Percentage
                                                                                   Change (APC)
     North West                 1986              to             2004                  1.1*
     North West                 1986              to             1997                  1.4*
     North West                 1997              to             2004                  0.5*
     LSCCN                      1986              to             2004                  2.1*
     LSCCN                      1986              to             1989                  3.9*
     LSCCN                      1989              to             1992                   -0.8
     LSCCN                      1992              to             1997                  4.2*
     LSCCN                      1997              to             2004                    1*
     GMCCN                      1986              to             2004                  0.8*
     GMCCN                      1986              to             1998                  1.2*
     GMCCN                      1998              to             2002                   -0.7
     GMCCN                      2002              to             2004                  3.6*
     MCCN                       1986              to             2004                  0.8*
     MCCN                       1986              to             1994                  1.5*
     MCCN                       1994              to             2004                   0.3
   *= the APC is significantly different from 0 (p<0.05)



    Table 2.2: Annual percentage change in lung cancer incidence rates in men for the time
    segments identified in the joinpoint analysis.

     Place                                 Segment (years)                       Annual Percentage
                                                                                   Change (APC)
     North West                  1986             to             2004                  -2.4*
     North West                  1986             to             1995                   -2*
     North West                  1995             to             2004                   -3*
     LSCCN                       1986             to             2004                  -1.5*
     GMCCN                       1986             to             2004                  -2.7*
     MCCN                        1986             to             2004                  -2.6*
     MCCN                        1986             to             1994                  -1.9*
     MCCN                        1994             to             2004                  -3.2*
    *= the APC is significantly different from 0 (p<0.05)




                                                                                                                 11
     2.2 Geographic variations
     When looking at smaller geographies, it becomes clear that lung cancer rates vary greatly across the North
     West. Incidence rates in Liverpool, Manchester and Knowsley are approximately double the English average,
     while in South Lakeland incidence is one third below the English average.

     Women
     There were substantial variations in the number of lung cancer cases by local authority for women ranging
     from 38 in Eden, to 713 in Liverpool during 2005. Age standardised lung cancer rates also varied. The highest
     rates occurred in Liverpool (78.2), Knowsley (69.1), Salford (65.2) and Manchester (58.7) being 125%, 99%,
     88% and 69% above the national average, respectively (Figure 2.4). In comparison the lowest incidence
     occurred in South Lakeland (21.8) - 37% below the national average.


      Figure 2.4: Funnel plot of age standardised (per 100,000) lung cancer incidence rates in women
      by local authorities in the North West compared to the England average, 2003-05.




     Between 1995-97 and 2003-05 incidence rates for women increased in most local authorities with the
     largest increases seen in Congleton (132%), Chorley (70%) and Crewe and Nantwich (52%) (Figure 2.5).
     Congleton, Chorley and Crewe and Nantwich were below the English average during 1995-97 but rose above
     it for 2003-05. Incidence rates decreased in West Lancashire (-28%), South Lakeland (-22%) and Copeland
     (-9.4%).




12
Figure 2.5: Change (%) in age-standardised lung cancer incidence rates for women by local
authorities from 1995-97 to 2003-05, North West.

                               West Lancashire
                                   South Lakeland
                                       Copeland
                             Barrow-in-Furness *
                                       Vale Royal
                                         Chester
                                       Lancaster
                                     Rossendale *
                                        Oldham *
                                          Wirral *
                                              Eden
                                      Hyndburn *
                                     Macclesfield
                                              Wyre
                                     South Ribble
                                     Manchester *
                                         Carlisle*
                                    Ribble Valley
                                         Pendle *
      Decrease                         Liverpool *
                                                                            Increase
                                          Wigan *
                                         Trafford
                                       Knowsley *
                                       Rochdale *
                                         Salford *
                                       St Helens *
                                          Sefton
                                        Allerdale
                                              Bury *
                                       Stockport
                                       Tameside *
                                         Bolton *
                                        Preston *
                                     Warrington *
                     Ellesmere Port and Neston
                                          Halton *
                                      Blackpool *
                                         Burnley*
                         Blackburn with Darwen *
                                              Fylde
                            Crewe and Nantwich

     * = spearhead local                 Chorley
         authority                     Congleton

  -100    -80      -60       -40        -20            0      20       40   60   80    100   120   140
                                                       Percentage change




                                                                                                         13
     Men
     Geographic variations for men during this time period were similar to women with Liverpool (109.6),
     Manchester (108.3), Knowsley (104.6) and Salford (97.0) having had the highest age-standardised incidence
     rates (Figure 2.6). South Lakeland (43.1) and Eden (43.2) had the lowest rates although these were not
     significantly below the English average. In 2005 the number of newly diagnosed cases ranged from 50 in Eden
     to 785 in Liverpool.

       Figure 2.6: Funnel plot of age standardised (per 100,000) lung cancer incidence rates in men by
       local authorities in the North West compared to the England average, 2003-05.

                           140



                           120

                                                             Knowsley                                       Liverpool
                                                                                                                           Manchester
                           100
                                                                                  Salford
                                                    Halton
                                                                  Rochdale
                                                                                 Tameside
         ASR per 100,000




                                                                                                    Wigan
                           80


                                                                                                                 national average
                           60



                                     Eden
                           40
                                               South
                                               Lakeland

                           20



                            0
                                 0          50000                       100000                  150000       200000                     250000
                                                                                   Population



     For men lung cancer incidence increased between 1995-97 and 2003-05 for the Ribble Valley (49%) and Fylde
     (1%) and decreased in all other local authorities in the North West (Figure 2.7). However the Ribble Valley has
     the smallest population and one of the smallest number of lung cancer cases in the North West, and hence the
     high excess incidence in 2003-05 might be due to annual fluctuations or random variation. Ellesmere Port and
     Neston (-38%), Macclesfield (-34%) and Chorley (-33%) experienced the greatest decrease in incidence.




14
Figure 2.7: Change (%) in age-standardised lung cancer incidence rates for men by local
authorities from 1995-97 to 2003-05, North West.


                              Ellesmere Port and Neston

                                           Macclesfield

                                               Chorley

                                                Sefton

                                        South Lakeland

                                       West Lancashire

                                              Allerdale

                                             Knowsley *

                                             St Helens *

                                           South Ribble

                                                Bolton *

                                                Halton *

                                           Warrington *

    Decrease                                 Tameside *
                                                                       Increase
                                                  Wyre

                                             Vale Royal

                                Blackburn with Darwen *

                                             Rochdale *

                                               England

                                                  Eden

                                           Manchester *

                                              Copeland

                                               Salford *

                                             Stockport

                                                Wirral *

                                                 Bury *

                                                Wigan *

                                              Oldham *

                                               Carlisle*

                                             Hyndburn *

                                               Trafford

                                               Pendle *

                                             Congleton

                                             Liverpool *

                                            Blackpool *

                                               Chester

                                    Barrow-in-Furness *

                                              Preston *

                                               Burnley*

                                           Rossendale *

                                             Lancaster

                                    Crewe and Nantwich
    * = spearhead local                           Fylde
        authority
                                          Ribble Valley

  -60              -40           -20                       0      20              40      60
                                              Percentage change




                                                                                               15
     2.3 Age specific trends
     Lung cancer incidence rates increase with age, peaking in the over 85s for men and 75 to 79 year olds for
     women (Figure 2.8). The number of patients reaches a peak in the 75-79 age group, with 563 men and
     461 women in this age group diagnosed with lung cancer in the North West in 2005. Incidence rates were
     consistently higher in men in all age groups.

       Figure 2.8: Lung cancer incidence (number and rates per 100,000) by age and sex, North West,
       2003-2005.
                                800                                                                                                                 2000
                                            number of cases men
                                            number of cases women
                                                                                                                                                    1800
                                700         age specific rate men
                                            age specific rate women
                                                                                                                                                    1600
                                600
                                                                                                                                                    1400

                                500
                                                                                                                                                    1200




                                                                                                                                                           number of cases
            age specific rate




                                400                                                                                                                 1000


                                                                                                                                                    800
                                300

                                                                                                                                                    600
                                200
                                                                                                                                                    400

                                100
                                                                                                                                                    200


                                 0                                                                                                                  0
                                      0-4   5-9   10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84   85+
                                                                                       age band



     We analysed trends in age specific lung cancer rates with particular focus on the younger age groups (30 to 49
     years) because changes in lung cancer incidence and mortality in this age group has been shown to correlate
     with smoking cessation measures3 and might also give an indication of future trends2.
     For both men and women, rates have been highest in MCCN and lowest in LSCCN for all age bands.

     Men
     The analysis by age bands shows that rates in men decreased across all the age bands included in our study in
     all cancer networks in the North West over the last 20 years, except for the 85 plus year olds in LSCCN, who
     showed a slight increase. From 1995-97 to 2003-05 lung cancer rates decreased the most in the younger age
     groups with the highest being a 40% decrease in the 30 to 54 year olds in MCCN (Table 2.3, Figure 2.9).

     Women
     In comparison rates in women show a more diverse picture, varying by cancer network and age band. Compared
     to 1994-96, rates in 2003-05 increased markedly in 75 to 84 and 85 plus year olds in all three cancer networks
     in the North West, the most striking being a 69.6% increase in the 85 plus in MCCN. These increases probably
     reflect changes in the smoking habits of women born during the period 1910 to 1930.
     Trend analysis highlights a decline in incidence in the 65 to 74 year olds in MCCN and also in the 55 to 64
     year old women in LSCCN for the most recent time periods highlighting cohorts that might contribute to a
     decrease in future female lung cancer rates in these areas. In contrast rates in the 55 to 64 year olds show
     increasing trends for the most recent time periods in MCCN and GMCCN. If these trends continue in these
     cohorts, future rates in GMCCN might increase further and the currently observed positive trend of a decline
     in the 65 to 74 and 75 to 84 year olds in MCCN might be reversed. LSCCN is the only network that shows
     an increasing trend in 30 to 54 year old women with a 7.5% increase compared with a 15.3% decrease for
     GMCCN and a 10.9% decrease for MCCN from 1994-96 to 2003-05 (Table 2.3, Figure 2.9). If this trend is to
     continue in this cohort, lung cancer rates in women in LSCCN might keep increasing.

16
Table 2.3: Change (%) in age-specific and All ages lung cancer incidence rates (per 100,000), by
sex, 1994-96 to 2003-05.

                           30-54      55-64      65-74       75-84       85 plus     all ages
  Men       North West     -31.9      -20.7      -24.3       -15.2       -8.7        -20.5
            LSCCN          -35.8      -8.4       -23.7       -9.1        2.4         -15.6
            GMCCN          -21.6      -26.3      -23         -21.2       -6          -21.1
            MCCN           -41.4      -19.3      -27.1       -10.9       -18.3       -22.4
  Women     North West     -7         5.3        -5.9        28.6        46.5        5.5
            LSCCN          7.5        -5         2.4         37.1        50.2        9.8
            GMCCN          -15.3      9.8        -0.2        29.2        25.4        7.3
            MCCN           -10.9      6.4        -13.4       24.8        69.6        2.4




                                                                                                  17
18
                                              Rate per 100,000                                                                      Rate per 100,000                                                                   Rate per 100,000




                                                                                                                                                                                                          0
                                                                                                                                                                                                                  5
                                                                                                                                                                                                                         10
                                                                                                                                                                                                                                   15
                                                                                                                                                                                                                                           20
                                                                                                                                                                                                                                                     25




                              0
                                   50
                                          100
                                                  150
                                                              200
                                                                      250
                                                                             300
                                                                                   350
                                                                                                                   0
                                                                                                                       20
                                                                                                                             40
                                                                                                                                    60
                                                                                                                                         80
                                                                                                                                               100
                                                                                                                                                     120
                                                                                                                                                             140
                                                                                                                                                                    160
                                                                                                                                                                          180
                  1985-1987                                                                                                                                                                   1985-1987
                                                                                                       1985-1987
                  1986-1988                                                                                                                                                                   1986-1988
                                                                                                       1986-1988
                  1987-1989                                                                                                                                                                   1987-1989
                                                                                                       1987-1989
                  1988-1990                                                                                                                                                                   1988-1990
                                                                                                       1988-1990




                                                                                                                                                                                Women 55-64
                                                                                                                                                                                                                                                          Women 30-54




                                                                                         Women 65-74
                  1989-1991                                                                            1989-1991                                                                              1989-1991

                  1990-1992                                                                            1990-1992                                                                              1990-1992




     MCCN


     LSCCN
     GMCCN
                                                                                                                                                                                              1991-1993




      MCCN
                  1991-1993                                                                            1991-1993




      GMCCN
                                                                                                                                                                                              1992-1994




     North West
                  1992-1994                                                                            1992-1994
                  1993-1995                                                                            1993-1995                                                                              1993-1995

                  1994-1996                                                                            1994-1996                                                                              1994-1996

                  1995-1997                                                                            1995-1997                                                                              1995-1997

                  1996-1998                                                                            1996-1998                                                                              1996-1998

                  1997-1999                                                                            1997-1999                                                                              1997-1999

                  1998-2000                                                                            1998-2000                                                                              1998-2000

                  1999-2001                                                                            1999-2001                                                                              1999-2001

                  2000-2002                                                                            2000-2002                                                                              2000-2002

                  2001-2003                                                                            2001-2003                                                                              2001-2003

                  2002-2004                                                                            2002-2004                                                                              2002-2004

                  2003-2005                                                                            2003-2005                                                                              2003-2005




                                              Rate per 100,000                                                                      Rate per 100,000                                                                   Rate per 100,000
                                                                                                                                                                                                          0
                                                                                                                                                                                                              5
                                                                                                                                                                                                                  10
                                                                                                                                                                                                                        15
                                                                                                                                                                                                                              20
                                                                                                                                                                                                                                   25
                                                                                                                                                                                                                                          30
                                                                                                                                                                                                                                                35
                                                                                                                                                                                                                                                     40




                                                                                                                   0
                                                                                                                        50
                                                                                                                                  100
                                                                                                                                         150
                                                                                                                                               200
                                                                                                                                                       250
                                                                                                                                                                   300
                                                                                                                                                                          350




                              0
                                  100
                                        200
                                                300
                                                        400
                                                                500
                                                                       600
                                                                             700
                                                                                   800
                                                                                                                                                                                              1985-1987
                  1985-1987                                                                            1985-1987
                                                                                                                                                                                              1986-1988
                  1986-1988                                                                            1986-1988
                                                                                                                                                                                              1987-1989
                                                                                                                                                                                 Men 55-64
                                                                                                                                                                                                                                                          Men 30-54




                                                                                         Men 65-74
                  1987-1989                                                                            1987-1989

                                                                                                       1988-1990                                                                              1988-1990
                  1988-1990
                                                                                                       1989-1991                                                                              1989-1991
                  1989-1991
                                                                                                       1990-1992                                                                              1990-1992
                  1990-1992
                                                                                                       1991-1993                                                                              1991-1993
                  1991-1993
                                                                                                                                                                                              1992-1994




     MCCN
                                                                                                       1992-1994




     LSCCN
                  1992-1994




     GMCCN
      MCCN
                                                                                                       1993-1995                                                                              1993-1995




      GMCCN
                  1993-1995




     North West
                                                                                                                                                                                                                                                                        network, North West, 1985-2005. Note that each chart uses different scale




                                                                                                       1994-1996                                                                              1994-1996
                  1994-1996
                                                                                                       1995-1997                                                                              1995-1997
                  1995-1997
                                                                                                       1996-1998                                                                              1996-1998
                  1996-1998
                                                                                                       1997-1999                                                                              1997-1999
                  1997-1999
                                                                                                       1998-2000                                                                              1998-2000
                  1998-2000
                                                                                                       1999-2001                                                                              1999-2001
                  1999-2001
                                                                                                       2000-2002                                                                              2000-2002
                  2000-2002
                                                                                                                                                                                                                                                                        Figure 2.9: Age-specific lung cancer incidence trends (rate per 100,000), by sex and cancer




                                                                                                       2001-2003                                                                              2001-2003
                  2001-2003
                                                                                                       2002-2004                                                                              2002-2004
                  2002-2004
                                                                                                       2003-2005                                                                              2003-2005
                  2003-2005
 Figure 2.9 continued: Age-specific lung cancer incidence trends (rate per 100,000), by sex and
 cancer network, North West, 1985-2005. Note that each chart uses different scale

 Women 75-84                                                                                                                                                                                                                                                    Men 75-84
                     500                                                                                                                                                                                                                                                               1200

                     450
                                                                                                                                                                                                                                                                                       1000
                     400
                     350




                                                                                                                                                                                                                                                                    Rate per 100,000
                                                                                                                                                                                                                                                                                        800
  Rate per 100,000




                     300
                     250                                                                                                                                                                                                                                                                600

                     200
                                                                                                                                                                                                                                                                                        400
                     150
                     100                                                                                                                                                                                                                                                                200
                      50
                       0                                                                                                                                                                                                                                                                  0




                                                                                                                                                                                                                                                                                                1985-1987
                                                                                                                                                                                                                                                                                                             1986-1988
                                                                                                                                                                                                                                                                                                                          1987-1989
                                                                                                                                                                                                                                                                                                                                       1988-1990
                                                                                                                                                                                                                                                                                                                                                    1989-1991
                                                                                                                                                                                                                                                                                                                                                                 1990-1992
                                                                                                                                                                                                                                                                                                                                                                              1991-1993
                                                                                                                                                                                                                                                                                                                                                                                           1992-1994
                                                                                                                                                                                                                                                                                                                                                                                                       1993-1995
                                                                                                                                                                                                                                                                                                                                                                                                                   1994-1996
                                                                                                                                                                                                                                                                                                                                                                                                                               1995-1997
                                                                                                                                                                                                                                                                                                                                                                                                                                           1996-1998
                                                                                                                                                                                                                                                                                                                                                                                                                                                       1997-1999
                                                                                                                                                                                                                                                                                                                                                                                                                                                                   1998-2000
                                                                                                                                                                                                                                                                                                                                                                                                                                                                               1999-2001
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2000-2002
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       2001-2003
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   2002-2004
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2003-2005
                           1985-1987

                                       1986-1988

                                                   1987-1989

                                                               1988-1990

                                                                            1989-1991

                                                                                        1990-1992

                                                                                                    1991-1993

                                                                                                                1992-1994

                                                                                                                            1993-1995

                                                                                                                                        1994-1996

                                                                                                                                                    1995-1997

                                                                                                                                                                1996-1998

                                                                                                                                                                            1997-1999

                                                                                                                                                                                        1998-2000

                                                                                                                                                                                                    1999-2001

                                                                                                                                                                                                                2000-2002

                                                                                                                                                                                                                            2001-2003

                                                                                                                                                                                                                                        2002-2004

                                                                                                                                                                                                                                                    2003-2005
  Women 85+                                                                                                                                                                                                                                                     Men 85+
                     400                                                                                                                                                                                                                                                           1400

                     350                                                                                                                                                                                                                                                           1200

                     300                                                                                                                                                                                                                                                           1000
                                                                                                                                                                                                                                                                Rate per 100,000
  Rate per 100,000




                     250
                                                                                                                                                                                                                                                                                       800
                     200
                                                                                                                                                                                                                                                                                       600
                     150
                                                                                                                                                                                                                                                                                       400
                     100
                                                                                                                                                                                                                                                                                       200
                      50

                       0                                                                                                                                                                                                                                                                 0
                                                                                                                                                                                                                                                                                              1985-1987
                                                                                                                                                                                                                                                                                                            1986-1988
                                                                                                                                                                                                                                                                                                                         1987-1989
                                                                                                                                                                                                                                                                                                                                      1988-1990
                                                                                                                                                                                                                                                                                                                                                   1989-1991
                                                                                                                                                                                                                                                                                                                                                                1990-1992
                                                                                                                                                                                                                                                                                                                                                                             1991-1993
                                                                                                                                                                                                                                                                                                                                                                                          1992-1994
                                                                                                                                                                                                                                                                                                                                                                                                       1993-1995
                                                                                                                                                                                                                                                                                                                                                                                                                   1994-1996
                                                                                                                                                                                                                                                                                                                                                                                                                               1995-1997
                                                                                                                                                                                                                                                                                                                                                                                                                                           1996-1998
                                                                                                                                                                                                                                                                                                                                                                                                                                                       1997-1999
                                                                                                                                                                                                                                                                                                                                                                                                                                                                   1998-2000
                                                                                                                                                                                                                                                                                                                                                                                                                                                                               1999-2001
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2000-2002
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       2001-2003
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   2002-2004
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2003-2005
                           1985-1987

                                       1986-1988

                                                   1987-1989

                                                               1988-1990

                                                                            1989-1991

                                                                                        1990-1992

                                                                                                    1991-1993

                                                                                                                1992-1994

                                                                                                                            1993-1995

                                                                                                                                        1994-1996

                                                                                                                                                    1995-1997

                                                                                                                                                                1996-1998

                                                                                                                                                                            1997-1999

                                                                                                                                                                                        1998-2000

                                                                                                                                                                                                    1999-2001

                                                                                                                                                                                                                2000-2002

                                                                                                                                                                                                                            2001-2003

                                                                                                                                                                                                                                        2002-2004

                                                                                                                                                                                                                                                    2003-2005




                                                                            MCCN
                                                                           MCCN                                                                                                                                                                                                                                                                                  MCCN
                                                                                                                                                                                                                                                                                                                                                                MCCN
                                                                           GMCCN                                                                                                                                                                                                                                                                                GMCCN
                                                                            GMCCN
                                                                           North West                                                                                                                                                                                                                                                                            GMCCN
                                                                                                                                                                                                                                                                                                                                                                North West
                                                                           LSCCN                                                                                                                                                                                                                                                                                LSCCN




Lung cancer incidence in younger adults (30 to 49 year olds)
Lung cancer rates in men have been constantly decreasing in those aged 30 to 49 in the North West, MCCN
and GMCCN at 4.5%, 4.3% and 4.9% per year respectively. In contrast rates show an increasing trend
in LSCCN over the last three years after they declined at an even faster rate than in the other two cancer
networks in the years before. As the increase relies on only three data points it remains to be seen if this trend
is to continue. However if the latest trend observed in LSCCN is a real trend and not just due to fluctuation
future rates might start increasing again in LSCCN and more attention needs to be paid to smoking prevention
and cessation in LSCCN.
For women aged 30 to 49 incidence rates declined between 1986 and 1994, but increased by 0.43% per
year between 1994 and 2005 in the North West. The three cancer networks in the North West show a diverse
picture with decreases in GMCCN and MCCN and an increase in LSCCN. Rates in GMCCN decreased by
1.3% per year and in MCCN they decreased by 3.9% till 1992 and then slowed to about 0.8% per year; in
comparison rates increased by 2.1% in LSCCN per year over the whole time period. More detailed information
on this analysis can be found in the appendix.
This analysis further confirms the trend of increasing lung cancer rates in the younger age groups in LSCCN
highlighting a cohort which could have higher lung cancer incidence in the future and indicates that more effort
with regards to smoking control programmes might be required. In contrast the trends currently observed in
MCCN and GMCCN suggest that smoking prevalence is decreasing in the younger age groups and highlights
a cohort that might have lower lung cancer rates in the future.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           19
     3. Mortality
     Lung cancer has a poor prognosis with mortality trends closely mirroring incidence trends. In the North West
     2,550 men and 1,953 women died of lung cancer in 2005. GMCCN registered the most lung cancer deaths
     (n=1,855) followed by MCCN (n=1,459) and LSCCN (n=960) in 2005. Over the past 20 years lung cancer
     mortality has decreased in men and been stable or slightly increasing in women in the North West (Figure 3.1).
     There is a consistent male/female pattern of trends across the networks with rates highest in MCCN followed
     by GMCCN and LSCCN.

     3.1 Trends
     Analysis of temporal trends using joinpoint regression technique (see appendix for details) showed that trends
     are decreasing in men in all cancer networks in the North West (Figure 3.1 and 3.2). Mortality decreased in all
     networks between 1986 and 2004 with the largest annual decrease occurring in MCCN (MCCN 3.3%, LSCCN
     2.9% GMCCN 3.2%). During the most recent time segments identified in the joinpoint analysis the reduction
     in mortality accelerated for GMCCN and MCCN (GMCCN 3.5%, MCCN 3.8% per year) and slowed for LSCCN
     (2.2% per year) (Table 3.1).



       Figure 3.1: Trends in lung cancer mortality (ASR per 100,000) by sex and cancer network in the
       North West 1985 to 2005
                              140
                                                                                                                             North West men
                                                                                                                             LSCCN men
                                                                                                                             GMCCN men
                              120
                                                                                                                             MCCN men
                                                                                                                             North West women
                                                                                                                             LSCCN women
                              100
                                                                                                                             GMCCN women
                                                                                                                             MCCN women
            ASR per 100,000




                              80



                              60



                              40



                              20



                               0
                                    1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005




     Mortality rates for women increased steeply in the North West during 1986-89 and then stabilised for the
     remaining time period (Figure 3.3). In women the trends differed by network with mortality rates in LSCCN
     fluctuating and increasing slowly by 0.3% between 1986 and 2004. In GMCCN rates increased for the first
     four years and showed an annual decrease of 0.2% from 1989 onward. In comparison rates are currently
     estimated to decrease at about 2.1% per year in MCCN after 2002 (Table 3.2). If the relatively faster decline
     in MCCN is to continue the gap between MCCN and the other cancer networks in the North West will keep
     decreasing.




20
Figure 3.2: Joinpoint analysis of trends in lung cancer mortality rates (ASR per 100,000) in
men in the North West 1986-2004 (          year rolling averages).
                                    (three y          g      g )




Figure 3.3: Joinpoint analysis of trends in lung cancer mortality rates (ASR per 100,000) in
women in the North West 1986-2004 (three year rolling averages).




                                                                                               21
     Table 3.1: Annual percentage change in lung cancer mortality rates in men for the time
     segments identified in the joinpoint analysis.

      Place                                Segment (years)                 Annual Percentage
                                                                             Change (APC)
      North West                        1986       to       2004                 -3.2*
      North West                        1986       to       1991                 -2.3*
      North West                        1991       to       2004                 -3.4*
      LSCCN                             1986       to       2004                 -3.0*
      LSCCN                             1986       to       1992                 -2.3*
      LSCCN                             1992       to       1997                 -4.2*
      LSCCN                             1997       to       2004                 -2.2*
      GMCCN                             1986       to       2004                 -3.3*
      GMCCN                             1986       to       1990                 -1.9*
      GMCCN                             1990       to       2004                 -3.5*
      MCCN                              1986       to       2004                 -3.2*
      MCCN                              1986       to       1995                 -2.7*
      MCCN                              1995       to       2004                 -3.8*
     *= the APC is significantly different from 0 (p<0.05)



     Table 3.2: Annual percentage change in lung cancer mortality rates in women for the time
     segments identified in the joinpoint analysis.

      Place                                 Segment (years)                Annual Percentage
                                                                             Change (APC)
      North West                        1986       to       2004                 0.2*
      North West                        1986       to       1989                  3.1*
      North West                        1989       to       2004                   0.0
      LSCCN                             1986       to       2004                 0.3*
      LSCCN                             1986       to       1989                  2.6*
      LSCCN                             1989       to       1995                 -1.0*
      LSCCN                             1995       to       1998                   1.9
      LSCCN                             1998       to       2004                   0.2
      GMCCN                             1986       to       2004                   0.2
      GMCCN                             1986       to       1989                  4.7*
      GMCCN                             1989       to       2004                 -0.2*
      MCCN                              1986       to       2004                 0.2*
      MCCN                              1986       to       1988                   3.0
      MCCN                              1988       to       1995                 0.6*
      MCCN                              1995       to       2002                  -0.1
      MCCN                              2002       to       2004                  -2.1
     *= the APC is significantly different from 0 (p<0.05)




22
3.2 Geographic variations
Lung cancer mortality rates vary greatly across the North West, with Liverpool local authority having age
standardised rates up to three times higher than South Lakeland where the lowest rates were seen. The
geographic pattern of lung cancer mortality is similar to that seen for incidence (section 2.2).

Women
Age standardised lung cancer rates for women were significantly above the English average in Liverpool (61.8)
Knowsley (56.3) and Salford (55.7), with rates being 117%, 98% and 96% above the national average. In
comparison rates in Chester (20.2) and South Lakeland (20.9) were below the national average (Figure 3.4).


 Figure 3.4: Funnel plot of age standardised (per 100,000) lung cancer mortality rates in women
 by local authorities in the North West compared to the England average, 2003-2005.

                            90


                            80


                            70

                                                                                                                    Liverpool
                            60                          Knowsley                 Salford
          ASR per 100,000




                            50                         Halton
                                                                                                            Manchester
                                                                                Rochdale
                                                                                                 Sefton
                            40


                            30                                                                                     national average


                                                                 Vale Royal
                            20       South Lakeland    Chester


                            10


                            0
                                 0             50000                   100000                  150000     200000                      250000
                                                                                  Population




There have been significant decreases in lung cancer mortality for women in Chester (30%), Rossendale (19%)
and West Lancashire (17%) between 1995-97 and 2003-05, while rates have increased in Congleton (124%),
Crewe and Nantwich (54%) and Burnley (45%) (Figure 3.5). Despite the increases in Congleton and Crewe
and Nantwich they were still below the English average in 2003-2005.




                                                                                                                                               23
     Figure 3.5: Change (%) in age-standardised lung cancer mortality rates for women by local
     authorities from 1995-97 to 2003-05, North West.


                                               Chester
                                          Rossendale *
                                      West Lancashire
                                                Wirral *
                                             Copeland
                                                   Eden
                                    Barrow-in-Furness *
                                          Macclesfield
                                              Oldham *
                                          Ribble Valley
                                            Knowsley *
                                          South Ribble
                                                   Bury *
                                            Vale Royal
                                        South Lakeland
                                            St Helens *
                                          Manchester *
                                               Pendle *
               Decrease                        Wigan *                   Increase
                                             Lancaster
                                            Tameside *
                                            Liverpool *
                                             Stockport
                                            Hyndburn *
                                                Sefton
                                                   Wyre
                                           Warrington *
                                              Salford *
                           Ellesmere Port and Neston
                                              Trafford
                                               Bolton *
                                               Chorley
                                               Halton *
                                            Rochdale *
                                                   Fylde
                                               Carlisle*
                                            Blackpool *
                                              Preston *
                                              Allerdale
                                Blackburn with Darwen *
                                               Burnley*
          * = spearhead local      Crewe and Nantwich
              authority
                                            Congleton

        -100             -60                 -20                   20           60   100         140
                                                            Percentage change




24
Men
The highest lung cancer mortality rates occurred in Liverpool (93.9), Manchester (86.5), Knowsley (84.2) and
Salford (79.7), which also had the highest incidence. In comparison Eden (34.6), South Lakeland (38.8) and
Macclesfield (42.8) had the lowest rates (Figure 3.6).

  Figure 3.6 Funnel plot of age standardised (per 100,000) lung cancer mortality rates in men by
  local authorities in the North West compared to the England average, 2003-2005.

                       140




                       120




                       100
                                                                                                   Liverpool

                                                     Knowsley
     ASR per 100,000




                        80                                                  Salford                               Manchester




                        60
                                                                                                           national average


                                                        Macclesfield
                        40              South
                                 Eden   Lakeland



                        20




                         0
                             0               50000                 100000                 150000      200000                   250000
                                                                             Population




For men lung cancer mortality only increased in the Ribble Valley local authority by 16% between 1995-97 and
2003-05 and decreased in all other local authorities and in the North West overall (Figure 3.7). Ellesmere Port
and Neston (-41%), Eden (-37%) and St. Helens (-37%) saw the greatest decline in mortality.




                                                                                                                                        25
     Figure 3.7: Change (%) in age-standardised lung cancer mortality rates for men by local
     authorities from 1995-97 to 2003-05, North West.

                                                    Ellesmere Port and Neston
                                                                         Eden
                                                                    St Helens *
                                                                        Sefton
                                                                 Macclesfield
                                                                       Halton *
                                                                    Knowsley *
                                                                 South Ribble
                                                                    Tameside *
                                                              South Lakeland
                                                                      Chester
                                                                      Trafford
                                                                  Warrington *
                                                                    Vale Royal

                  Decrease                                            Salford *
                                                                                      Increase
                                                                     Allerdale
                                                                       Wigan *
                                                          Crewe and Nantwich
                                                             West Lancashire
                                                                 Manchester *
                                                                         Wyre
                                                                       Bolton *
                                                                     Copeland
                                                                    Lancaster
                                                                       Wirral *
                                                                      Oldham *
                                                                     Stockport
                                                                    Blackpool *
                                                                         Bury *
                                                                       Chorley
                                                                      Carlisle*
                                                                    Liverpool *
                                                                    Rochdale *
                                                                      Preston *
                                                      Blackburn with Darwen *
                                                                    Congleton
                                                                    Hyndburn *
                                                                       Pendle *
                                                                      Burnley*
                                                          Barrow-in-Furness *
                                                                         Fylde
               * = spearhead local                               Rossendale *
                   authority
                                                                Ribble Valley

         -50             -40         -30      -20             -10                 0     10       20
                                              Percentage change




26
3.3 Performance against the national cancer target
The national target for cancer is to reduce mortality rates by at least 20% in under 75 year olds by 2010
(measured from the 1995-1997 baseline) with a reduction in the inequalities gap of at least 6%.
With the exception of Hyndburn all local authorities in the North West saw a decrease in the under 75 year
olds lung cancer mortality rates between 1995-97 and 2003-05. Over half of the local authorities in the North
West have already achieved a 20% decrease in lung cancer mortality rates (Figure 3.8). The inequalities target
remains a bigger challenge to tackle with 13 of the 23 spearhead local authorities in the North West seeing an
increase in the difference to the England average. Despite the progress made in the North West, lung cancer
mortality in England as a whole is improving even more rapidly and hence the inequalities gap is widening
(Figure 3.9).
Changes to the ranking of the local authorities compared to analysis of all ages highlights the differences and
impact of mortality in those over 75.




                                                                                                                  27
     Figure 3.8: Change (%) in age-standardised lung cancer mortality rates in patients under 75 years
     from 1995-97 to 2003-05, by local authority in the North West.

                                                        Macclesfield

                                                              Chester

                                                          St Helens *

                                                    West Lancashire

                                                               Sefton

                                                                 Eden

                                                          Knowsley *

                                           Ellesmere Port and Neston

                                                     South Lakeland

                                                          Vale Royal

                                                        South Ribble

                                                              Halton *

                                                              Chorley

                                                              Bolton *

                                                        Manchester *

                                                              Salford *

                                                              Trafford

                                                               Wirral *

                Decrease                                  Tameside *
                                                                                   Increase
                                                             Oldham *

                                                        Warrington *

                                                               Wigan *

                                                             Allerdale

                                                       Ribble Valley

                                                 Barrow-in-Furness *

                                                         Blackpool *

                                                             Copeland

                                                          Liverpool *

                                                          Lancaster

                                                              Pendle *

                                                                 Wyre

                                                                Bury *

                                                        Rossendale *

                                                          Rochdale *

                                                          Stockport

                                                              Carlisle*

                                                              Burnley*

                                                             Preston *

                                             Blackburn with Darwen *

                                                          Congleton

                                                 Crewe and Nantwich

             * = spearhead local                                Fylde

                 authority
                         y                                Hyndburn *

       -60          -50       -40   -30    -20         -10                0   10   20   30      40

                                                 Percentage change




28
Figure 3.9: Change (%) in the gap for mortality between the national average for those under 75
years from 1995-97 to 2003-05 by local authority, North West.

                                            Macclesfield

                                              St Helens *

                                              Knowsley *

                                                 Chester

                                                  Sefton

                                         West Lancashire

                                                   Eden

                               Ellesmere Port and Neston

                                          South Lakeland

                                              Vale Royal

                                            South Ribble

                                                 Halton *

                                            Manchester *

                                                Salford *

                                                 Chorley

                                                 Bolton *

           Decrease                           Tameside *
                                                                        Increase
                                                  Wirral *

                                                Trafford

                                                Oldham *

                                             Warrington *

                                                 Wigan *

                                            Ribble Valley

                                                Allerdale

                                     Barrow-in-Furness *

                                               Copeland

                                              Blackpool *

                                               Lancaster

                                                   Wyre

                                                 Pendle *

                                                   Bury *

                                              Liverpool *

                                            Rossendale *

                                               Stockport

                                              Rochdale *

                                                 Carlisle*

                                                   Fylde

                                              Congleton

                                     Crewe and Nantwich

                                                Preston *

                                                Burnley*
         * = spearhead local     Blackburn with Darwen *
             authority
                                              Hyndburn *

   -60                -40          -20                       0     20         40          60
                                               Percentage change




                                                                                                  29
     3.4 Age specific analysis
     Lung cancer mortality by age shows a similar pattern to that of incidence. Men had the highest age specific
     lung cancer mortality rates in the oldest age groups (80 to 84 and 85 plus), whereas women had the highest
     rates in those 75 to 79 years (Figure 3.10).
     For both men and women, age specific rates have been highest in MCCN and lowest in LSCCN for all age
     bands.

       Figure 3.10: Lung cancer mortality (Number and rates per 100,000) by age and sex, North West,
       2003-2005.
                               800                                                                                                                 2000
                                           number of cases men
                                           number of cases women
                                                                                                                                                   1800
                               700         age specific rate men
                                           age specific rate women
                                                                                                                                                   1600
                               600
                                                                                                                                                   1400

                               500
                                                                                                                                                   1200




                                                                                                                                                          number of cases
           age specific rate




                               400                                                                                                                 1000


                                                                                                                                                   800
                               300

                                                                                                                                                   600
                               200
                                                                                                                                                   400

                               100
                                                                                                                                                   200


                                0                                                                                                                  0
                                     0-4   5-9   10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84   85+
                                                                                      age band




     Men
     Over the past 20 years mortality decreased for men in all cancer networks and the North West overall except
     among 85 plus year olds in LSCCN, for whom mortality increased slightly (Figure 3.11, Table 3.3). From
     1995-97 to 2003-05 the largest declines in lung cancer mortality rates in men were seen in the younger age
     groups, the largest decreases being 41% and 42% in the 30-54 year olds in MCCN and LSCCN respectively.
     Rates in 55 to 64 year old males only declined by just 1.4% in LSCCN compared to 29% in GMCCN and 24%
     in MCCN. This is mainly due to increasing lung cancer mortality rates over the last three years in LSCCN (Table
     3.3).
     Joinpoint regression analysis showed that for men lung cancer mortality rates decreased over the whole time
     period and are also currently showing a decreasing trend in all age groups except the 85 plus year olds in
     GMCCN and the 55 to 64 year olds in LSCCN for whom there is a recent upward trend. For GMCCN and
     LSCCN the increase relies on only four and three data points respectively and it remains to be seen if this trend
     is to continue. Rates in the over 85 year olds show higher fluctuations throughout the time period as the
     number of cases is changing while at the same time the denominator might be subject to change depending
     on life expectancy.

     Women
     For women lung cancer mortality decreased for the under 75 year olds, with the exception of 65 to 74 year
     olds in LSCCN which saw a small and non-significant increase (Table 3.3). It should be noted that for women
     numbers are small in the younger age groups and a direct comparison of two time periods might not be
     accurate due to fluctuations over the time period. The largest decreases in lung cancer mortality rates in
     women were among the 55 to 64 year olds in MCCN (20%) and the largest increases were among the over
     85 year olds in MCCN (79%).

30
      Table 3.3: Change (%) in age-specific and all ages lung cancer mortality rates (per 100,000),
      by sex, 1995-95 to 2003-05.

                                                                                                            place                                                                                                            30-54                                                                                            55-64                                             65-74                                                                                        75-84                                                                                   85 plus                                                                            all ages
                    Men                                                                                    North West                                                                                                        -37.3                                                                                            -22.4                                             -29                                                                                          -19.1                                                                                   -7.8                                                                               -24.3
                                                                                                           LSCCN                                                                                                             -41.9                                                                                            -1.4                                              -25.3                                                                                        -11.1                                                                                   2.6                                                                                -16.7
                                                                                                           GMCCN                                                                                                             -31.8                                                                                            -28.7                                             -28                                                                                          -22.3                                                                                   -1.7                                                                               -24.9
                                                                                                           MCCN                                                                                                              -41                                                                                              -24.1                                             -33.9                                                                                        -20.7                                                                                   -19.2                                                                              -27.8
                    Women                                                                                  North West                                                                                                        -4.1                                                                                             -10                                               -10.7                                                                                        29.4                                                                                    50.3                                                                               0.3
                                                                                                           LSCCN                                                                                                             -0.1                                                                                             -14.1                                             2.3                                                                                          36.6                                                                                    59.3                                                                               6.7
                                                                                                           GMCCN                                                                                                             -7.9                                                                                             -2.5                                              -9.1                                                                                         31.6                                                                                    24.8                                                                               2.0
                                                                                                           MCCN                                                                                                              -2.9                                                                                             -20.4                                             -17.7                                                                                        23.2                                                                                    79.2                                                                               -5.5




Figure 3.11: Age-specific lung cancer mortality trends (rate per 100,000), by sex and cancer
network, North West, 1985-2005. Note that each chart uses different scale


Women 30-54                                                                                                                                                                                                                                                                                                                                                                    Men 30-54
                   18                                                                                                                                                                                                                                                                                                                                                                              35
                   16
                                                                                                                                                                                                                                                                                                                                                                                                   30
                   14
                                                                                                                                                                                                                                                                                                                                                                                                   25
Rate per 100,000




                   12
                                                                                                                                                                                                                                                                                                                                                                                Rate per 100,000




                   10                                                                                                                                                                                                                                                                                                                                                                              20

                          8
                                                                                                                                                                                                                                                                                                                                                                                                   15
                          6
                                                                                                                                                                                                                                                                                                                                                                                                   10
                          4

                          2                                                                                                                                                                                                                                                                                                                                                                          5

                          0                                                                                                                                                                                                                                                                                                                                                                          0
                                  1985-1987

                                                  1986-1988

                                                                  1987-1989

                                                                                  1988-1990

                                                                                                      1989-1991

                                                                                                                         1990-1992

                                                                                                                                            1991-1993

                                                                                                                                                               1992-1994

                                                                                                                                                                                  1993-1995

                                                                                                                                                                                                    1994-1996

                                                                                                                                                                                                                      1995-1997

                                                                                                                                                                                                                                        1996-1998

                                                                                                                                                                                                                                                          1997-1999

                                                                                                                                                                                                                                                                           1998-2000

                                                                                                                                                                                                                                                                                            1999-2001

                                                                                                                                                                                                                                                                                                             2000-2002

                                                                                                                                                                                                                                                                                                                              2001-2003

                                                                                                                                                                                                                                                                                                                                               2002-2004

                                                                                                                                                                                                                                                                                                                                                               2003-2005




                                                                                                                                                                                                                                                                                                                                                                                                             1985-1987

                                                                                                                                                                                                                                                                                                                                                                                                                              1986-1988

                                                                                                                                                                                                                                                                                                                                                                                                                                               1987-1989

                                                                                                                                                                                                                                                                                                                                                                                                                                                                1988-1990

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1989-1991

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1990-1992

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1991-1993

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1992-1994

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1993-1995

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                1994-1996

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               1995-1997

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              1996-1998

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             1997-1999

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            1998-2000

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          1999-2001

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        2000-2002

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      2001-2003

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    2002-2004

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 2003-2005
                                                                                                                                                                                                                                                                                                                                                                               Men 55-64
Women 55-64
                                                                                                                                                                                                                                                                                                                                                                                                     350
                          160

                          140                                                                                                                                                                                                                                                                                                                                                                        300

                          120                                                                                                                                                                                                                                                                                                                                                                        250
                                                                                                                                                                                                                                                                                                                                                                                  Rate per 100,000
       Rate per 100,000




                          100
                                                                                                                                                                                                                                                                                                                                                                                                     200
                           80
                                                                                                                                                                                                                                                                                                                                                                                                     150
                           60
                                                                                                                                                                                                                                                                                                                                                                                                     100
                           40
                                                                                                                                                                                                                                                                                                                                                                                                      50
                           20

                              0                                                                                                                                                                                                                                                                                                                                                                          0
                                                                                                                                                                                                                                                                                                                                                                                                                  1985-1987

                                                                                                                                                                                                                                                                                                                                                                                                                                   1986-1988

                                                                                                                                                                                                                                                                                                                                                                                                                                                    1987-1989

                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1988-1990

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1989-1991

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1990-1992

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1991-1993

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1992-1994

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    1993-1995

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   1994-1996

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  1995-1997

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1996-1998

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                1997-1999

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              1998-2000

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            1999-2001

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          2000-2002

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        2001-2003

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     2002-2004

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  2003-2005
                                          1985-1987

                                                          1986-1988

                                                                          1987-1989

                                                                                          1988-1990

                                                                                                             1989-1991

                                                                                                                                1990-1992

                                                                                                                                                   1991-1993

                                                                                                                                                                      1992-1994

                                                                                                                                                                                        1993-1995

                                                                                                                                                                                                          1994-1996

                                                                                                                                                                                                                            1995-1997

                                                                                                                                                                                                                                              1996-1998

                                                                                                                                                                                                                                                               1997-1999

                                                                                                                                                                                                                                                                                1998-2000

                                                                                                                                                                                                                                                                                                 1999-2001

                                                                                                                                                                                                                                                                                                                  2000-2002

                                                                                                                                                                                                                                                                                                                                   2001-2003

                                                                                                                                                                                                                                                                                                                                                   2002-2004

                                                                                                                                                                                                                                                                                                                                                                   2003-2005




                                                                                                 MCCN
                                                                                                MCCN                                                                                                                                                                                                                                                                                                                                                                                                    MCCN
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       MCCN
                                                                                                GMCCN                                                                                                                                                                                                                                                                                                                                                                                                  GMCCN
                                                                                                 GMCCN
                                                                                                North West                                                                                                                                                                                                                                                                                                                                                                                              GMCCN
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       North West
                                                                                                LSCCN                                                                                                                                                                                                                                                                                                                                                                                                  LSCCN




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              31
32
                                                Rate per 100,000                                                                               Rate per 100,000                                                                 Rate per 100,000




                              0
                                   50
                                              100
                                                       150
                                                                   200
                                                                           250
                                                                                   300
                                                                                               350
                                                                                                                                                                                                                    0
                                                                                                                                                                                                                         50
                                                                                                                                                                                                                                100
                                                                                                                                                                                                                                            150
                                                                                                                                                                                                                                                        200
                                                                                                                                                                                                                                                                250
                                                                                                                                                                                                                                                                       300




                                                                                                                              0
                                                                                                                                  50
                                                                                                                                         100
                                                                                                                                                 150
                                                                                                                                                       200
                                                                                                                                                             250
                                                                                                                                                                     300
                                                                                                                                                                             350
                                                                                                                                                                                   400
                  1985-1987                                                                                       1985-1987                                                                             1985-1987

                  1986-1988                                                                                       1986-1988                                                                             1986-1988

                  1987-1989                                                                                       1987-1989                                                                             1987-1989




                                                                                                      Women 85+
                  1988-1990                                                                                       1988-1990                                                                             1988-1990




                                                                                                                                                                                          Women 75-84
                                                                                                                                                                                                                                                                             Women 65-74
                  1989-1991                                                                                       1989-1991                                                                             1989-1991

                  1990-1992                                                                                       1990-1992                                                                             1990-1992




     MCCN


     LSCCN
     GMCCN
      MCCN
                  1991-1993                                                                                       1991-1993                                                                             1991-1993




      GMCCN
     North West
                  1992-1994                                                                                       1992-1994                                                                             1992-1994

                  1993-1995                                                                                       1993-1995                                                                             1993-1995

                  1994-1996                                                                                       1994-1996                                                                             1994-1996

                  1995-1997                                                                                       1995-1997                                                                             1995-1997

                  1996-1998                                                                                       1996-1998                                                                             1996-1998

                  1997-1999                                                                                       1997-1999                                                                             1997-1999

                  1998-2000                                                                                       1998-2000                                                                             1998-2000

                  1999-2001                                                                                       1999-2001                                                                             1999-2001

                  2000-2002                                                                                       2000-2002                                                                             2000-2002

                  2001-2003                                                                                       2001-2003                                                                             2001-2003

                  2002-2004                                                                                       2002-2004                                                                             2002-2004

                  2003-2005                                                                                       2003-2005                                                                             2003-2005


                                                    Rate per 100,000                                                                           Rate per 100,000                                                                 Rate per 100,000
                                                                                                                                                                                                                    0
                                                                                                                                                                                                                        100
                                                                                                                                                                                                                              200
                                                                                                                                                                                                                                      300
                                                                                                                                                                                                                                                  400
                                                                                                                                                                                                                                                          500
                                                                                                                                                                                                                                                                 600
                                                                                                                                                                                                                                                                       700




                                                                                                                              0
                                                                                                                                   200
                                                                                                                                               400
                                                                                                                                                       600
                                                                                                                                                               800
                                                                                                                                                                           1000
                                                                                                                                                                                   1200




                              0
                                  100
                                        200
                                               300
                                                      400
                                                             500
                                                                     600
                                                                           700
                                                                                 800
                                                                                         900
                                                                                               1000
                                                                                                                  1985-1987                                                                             1985-1987
                  1985-1987
                                                                                                                                                                                                        1986-1988




                                                                                                      Men 85+
                  1986-1988                                                                                       1986-1988
                                                                                                                                                                                           Men 75-84
                                                                                                                                                                                                                                                                             Men 65-74




                  1987-1989                                                                                       1987-1989                                                                             1987-1989

                  1988-1990                                                                                       1988-1990                                                                             1988-1990

                  1989-1991                                                                                       1989-1991                                                                             1989-1991

                  1990-1992                                                                                       1990-1992                                                                             1990-1992

                  1991-1993                                                                                       1991-1993                                                                             1991-1993




     MCCN


     LSCCN
                  1992-1994                                                                                       1992-1994                                                                             1992-1994




     GMCCN
      MCCN

      GMCCN
                  1993-1995                                                                                       1993-1995                                                                             1993-1995




     North West
                  1994-1996                                                                                       1994-1996                                                                             1994-1996

                  1995-1997                                                                                       1995-1997                                                                             1995-1997

                  1996-1998                                                                                       1996-1998                                                                             1996-1998
                                                                                                                                                                                                                                                                                           cancer network, North West, 1985-2005. Note that each chart uses different scale




                  1997-1999                                                                                       1997-1999                                                                             1997-1999

                  1998-2000                                                                                       1998-2000                                                                             1998-2000

                  1999-2001                                                                                       1999-2001                                                                             1999-2001

                  2000-2002                                                                                       2000-2002                                                                             2000-2002

                  2001-2003                                                                                       2001-2003                                                                             2001-2003

                  2002-2004                                                                                       2002-2004                                                                             2002-2004
                                                                                                                                                                                                                                                                                           Figure 3.11 continued: Age-specific lung cancer mortality trends (rate per 100,000), by sex and




                  2003-2005                                                                                       2003-2005                                                                             2003-2005
Joinpoint regression shows a decreasing trend in lung cancer mortality in women for the most recent time
periods in all cancer networks in all age groups under 75 years, except for the 55 to 64 year olds in LSCCN
where rates increased slightly in the most recent years. In comparison all Networks show increasing trends for
the 75 to 84 and 85 plus year olds. Only GMCCN shows a slow down in the increase in lung cancer mortality
rates in 75 to 84 year old women.
Differences in the change in the age specific rates in lung cancer incidence compared to mortality might also
give an indication of expected changes in mortality trends as lung cancer mortality trends follow incidence
trends closely.

Lung cancer mortality in younger adults (30 to 49 year olds)
In contrast to incidence trends in the 30 to 49 year olds, where LSCCN showed an upward trend for males and
females, lung cancer mortality in this age group showed a downward trend in all cancer networks in the North
West. The difference in LSCCN might be due to several reasons. For example individuals might be diagnosed
in the 30-49 year age band, but not die until a later age. Also, the number of people dying in this age group
is quite small, hence fluctuations are bigger and it is more difficult to identify trends.




                                                                                                                 33
     4. Survival
     Lung cancer has a poor survival with only 7.5% of men and 8.3% of women diagnosed during 1998-2000
     in the North West surviving five years after diagnosis. This is similar to national rates of 6.5% for men and
     7.6% for women who were diagnosed during 1999-2001 and followed up to 200312. Survival rates are low
     mainly because most patients present with late stage disease, making them unsuitable for surgery, the only
     potentially curative therapy for the vast majority of patients.

      Figure 4.1: Relative survival (%) for patients diagnosed 1989-1991 to 2004-2005 in the North West.
                                  35


                                  30
                                                                           1 year

                                  25
              Relative survival (%)




                                  20


                                  15


                                  10                              5 year


                                                                                                                 LSCCN
                                      5                                                                          GMCCN
                                                                                                                 MCCN
                                                                                                                 North West

                                      0
                                          1989-1991   1992-1994        1995-1997         1998-2000   2001-2003    2004-2005
                                                                              Year of diagnosis




     One and five year lung cancer survival rates have improved in all cancer networks in the North West from
     1989-91 to 2004-05 and 1989-91 to 1998-2000 respectively. The greatest increases for five year survival were
     seen in MCCN (2.3%) and for one year survival in GMCCN (9.1%). For both one and five year survival MCCN
     has the highest rates throughout the time period. However, five year survival remains low in the North West
     at 7.9%. Short term survival has improved more than long term survival. There were no significant differences
     in survival between men and women.




34
  Figure 4.2: Five and one year relative survival (%) by age at diagnosis in the North West, (based
  on 2004-05 data for one year survival and 1998-00 data for five year survival analysis).
                                45

                                40

                                35
                                                                        1 year
        Relative survival (%)




                                30

                                25

                                20

                                15
                                                       5 year

                                10

                                5
                                                                                                     men
                                                                                                     women
                                0
                                     30-54   55-64              65-74            75-84          85+
                                                        Age at diagnosis




Lung cancer survival rates decrease with increasing age at diagnosis (Figure 4.2). The age specific differences
in survival are mainly due to fewer older patients being fit for treatment.
The higher survival rates in MCCN compared to the other two cancer networks in the North West (Table 4.1)
could be explained by the higher proportion of patients undergoing surgery in that network (see chapter 5).


   Table 4.1: One and five year survival in patients diagnosed in cancer networks and the North
   West.

                                                     5 year survival                     1 year survival
                                                       1998-2000                           2004-2005
    LSCCN                                                   6.7                               24.4
    GMCCN                                                   7.2                               29.5
    MCCN                                                    9.8                               31.2
    North West                                              7.9                               28.7




                                                                                                                 35
     5. Histological type and treatment
     5.1 Histological types of lung cancer
     Lung cancer is generally classified into the two main categories – non-small cell lung cancer and small cell lung
     cancer. Non-small cell lung cancer includes squamous cell carcinoma, adenocarcinoma and large cell carcinoma.

     Analysis by type
     The following analysis is based on lung cancer cases diagnosed in the North West between 2003 and 2005. Lung
     cancer was grouped by histological type into the five groups: i) small cell carcinoma, ii) large cell carcinoma, iii)
     adenocarcinoma, iv) squamous cell carcinoma and v) not other specified (NOS) (rarer types of carcinoma and
     tumours other than carcinoma were excluded from this analysis). A large proportion of tumours (49%) have
     not been allocated a specific type and are recorded as NOS, making comparisons difficult. The main reasons
     for this are that many tumours are not confirmed microscopically and a number of laboratories do not provide
     NWCIS with details on every tumour they report on. The most common types diagnosed in the North West
     were NOS (49%) followed by squamous cell carcinoma (20%), adenocarcinoma (17%), small cell carcinoma
     (13%) and large cell carcinoma (1%).

     The comparable higher number of non small cell lung cancers in MCCN is due to the higher proportion of
     adenocarcinomas (23.9%) compared to 15.1% in GMCCN and 12.4% in LSCCN (Figure 5.1). The percentage
     of NOS was lower for MCCN at 42.8% than for GMCCN at 51.6% or LSCCN at 53.1%, which might suggest
     that a greater proportion of tumours in MCCN are confirmed microscopically.

     The greatest difference between men and women is the larger proportion of squamous cell carcinomas
     (24.1%) in men compared to 15.2% in women. Women had higher proportions of small cell lung cancers
     (14.3%) adenocarcinomas (18.4%) and NOS lung cancers (51.3%) compared to men with 11.2%, 16.6% and
     47.3% respectively.

     Lung cancers in patients over the age of 75 at diagnosis were more likely to be classified as NOS (61.4%) than
     those under 75 years (40.3%), resulting in specific morphological types being relatively more common in
     patients under 75 at diagnosis (Figure 5.2).

      Figure 5.1: Distribution (%) of histological types of lung cancer by cancer network, North West,
      2003-05.
                            60

                                 GMCCN

                                 LSCCN

                            50   MCCN




                            40
                  Percent




                            30




                            20




                            10




                            0
                                 small cell   squamous cell carcinoma   adenocarcinoma   large cell   NOS




36
  Figure 5.2: Distribution (%) of histological types of lung cancer by age at diagnosis, North West,
  2003-05.
                     70

                          under 75


                     60   over 75




                     50




                     40
           Percent




                     30




                     20




                     10




                     0
                          small cell   squamous cell carcinoma   adenocarcinoma   large cell   NOS




5.2 Lung cancer treatment
In addition to providing information on the incidence, mortality and survival for different cancers, it is important
to inform providers and commissioners of cancer services on how patients are managed and at which hospitals.
Traditionally NWCIS has collected details of treatments given in the six months following diagnosis, which should
include in most instances all primary treatments. In future details of every treatment given from diagnosis to
death or cure will be recorded. Details are recorded on each surgical procedure undertaken and whether each
patient had chemotherapy, radiotherapy or hormone therapy. Despite considerable effort to obtain details
from a range of sources, our data on treatment for the period 2003-2005 were incomplete, probably only
slightly for surgery but more so for non-surgical treatments. The results presented below should therefore be
considered as the first step in an informed dialogue with clinicians, managers and commissioners.

Of the 15,547 patients diagnosed with lung cancer in the three cancer networks in the North West in
2003-2005, 491 had no record of hospital attendance and so were excluded from the analysis.

Treatment by Cancer Network
Most lung cancer patients diagnosed during 2003-2005 are recorded as not receiving any treatment (58%).
Patients were treated with radiotherapy alone (13.3%), chemotherapy alone (9.8%), a combination of both
(10%), surgery only (6.5%) or surgery in combination with other treatment (2%) (Table 5.1). A small number
of patients received other treatments (0.3%) which would include hormone and immunotherapy. Trends in
treatment were similar for men and women.

Lung cancer treatment varied across the North West with MCCN having the largest proportion of lung cancer
patients without treatment (70.7%), compared to 52.1% in LSCCN and 51.5% in GMCCN (Figure 5.3). However
in MCCN 10.4% patients underwent surgery or a combination of surgery and other treatment compared to
5.3% in LSCCN and 8.5% in GMCCN. GMCCN had the highest percentage receiving chemotherapy alone
(11.7%) or chemotherapy and radiotherapy (15.2%); LSCCN had the highest proportion receiving radiotherapy
alone (23.7%), and MCCN had the lowest percentage for all three.



                                                                                                                       37
       Table 5.1: Treatment for lung cancer patients, North West 2003-2005.

                                                                                                             Number of cases                          Percentage
         surgery only                                                                                                    968                             6.5
         radiotherapy only                                                                                             1,999                             13.3
         chemotherapy only                                                                                             1,472                             9.8
         surgery & any other treatment                                                                                   291                             2.0
         radiotherapy & chemotherapy                                                                                   1,501                             10.0
         other treatment                                                                                                  52                             0.3
         no treatment                                                                                                  8,705                             58.1
         total                                                                                                        14,988                            100.0



       Figure 5.3: Lung cancer treatment by cancer network, North West, 2003-2005.

                           80
                                      GMCCN

                                      LSCCN
                           70
                                      MCCN


                           60



                           50
                 Percent




                           40



                           30



                           20



                           10



                           0
                                surgery only   radiotherapy only   chemotherapy    surgery & any    radiotherapy &   other treatment   no treatment
                                                                       only       other treatment   chemotherapy




     Treatment by histological type
     Of those lung cancers which receive treatment, most small cell lung cancers were treated by either chemotherapy
     only (29.5%) or a combination of radiotherapy and chemotherapy (17.3%). In comparison non-small cell lung
     cancers (adenocarcinoma, large cell and squamous cell carcinoma) were more likely to be treated by surgery
     (14%) or surgery in combination with another form of treatment (4.1%) (Figure 5.4).




38
  Figure 5.4: Lung cancer treatment by histological type in all cancer networks in the North West,
  2003-2005.
                        80
                                         NOS
                                         small cell
                        70
                                         non small cell



                        60



                        50
              Percent




                        40



                        30



                        20



                        10



                            0
                                    surgery only      radiotherapy only   chemotherapy    surgery & any     radiotherapy &    other treatment     no treatment
                                                                              only       other treatment    chemotherapy




Treatment by age and cancer network
The majority of patients over 75 years were not treated (72.2%) compared to 48.3% of those under 75 years
old. Older patients were more likely to receive radiotherapy only (14.4% compared to 12.6%), and less likely
to be treated with chemotherapy or receive surgery (Figure 5.5, 5.6). MCCN had the highest proportion of
lung cancer patients who were not treated in both age groups. However, compared to the younger age group,
the proportion of lung cancer patients in the older age group who did not receive treatment increased by
around 26% in LSCCN and GMMCN and by 20% in MCCN. Across both age groups a considerably larger
proportion of patients were treated with radiotherapy only in LSCCN than in the other two cancer networks
(Figure 5.5, 5.6).


  Figure 5.5: Treatment (%) for lung cancer patients under and over age 75 at diagnosis in all
  cancer networks in the North West 2003-2005.
                            80



                            70            under75         over 75



                            60



                            50
                  Percent




                            40



                            30



                            20



                            10



                                0
                                     surgery only     radiotherapy only   chemotherapy    surgery & any    radiotherapy &    other treatment    no treatment
                                                                              only       other treatment   chemotherapy




                                                                                                                                                                 39
       Figure 5.6: Difference (%) in lung cancer treatment (over 75 year olds compared to under 75 year
       olds) by cancer network, North West 2003-2005.

                                MCCN
                                                                                      no treatment
                                LSCCN

                                GMCCN
                                                                                    other treatment




                                                                      radiotherapy & chemotherapy



                                Lower proportion in                                                                                   Higher proportion in
                                over 75 year olds                     surgery & any other treatment                                   over 75 year olds




                                                                                  radiotherapy only




                                                                                 chemotherapy only




                                                                                      surgery only



                -30                              -20                       -10                        0   Percent         10                    20                    30




     Treatment by deprivation
     There is a weak association between lack of treatment and increasing deprivation. Among lung cancer patients
     from the most affluent group 52.8% did not receive treatment compared with 61% from the most deprived
     group. A higher proportion of patients from the most affluent group underwent surgery (10.5%) compared
     to 8.2% in the most deprived group (Figure 5.7). This difference could be due to several reasons, including a
     greater proportion of patients from deprived backgrounds presenting with late stage disease or whose general
     health makes them unsuitable for surgery.



       Figure 5.7: Lung cancer treatment by deprivation quintile (1= least deprived and 5 = most
       deprived) in all cancer networks in the North West, 2003-2005.
                                70

                                        1    2         3   4     5

                                60




                                50




                                40
                      Percent




                                30




                                20




                                10




                                 0
                                       surgery only            chemotherapy   radiotherapy only    surgery & any    radiotherapy &   other treatment   no treatment
                                                                   only                           other treatment   chemotherapy




40
Treatment by acute trust
Within each cancer network the majority of patients are treated at only two or three acute trusts.
In GMCCN most lung cancer surgery (71%; n=412) was carried out at the South Manchester University Hospi-
tal Trust with another 18% undertaken at the Central Manchester University Hospitals Trust. Christie Hospital
NHS Foundation Trust treated 72% (n=1,472) of patients receiving chemotherapy with South Manchester
Trust also treating 24% (n=490). The majority (96%) of all radiotherapy treatments (n=1,839) were at the
Christie Hospital.
In LSCCN 84% of all lung cancer surgeries (n=154) were recorded at the Blackpool Victoria Hospital and 93%
of all lung cancer radiotherapy treatments (n=1101) were administered at the Lancashire Teaching Hospital
NHS Trust. In comparison, chemotherapy treatment (n=679) was provided at a number of centres with 30%
being treated at the Lancashire Teaching Hospital NHS Trust, 25% at the Blackpool Victoria Hospital, 12% at
the Royal Lancaster Infirmary, 12% at the Burnley General Hospital and the remaining 21% at various other
hospitals.
The picture in MCCN is more centralised, with 98% of all lung cancer surgeries (n=520) being carried out at
the Cardiothoracic Centre, Liverpool NHS Trust and 98% of all chemotherapies (n=980) and radiotherapies
(n=672) being administered at the Clatterbridge Centre for Oncology.

Interpretation of differences between networks
The results for MCCN differ from those for the other two networks in the following ways:-
    1. Higher survival
    2. Higher proportion with specific histology
    3. Higher proportion with adenocarcinoma
    4. Higher proportion undergoing surgery
    5. Lower proportion undergoing chemotherapy or radiotherapy
    6. Higher proportion receiving no treatment
It is possible that some of these findings could be due at least in part to differences in data collection. Most of
MCCN is covered by the Liverpool office of NWCIS and almost all of the other two networks by the Manchester
office. The sources used by each office during the period covered by this report differed to some extent.
However, the findings of a higher survival with a greater proportion undergoing surgery and with a high pro-
portion with specific histology paints a picture of more patients in MCCN being biopsied, undergoing surgery
and being cured. This interpretation needs to be confirmed by further investigation.




                                                                                                                     41
     6. Estimating the number of deaths attributable to
        active and passive smoking in the North West
     When writing a report on lung cancer one cannot ignore smoking because of its very strong link with lung
     cancer. In the following section we estimate the number of cancer death attributable to active smoking and
     the total number of deaths due to passive smoking in the North West. This study originated from the two
     questions:
     ■ What is the contribution of smoking to cancer mortality in the North West?
     ■ How will the smoking ban influence future death rates in the North West?
     It is difficult to estimate how the smoking ban will influence smoking prevalence, but it has effectively elimi-
     nated passive smoking in enclosed public spaces and workplaces. As a consequence our calculations on the
     effects of the smoking ban primarily focus on passive smoking.

     6.1 Active smoking attributable cancer deaths
     To calculate the number of cancer deaths attributable to smoking we need to know three variables: i) The
     number of people dying of the disease under investigation, ii) the proportion of smokers and ex-smokers in the
     population and iii) the strength of the association between smoking and the relevant health outcome (relative
     risk ratios). For the relative risk (RR) ratios we adopted the values from a large population based prospective
     cohort study (n=1mio.) from the USA, carried out by the American Cancer Society33. These values have been
     found to be transferable to the UK and have been previously applied in other studies in the UK19,47,48. The RR
     ratios represent the risk of male and female current and ex-smokers who die of the relevant disease compared
     to non-smokers. We calculated the smoking attributable fractions for the different cancers under investigation
     using the following formula:
     AF=(Pcur(Rcur-1)+Pex(Rex-1))/(1+Pcur(Rcur-1)+Pex(Rex-1))
     where
     AF = attributable fraction for the disease
     Pcur = proportion of the population who are current smokers
     Rcur = relative risk of current smokers
     Pex = proportion of ex-smokers
     Rex = relative risk of ex-smokers
     We used 2005 mortality data44 and 1980 smoking prevalence data for smokers and 1982 data for ex-smokers
     (1980 had no data recorded for ex-smokers) from the general household survey 200549 in our study. We chose
     25 and 23 year old smoking prevalence data to allow for a time lag between exposure and effect.
     In 2005 a total of 6,961 people (4,207 men and 2,754 women) were estimated to have died of cancer due
     to smoking in the North West. The majority of these, 56% of men and 62% of women, died of lung cancer,
     followed by cancer of the oesophagus (11% of men and 10% of women) and cancers of unspecified site
     (11% of men and 14% of women). In the same year a total of 18,942 persons were registered to have died
     of all cancers in the North West (COO-C97). This means that active smoking attributes for about 36.7% of all
     cancer death in the North West.




42
   Table 6.1: Smoking attributable mortality for cancers in the North West; 2005 mortality data.
                                                   Smoking
                                                 attributable                                 Smoking
                                                                     Cancer deaths
                                                fractions (%)                               attributable
                                                                         2005
                                               current and ex                                  deaths
                                                   smokers
     Site                     ICD 10           men      women        men      women       men       women
     lung                     C33-34           92.8      87.1        2546      1950       2364       1699
     upper respiratory        C00-C14,
                                                82.3      71.1       309        110        254         78
     sites                    C32
     oesophagus               C15               73.2      79.7       645        332        472        264
     bladder                  C67               53.2      35.8       354        206        189         74
                              C64-C66,
     kidney                                     48.5      22.7       253        145        123         33
                              C68
     stomach                  C16               39.3      20.5       430        249       169         51
     pancreas                 C25               34.9      33.3       410        443       143        147
     unspecified site          C80               64.7      44.4       721        884       466        393
     myeloid leukaemia        C92               20.7      14.2       132        104        27         15
                                                                               Total      4207       2754




6.2 Passive smoking attributable deaths
Whereas the calculation of cancer death attributable to active smoking is more or less straightforward by adapt-
ing established values from other studies, it gets more complicated when estimating the number of deaths due
to passive smoking. Calculating the number of passive smoking attributable cases in non smokers again requires
three key variables: i) The proportion of deaths in non smokers, ii) the level of passive smoking exposure and iii)
the strength of the association between passive smoking and negative health outcomes (RR ratios). Initially we
intended to only focus on deaths from cancers related to passive smoking, but we soon realised that lung cancer
only contributes a minor fraction of passive smoking related deaths and extended our analysis to all causes of
death that have been linked with passive smoking and where the evidence was strong enough.

Strength of the association
Much of the research on passive smoking originated from the findings of the harmful effects of active smok-
ing. As active smoking has been strongly linked with a range of adverse health effects, passive smoking might
also contribute to these diseases in non smokers. However it is much more difficult to investigate the effects
of passive smoking than those of active smoking as the exposure levels are much lower. The strength of the
association between passive smoking and negative health outcomes has been primarily measured in obser-
vational studies, either case control studies or cohort studies, looking at non smokers living with smokers.
However, due to their design, these studies may be affected by different sources of bias. For example, the
exposure to passive smoking of each individual is different due to their lifestyle choices and, when collecting
data in retrospective (case control studies) people might not remember the true exposure accurately. Moreover,
the individual may have been exposed to other risk factors contributing to the negative health outcome under
investigation. Studies on the negative health effects of passive smoking have looked at a range of different
health outcomes but the largest numbers of studies focussed on lung cancer (more than 50) and CHD (more
than 20). This can be explained by the strong positive relationship between active smoking and lung cancer
and the large number of people affected by CHD. Only a small number of studies looked at stroke and respira-
tory diseases in relation to passive smoking.
We considered the evidence to be strong enough to include lung cancer (C33-34), coronary heart disease
(I20-I25), stroke (I60-I69) and respiratory diseases (J40-J44) in our study and we adopted a risk ratio of 1.24
(95%CI 1.13-1.36) for lung cancer50, 1.27 (95%CI 1.1-1.46) for stroke18, 1.25 (95%CI 1.1-1.43) for respira-
tory diseases32 and 1.3 (95%CI 1.22-1.38) for coronary heart disease30.

                                                                                                                      43
     Passive smoking exposure
     We had to limit our calculations to exposure in the workplace and exposure at home, as robust data are not
     available for exposure during leisure activities in indoor public spaces, such as pubs and clubs. Nevertheless,
     our results are still useful as people spend most of their time at work or at home. To estimate how many deaths
     may be avoided by the smoking ban we adopted exposure data of 10.2% for passive smoking at home18 and
     9% at work51. Data for exposure at work was taken from calculations by the organisation Action on Smoking
     and Heath (ASH) based on the National Statistics Omnibus survey from 200351. Exposure at work was adjusted
     to allow for 23.5% of men and 30.5% of women not working52. Passive smoking data for exposure at home
     was taken from the health survey for England (1996-2003). It is based on whether non smokers live with a
     smoking partner and allows adjustment for whether the smoking partner smokes inside the house or not.
     Passive smoke exposure at home has decreased substantially over the past years with the number of homes
     with “smoke free policies” increasing from 22% in 1996 to 37% in 200318.

     People at risk
     Most population estimates of the negative health effects of passive smoking usually only look at lifelong non
     smokers alone or lifelong non smokers and ex-smokers combined. One exception recently calculated passive
     smoking attributable deaths for smokers and non smokers combined31, applying the same attributable fraction
     to both groups. We only included non smokers in our calculations, as the risk of passive smoking in active
     smokers, and in ex-smokers, is far outweighed by active smoking and the evidence on passive smoking is
     based on non smokers. To estimate the number of deaths due to passive smoking from the conditions included
     in our study we firstly estimated how many of these deaths occur in non smokers. To do so we calculated the
     number of deaths in active smokers as described above, and subtracted these from the total number of deaths
     of the target conditions. For these calculations we used 2004 smoking prevalence. The number of deaths
     attributable to passive smoking was then calculated using the formula:
     AF= P(R-1)/ (1+P(R-1))
     where
     AF = attributable fraction for the disease
     P = proportion of people exposed to passive smoking
     R = relative risk of exposed person
     A sensitivity analysis was carried out for the following scenarios:
     1. Lower 95% confidence interval
     2. Upper 95% confidence interval
     3. Combining non and ex-smokers – assuming that ex smokers return to the same risk of non smokers

     Results
     An estimated 557 future deaths (252 female and 305 male) may be attributable to current passive smoking
     exposure each year; 218 of these are estimated to be due to exposure at work and 339 due to exposure at
     home.
     The vast majority of these cases (90%) are contributed by circulatory diseases, with an estimated 375 cases
     (67%) of coronary heart disease and 128 cases (23%) of stroke. Lung cancer and respiratory diseases contribute
     a minor fraction with 28 (5%) and 26 (5%) cases respectively (Table 6.2).
     The sensitivity analysis returned estimates of 352 and 772 deaths for the lower and upper 95% confidence
     interval limits and assuming that ex smokers have the same risk as non smokers resulted in 620 deaths.




44
  Table 6.2: Estimated annual number of deaths attributable to passive smoking in non smokers
  in the North West of England.

                                                     Percent-
                  Place                Percentage                                       Total    Number      Deaths
                                                       age       Rela-     Attribut-
                    of                  death in                                       number   of deaths    due to
    Outcome               Population                 exposed     tive        able
                  expo-                   non                                            of       in non     passive
                                                    to passive    risk     fraction
                   sure                 smokers                                        deaths   smokers*    smoking
                                                     smoking


                             men          10.4        10.3       1.24       0.02       2596       270          7
                   at
                  home
    Lung                   women          22.7        10.3       1.24       0.02       1955       444         11
    cancer
    (C33-C34)                men          10.4         9.0       1.24       0.02       2596       207          4
                   at
                  work
                           women          22.7         9.0       1.24       0.02       1955       308          7

                             men          59.2        10.3       1.30       0.03       7057      4178        125
                   at
    Coronary      home
                           women          61.0        10.3       1.30       0.03       5645      3443        103
    heart
    disease
                             men          59.2         9.0       1.30       0.03       7057      3196         84
    (I20-I25)      at
                  work
                           women          61.0         9.0       1.30       0.03       5645      2393         63

                             men          62.0        10.3       1.27       0.03       2619      1624         44
                   at
                  home
                           women          64.0        10.3       1.27       0.03       1964      1257         34
    Stroke
    (I60-I69)
                             men          62.0         9.0       1.27       0.02       2619      1242         29
                   at
                  work
                           women          64.0         9.0       1.27       0.02       1964       874         21

                             men          15.0        10.3       1.25       0.03       1903       285          7
                   at
                  home
    Respiratory            women          18.0        10.3       1.25       0.03       1909       344          9
    diseases
    (J40-J44)                men          15.0         9.0       1.25       0.02       1903       218          5
                   at
                  work
                           women          18.0         9.0       1.25       0.02       1909       239          5

                                                                                                 Total       557


  * Exposure at work was adjusted to allow for 23.5% of men and 30.5% of women not working.



Discussion
We estimated that more than 500 individuals might die in the North West due to current exposure to passive
smoking per year. About 200 deaths may be avoided by the smoking ban by eliminating exposure to passive
smoking at work. However due to the nature of these calculations and the underlying assumptions they can
only give an estimate of the magnitude of the burden of passive smoking in the North West.
The true value may be even higher for the following reasons:
1. Exposure in public places other than at work were not included in our study
2. Ex-smokers were not included in our main model
3. Only the major diseases caused by passive smoking were included
4. Passive smoke exposure in North West is probably higher than national levels used



                                                                                                                       45
     The estimate of about 200 lives saved by the introduction of the smoking ban in enclosed public places
     is also probably an underestimate for the same reasons, plus any effect the ban may have in decreasing
     smoking prevalence. A recent study found smoking prevalence to have declined by 4.3% in England in the
     first nine month after the introduction of the smoking ban53 which is the largest fall in smoking prevalence
     ever recorded.
     The number of deaths due to exposure in the home (339) was 1.5 times the number of deaths due to exposure
     at work. This shows the scope for saving lives by further decreasing exposure to passive smoking in the home.
     Contrary to previous statements that a smoke free policy might increase passive smoke exposure at home, a
     recent study indicates that, in fact, smoke free policies may reduce home exposure54.
     The greatest benefits from the smoking ban are to be expected with regards to circulatory diseases. These
     affect the largest proportion of people and the time from exposure to effect (5 to 10 years) is shorter than for
     cancers55. Studies evaluating smoke free policies in Scotland, Italy and the United States of America36,37,38,39
     found a reduction in hospital admissions for acute myocardial infarction after the introduction of smoking
     bans. Khuder and colleagues37 reported a reduction of 39% after one year and 47% after three years after
     the introduction of a smoking ban in Bowling Green, Ohio in 2002. A recent Scottish study found a 20%
     reduction in hospital admissions for heart diseases since the introduction of the smoking ban in March 200656.
     However these findings rely on ecological data and hence no causal relationship can be established.




46
7. Smoking cessation
The NHS initiated stop smoking services as part of the programme to tackle the underlying determinants of ill
health and health inequalities. The Public Service Agreement (PSA) aims to reduce smoking rates in England to
21% by 201057, with a reduction in prevalence among routine and manual occupation groups to 26% or less.
Smoking cessation services were first established in 26 of the Health Action Zones between 1999 and 2000 and
then extended to cover the whole country between 2000 and 200258. Each attendee sets a quit date and details
are collected quarterly at PCT level on the number of individuals who use the service and on how many are not
smoking four weeks after their quit date59.
Our definition of smoking cessation was not smoking one year after the quit date. As this information is not
collected routinely, we used the results from an evaluation of the smoking cessation services undertaken by
Raw et al58, who reported an abstinence rate at 52 weeks of 15% of those who set a quit date with the NHS
smoking cessation service. Using this estimate plus local data on attendance and quitters at four weeks, we
estimated the number of successful quitters at 52 weeks for 2003-04, 2004-05, 2005-06 and 2006-07 for
England, the North West and each PCT in the North West. As smoking cessation data are available by new
PCT boundaries for 2006-07 only, the analysis was carried out by old PCT boundaries in order to look at trends
over the last four years.
In 2006-07 the estimated percentage of people treated by the NHS smoking cessation service in the North
West, who were not smoking after 52 weeks ranged from 0.043% in Bebington and West Wirral to 0.23%
in Blackburn with Darwen (measured per 100 population aged 16 and above) (Table A7.1). In 2006-07 the
estimated average for the North West was 0.14% compared to 0.12% in England. The averages of the four
year time period 2003-04 to 2006-07 show a similar range to the 2006-07 values. The four year averages
range from 0.064% in Bebington and West Wirral to 0.226% in North Manchester. Over the four year time
period North Manchester, Blackburn with Darwen and Central Liverpool are estimated to have had the highest
rate of successful quitters. Bebington and West Wirral, Eastern Cheshire and Eden Valley had the lowest rates
(Figure 7.1).
These results are in line with those reported by Milne60 in 2005, who calculated the annual attributable fall
in smoking prevalence due to NHS smoking cessation services for Northumberland and Tyne and Wear in
2003-04. His results are slightly higher, because he assumed that about 17-20% of those who set a quit date
would still not smoke at 52 weeks, whereas we adopted a rate of 15%.
Our results may be a slight overestimate of the impact of smoking cessation services, as some individuals who
stopped smoking following attendance might have quit anyway. It is not possible to measure this directly,
but figures on smoking cessation in the general population do shed some light. A recent study estimated the
background smoking cessation rate for England to be between 1% and 2% over the past 40 years, and for the
last year it was estimated to have increased to between 2% and 3%61. In the North West smoking prevalence
decreased on average per year by 1% and 1.2% from 1998-2000 and 2000-2005 respectively62. Much of this
decrease is due to a decrease in smoking prevalence of 4% between 2004 and 200562.
When interpreting smoking cessation rates we need to consider the smoking prevalence in the relevant
PCT. We expect more people to stop smoking in areas with higher smoking prevalence, because the pool
of potential quitters is bigger. However, smoking prevalence data are usually not readily available at PCT or
local authority level but rather collected in surveys covering bigger geographical areas. PCT data are therefore
derived through modelling the data which have been collected at, for example, ward level to the boundaries
required. For PCTs in the North West we have two different estimates, one from ONS and another one from the
Health Development Agency (Table A7.2). Each of these estimates relies on a different model. ONS estimates
are based on 2001 census and 2001-02 health survey data, whereas the HDA uses 2001 census data and data
from the four health surveys for England from 1998-01. The way these two estimates differ is shown in figure
7.2. The different outcomes are due to the different models used as well as the different data and time periods
employed in the model (on average the estimated percentage is 2.42% higher in the HDA model).




                                                                                                                   47
     Figure 7.1: Estimated average annual percentage of successful smoking quitters treated in the
     NHS smoking cessation service 2003-04 to 2006-07.

                   North Manchester

                 Blackburn & Darwen

                    Central Liverpool

                     North Liverpool

              Birkenhead & Wallasey

            Hyndburn & Ribble Valley

                     South Liverpool

                           Knowsley

                                Wyre

                              Salford

                              Halton

                           Blackpool

                  Central Manchester

        Burnley, Pendle & Rossendale

               Heywood & Middleton

                           Rochdale

                        South Sefton

                             Oldham

                      Trafford North

                   South Manchester

             Greater Manchester SHA

          Cheshire & Merseyside SHA

                     Northwest GOR

           Cumbria & Lancashire SHA

                              Bolton

              Ashton, Leigh & Wigan

                             Preston

             Ellesmere Port & Neston

              Chorley & South Ribble

                       West Cumbria

                           St Helens

                    Central Cheshire

                Tameside & Glossop

                    West Lancashire

                                Bury

                             England

                           Stockport

                                Fylde

                 Southport & Formby

                     Morecambe Bay

                      Trafford South

                         Warrington

                   Carlisle & District

                      Cheshire West

                         Eden Valley

                    Eastern Cheshire

             Bebington & West Wirral



                                    0.00   0.05            0.10             0.15             0.20   0.25
                                             estimated average successful quitters (%) per year




48
  Figure 7.2: Difference in smoking prevalence estimates from two different models; the data is
  sorted by ONS synthetic estimates.
                              45


                              40


                              35
     smoking prevalence (%)




                              30


                              25


                              20


                              15

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            HDA estimates
                              10
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ONS synthetic estimate

                              5


                              0
                                                                                                                                                                                                                                                                    Hyndburn and Ribble Valley
                                                                                                                                                                                          Bury
                                                                                                   Fylde




                                                                                                                                                                                                                               Morecambe Bay




                                                                                                                                                                                                                                                                                                                                                                                                Burnley, Pendle and Rossendale




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Knowsley
                                                                                                           Southport and Formby




                                                                                                                                                               Chorley and South Ribble




                                                                                                                                                                                                                                                      Eden Valley




                                                                                                                                                                                                                                                                                                                             Trafford North




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Birkenhead and Wallasey
                                                                                                                                                                                                                                               Wyre
                                                               Trafford South
                                                                                Eastern Cheshire




                                                                                                                                                                                                                                                                                                          Central Cheshire
                                                                                                                                                                                                                   Stockport




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Central Manchester
                                                                                                                                                                                                                                                                                                                                                                                                                                 Rochdale




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Tameside and Glossop




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Heywood and Middleton




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 North Manchester
                                                                                                                                                                                                                                                                                                                                                                                                                                            St Helens




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Preston




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Halton
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Carlisle and District
                                                                                                                                                                                                                                                                                                 Bolton




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Blackpool
                                                                                                                                                                                                                                                                                                                                              Ashton, Leigh and Wigan




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Central Liverpool
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               South Sefton




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Salford
                                                                                                                                                                                                                                                                                                                                                                                                                                                        Ellesmere Port and Neston




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         South Manchester




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               North Liverpool
                                                                                                                                  Cheshire West




                                                                                                                                                                                                 West Lancashire




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Oldham
                                                                                                                                                                                                                                                                                                                                                                        Blackburn with Darwen




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             South Liverpool
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           West Cumbria
                                                                                                                                                  Warrington
                                   Bebington and West Wirral




As expected, the number of smoking quitters increases with increasing smoking prevalence (Figure 7.3).
Nevertheless, some PCTs seem to have higher numbers than expected while others have lower. For example,
Blackburn and Darwen recorded the second highest rate of successful quitters, but takes a middle position
with regards to smoking prevalence. On the other hand, Carlisle and District is estimated to have the 11th
highest smoking prevalence, but only ranks fifth from the bottom with regards to smoking cessation. This
shows that, besides smoking prevalence, a range of other factors may influence the attendance and success
of NHS smoking cessation services. Moreover, the PCT data give no information on the number of smoking
cessation services per capita or their accessibility. For example, access in terms of physical distance could be a
contributory factor in Carlisle and District.
The rate of successful smoking quitters using NHS services shows a positive correlation with increasing levels
of deprivation as measured using the Index of Mulpitle Deptrivation (IMD), suggesting that NHS smoking
cessation services may contribute to the reduction of health inequalities in the North West (Figure 7.4). This is
not unexpected, as smoking has been linked with deprivation and more deprived areas tend to have higher
smoking prevalence, hence the pool of potential quitters is bigger in these areas.




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    49
50
                                                                                                                                                                                                                                            estimated quitters at 52 weeks per 100,000




                                                                                                                                                                                                                                        0
                                                                                                                                                                                                                                             50
                                                                                                                                                                                                                                                         100
                                                                                                                                                                                                                                                                     150
                                                                                                                                                                                                                                                                                        200
                                                                                                                                                                                                                                                                                                                                                                                  250
                             estimated average percent of quitters at 52 weeks




                                                                                                       score.
                                                                                                                                                                                                          Bebington and West Wirral
                                                                                                                                                                                                                     Trafford South




                      0.00
                             0.05
                                            0.10
                                                            0.15
                                                                                         0.20
                                                                                                0.25




                 0
                                                                                                                                                                                                                   Eastern Cheshire
                                                                                                                                                                                                                               Fylde
                                                                                                                                                                                                              Southport and Formby
                                                                                                                                                                                                                     Cheshire West
                                                                                                                                                                                                                         Warrington
                                                                                                                                                                                                           Chorley and South Ribble




                 10
                                                                                                                                                                                                                                Bury
                                                                                                                                                                                                                   West Lancashire
                                                                                                                                                                                                                          Stockport
                                                                                                                                                                                                                                                                                    52 weeks per 100.000 population over 16
                                                                                                                                                                                                                                                                                                                                      ONS synthetic estimate smoking prevalence




                                                                                                                                                                                                                    Morecambe Bay
                                                                                                                                                                                                                                                                                    average estimated rate of succesful quitters at




                                                                                                                                                                                                                               Wyre




                 20
                                                                                                                                                                                                                        Eden Valley
                                                                                                                                                                                                         Hyndburn and Ribble Valley
                                                                                                                                                                                                                             Bolton
                                                                                                                                                                                                                   Central Cheshire
                                                                                                                                                                                                                      Trafford North
                                                                                                                                                                                                           Ashton, Leigh and Wigan




                 30
                                                                                                                                                                                                             Blackburn with Darwen
                                                                                                                                                                                                     Burnley, Pendle and Rossendale
                                                                                                                                                                                                                          Rochdale
                                                                                                                                                                                                                          St Helens




     IMD Score
                                                                                                                                                                                                          Ellesmere Port and Neston
                                                                                                                                                                                                             Tameside and Glossop




                 40
                                                                                                                                                                                                                      West Cumbria
                                                                                                                                                                                                                            Oldham
                                                                                                                                                                                                                            Preston
                                                                                                                                                                                                                    South Liverpool
                                                                                                                                                                                                                       South Sefton




                 50
                                                                                                                                                                                                                              Halton
                                                                                                                                                                                                                Carlisle and District
                                                                                                                                                                                                                                                                                      2




                                                                                                                                                                                                                             Salford




                                                                         2
                                                                                                                                                                                                                  South Manchester
                                                                                                                                                                                                                                                                                                                                                                                        successful quitters at 52 weeks 2003-2007, per 100,000 population aged over 16.




                                                                                                                                                                                                           Birkenhead and Wallasey
                                                                                                                                                                                                                                                                                    R = 0.4494




                                                                                                                                                                                                            Heywood and Middleton




                                                                       R = 0.5979




                 60
                                                                                                                                                                                                                                                                               y = 1.9261x + 91.672




                                                                                                                                                                                                                          Blackpool




                                                                   y = 0.0023x + 0.068
                                                                                                                                                                                                                Central Manchester
                                                                                                                                                                                                                   Central Liverpool
                                                                                                                                                                                                                                                                                                                                                                                        Figure 7.3: Synthetic estimate of smoking prevalence (01-03) and average estimated rate of




                                                                                                                                                                                                                          Knowsley
                                                                                                       Figure 7.4: Estimated average annual percentage of smoking quitters (03-04 to 06-07) by IMD




                                                                                                                                                                                                                    North Liverpool




                 70
                                                                                                                                                                                                                  North Manchester
Appendix
Appendix 1
Data
The data on cancer incidence are produced from information collected and recorded by the North West
Cancer Intelligence Service. Mortality and population data are provided by the Office for National Statistics
(ONS), mortality data being derived from death certificates. Smoking prevalence data were taken from the
General Household Survey10,49 and smoking cessation data from the Local Delivery Plan (LDP) returns compiled
by the Information Centre for Health and Social Care59. Risk Ratios for the calculation of active and passive
smoking attributable fractions were derived from epidemiological studies as stated in the text.

Age standardisation
Incidence and mortality data were compared by age standardisation using the European standard population.
Age standardisation adjusts for age differences in different populations and hence makes them more easily
comparable.

Funnel plots
Funnel plots were used to compare lung cancer rates for different geographies. In these funnel plots the
lung cancer rates are plotted against the population and the funnel is the upper and lower 95% and 99%
confidence intervals of the national average, which is displayed as a line. The funnel shape is due to the
confidence intervals being wider for smaller populations. Data points outside the 95% or 99% confidence
interval limits are statistically significant different at the 95% or 99% level from the national average.

Joinpoint analysis
Changes in lung cancer incidence and mortality trends over time were evaluated by joinpoint analysis46 using
a software program developed by the US National Cancer Institute programme for Surveillance, Epidemiology
and End Results (SEER)63 . Joinpoint analysis investigates changes in cancer trends by fitting a series of joined
straight lines on a log scale to the age standardised lung cancer rates and tests whether a multi-segmented
line is a significantly better fit than a straight or less-segmented line. Each joinpoint indicates a statistically
significant change in trend. The model starts with the minimum number of joinpoints and tests if more are
statistically significant and could be fitted into the model. For each change in trend the model calculates the
annual percentage change (APC). In our analysis we looked at changes in lung cancer trends from 1985 to
2005, by sex, cancer network and the North West. We used three year rolling averages rather than single years
due to small numbers and to increase stability

Survival
Age-standardised survival analysis was carried out using the maximum-likelihood approach64 for individual
records using an algorithm65 developed in STATA 8.066. The analysis was limited to patients aged 15 to 99 years
at diagnosis. Relative survival is the ratio of observed survival to population mortality and therefore produces
the net survival in the cancer population. Analysis of relative survival requires population mortality from life
tables. The life tables used for this analysis were for the North West of England based on 1998 population and
mortality.




                                                                                                                    51
     Appendix 2 - Incidence
       Table A2.1: Age standardised lung cancer incidence rates in women (per 100,000) relative
       change and difference to England. (*=spearhead local authority)
        Place                       1995-   1999-   2003-   Change 95-97    03-05 difference to    Change in difference to
                                    1997    2001    2005     to 03-05 (%)      England (%)        England 95-97 to 03-05 (%)
        Allerdale                   31.6    36.8    34.9        10.5                0.6                       7.1
        Barrow-in-Furness *          42     37.2    38.2        -9.2               10.1                     -14.2
        Blackburn with Darwen *     34.8    42.5    49.2        41.4               41.9                      38.8
        Blackpool *                 40.2    46.6    49.7        23.6               43.4                      24.3
        Bolton *                    37.4    42.2    42.7        14.3               23.1                      12.4
        Burnley*                    37.8    48.5    53.5        41.4               54.1                      42.3
        Bury *                      42.3    40.4    47.3        11.9               36.4                      11.2
        Carlisle*                   37.2    49.4    37.8         1.6                9.1                      -1.1
        Chester                     36.3     35     33.1        -8.7               -4.6                     -12.0
        Chorley                     26.5    39.9    45.1        70.2                30                       51.6
        Congleton                   15.5    26.4     36        132.1                3.8                      57.9
        Copeland                    36.8    27.2    33.4        -9.4               -3.8                     -12.6
        Crewe and Nantwich          23.7     25      36         51.6                3.6                      33.6
        Eden                        32.2     32     30.2        -6.3              -13.1                      -8.2
        Ellesmere Port and Neston   38.3    53.2    44.9        17.3               29.5                      16.1
        Fylde                       22.6    24.9    32.4        43.4               -6.5                      26.5
        Halton *                    49.2    56.7    59.7        21.4               72.1                      26.5
        Hyndburn *                   40     37.9    38.4         -4                10.6                      -7.7
        Knowsley *                  64.2     77     69.1         7.5               99.1                       9.2
        Lancaster                   36.2    36.9    33.1        -8.6               -4.6                     -11.7
        Liverpool *                 75.2     72     78.2          4               125.5                       2.9
        Macclesfield                 30.3    26.3    29.2        -3.7              -15.8                      -5.5
        Manchester *                59.8     64     58.7        -1.9               69.1                      -7.8
        Oldham *                    43.2    46.4    40.3        -6.8               16.1                     -11.7
        Pendle *                     37     34.7    38.4        3.7               10.6                       1.2
        Preston *                   37.1    48.2    43.2        16.5               24.7                      14.7
        Ribble Valley               28.6    32.7    29.5         3.4              -14.9                       0.4
        Rochdale *                  46.7    43.2    50.3         7.7               44.9                       6.8
        Rossendale *                54.1    47.4    49.6        -8.2               43.1                     -17.1
        Salford *                   60.4    59.5    65.2         7.9               87.8                       9.2
        Sefton                      43.9    42.4    48.1         9.4               38.6                       8.7
        South Lakeland               28     23.7    21.8        -22               -37.2                     -20.0
        South Ribble                43.6    35.9    42.6        -2.4               22.7                      -6.2
        St Helens *                 40.1    45.7    43.3          8                24.9                       6.1
        Stockport                   31.5    32.4    35.7        13.1                2.8                       9.7
        Tameside *                  42.1    42.8     48          14                38.4                      13.8
        Trafford                    41.3    39.5     44          6.6               26.8                       4.6
        Vale Royal                  29.8    32.7    27.2        -8.9              -21.7                      -9.8
        Warrington *                 35     37.5    40.9         17                 18                       14.3
        West Lancashire             44.4    43.1    31.9       -28.2                -8                      -39.4
        Wigan *                     43.5    41.3    45.7          5                31.7                       3.0
        Wirral *                    49.9    51.2    46.6        -6.6               34.4                     -13.3
        Wyre                        34.7    33.9    33.5        -3.4               -3.4                      -6.1
        North West                  43.1    44.4    45.4         5.5                31                        3.3
        LSCCN                       33.6    35.7    36.8         9.8                6.2                       6.6
        GMCCN                       41.8    42.4    44.8         7.3               29.2                       5.4
        MCCN                        53.8    55.4    55.1         2.4               58.8                      -0.4
        England                     33.8    34.4    34.7         2.8                n.a                      n.a.




52
Table A2.2: Age standardised lung cancer incidence rates in men (per 100,000) relative change
and difference to England. (*=spearhead local authority)
                                                                  Change         03-05       Change in difference to
 Place                       1995-1997   1999-2001   2003-2005    95-97 to   difference to   England 95-97 to 03-05
                                                                 03-05 (%)   England (%)              (%)
 Allerdale                      81.3         67         59.5       -26.8          -2.2                 -7.7
 Barrow-in-Furness *             85         71.8        76.1       -10.5           25                  14.8
 Blackburn with Darwen *       102.1        91.2        79.9       -21.7          31.4                 -1.2
 Blackpool *                    92.8        87.7         81        -12.6          33.2                 12.7
 Bolton *                       92.1       83.7         68.8       -25.4           13                  -6.5
 Burnley*                       91.4        79.8        84.7        -7.3          39.3                 20.6
 Bury *                         88.7       81.1         72.4       -18.3           19                   3.9
 Carlisle*                      81.9        76.9        68.6       -16.3          12.7                  6.5
 Chester                        69.4       66.4         60.7       -12.5          -0.2                  9.7
 Chorley                        96.7        83.7        65.3       -32.5           7.3                -18.2
 Congleton                      65.6        57.4        56.9       -13.3          -6.5                  8.4
 Copeland                       76.4       74.1         60.6       -20.6          -0.4                  0.5
 Crewe and Nantwich             70.2        67.9        66.5        -5.3           9.3                 18.2
 Eden                           54.6        62.7        43.2        -21          -29.1                  0.1
 Ellesmere Port and Neston      98.2        85.7        60.5       -38.4          -0.6                -28.0
 Fylde                          53.4        61.8         54          1.1         -11.3                 19.5
 Halton *                      120.9        78.1        90.4       -25.3          48.5                 -8.3
 Hyndburn *                     92.6        85.8        78.6       -15.1          29.2                  9.0
 Knowsley *                    142.1       125.3       104.6       -26.4           72                 -12.5
 Lancaster                      77.6        67.1        72.7        -6.3          19.5                 18.8
 Liverpool *                   125.7       124.1       109.6       -12.8          80.2                 17.0
 Macclesfield                    78.4         66         52.1       -33.6         -14.4                -16.1
 Manchester *                  136.9       117.2       108.3       -20.9           78                   0.3
 Oldham *                       91.7        93.7        75.5       -17.7          24.1                  5.1
 Pendle *                       78.2        61.9        67.5       -13.7          10.9                  9.5
 Preston *                      90.6        78.4        81.7        -9.9          34.2                 16.7
 Ribble Valley                  46.2        63.9        66.9        44.8           10                  50.0
 Rochdale *                    104.1        83.8        81.9       -21.3          34.6                 -0.5
 Rossendale *                    66         77.2        61.2        -7.3           0.7                 14.9
 Salford *                     121.2       100.1         97        -19.9          59.5                  2.1
 Sefton                         99.7        87.3        68.1       -31.7          11.9                -17.5
 South Lakeland                 62.4        47.5        43.1       -30.9         -29.2                -10.2
 South Ribble                    69         74.6        51.2       -25.8         -15.8                 -5.4
 St Helens *                   101.7        80.4        75.1       -26.2          23.4                 -8.6
 Stockport                      81.8       72.1         66.2       -19.2           8.7                  2.6
 Tameside *                    106.9        96.1        81.6       -23.7          34.1                 -4.6
 Trafford                       85.5        72.5        73.5       -13.9          20.9                  9.8
 Vale Royal                     75.7        67.6        59.1        -22           -2.9                 -1.1
 Warrington *                   87.6       78.7         66.3       -24.3            9                  -4.7
 West Lancashire                85.3        70.9        62.4       -26.9           2.6                 -8.1
 Wigan *                         95         89.9        77.7       -18.1          27.8                  4.4
 Wirral *                       90.9       85.2         73.6       -19.1           21                   3.0
 Wyre                           77.1        67.1        59.8       -22.5          -1.8                 -1.8
 North West                      94          84         74.8       -20.5          22.9                  0.9
 LSCCN                           75         68.5        63.3       -15.6            4                   6.7
 GMCCN                          96.5       85.3         76.2       -21.1          25.2                  0.0
 MCCN                          108.9        96.9        84.5       -22.4          38.9                 -2.4
 England                         77         68.3        60.8        -21           n.a.                 n.a.




                                                                                                                       53
     Table A2.3: Number of lung cancer cases in women and men and change 95-97 to 03-05 (%).
     (*=spearhead local authority)
                                                  Men                                       Women
                                  1995-   1999-   2003-   Change 95-97    1995-    1999-     2003-    Change 95-97
      Place
                                   1997    2001   2005     to 03-05 (%)    1997     2001      2005     to 03-05 (%)
      Allerdale                     144     127    120         -16.7         70       80        83          18.6
      Barrow-in-Furness *           108      95    103          -4.6         67       57        62          -7.5
      Blackburn with Darwen *       198     180    166         -16.2         91      108       128          40.7
      Blackpool *                   265     257    240          -9.4        144      175       176          22.2
      Bolton *                      371     352    305         -17.8        207      224       244          17.9
      Burnley*                      131     117    133           1.5         72       88       101          40.3
      Bury *                        248     237    222         -10.5        160      155       190          18.8
      Carlisle*                     150    146     142          -5.3        89       123       97             9
      Chester                       147     145    145          -1.4        100      109        97           -3
      Chorley                       141     136    116         -17.7         53       80        97           83
      Congleton                      95      93    102           7.4         33       54        73         121.2
      Copeland                       89      94     81           -9          53       39        54           1.9
      Crewe and Nantwich            131     133     140          6.9         54       64        91          68.5
      Eden                           51      63     50           -2          36       39        38           5.6
      Ellesmere Port and Neston     128     122     91         -28.9         66      100        89          34.8
      Fylde                          85     107     99          16.5         44       51        79          79.5
      Halton *                      204     138    173         -15.2        107      124       142          32.7
      Hyndburn *                    117     112    106          -9.4         69       65        63          -8.7
      Knowsley *                    302     281    249         -17.5        191      242       225          17.8
      Lancaster                     189     161    193           2.1        115      127       101         -12.2
      Liverpool *                   881     879    785         -10.9        715      676       713          -0.3
      Macclesfield                   214     198    169          -21         110      112       128          16.4
      Manchester *                  810     679    617         -23.8        451      482       432          -4.2
      Oldham *                      302     314    265         -12.3        188      205       183          -2.7
      Pendle *                      111      91    106          -4.5         70       62        81          15.7
      Preston *                     181     165    176          -2.8         94      124       113          20.2
      Ribble Valley                  44      66     72          63.6         36       39        42          16.7
      Rochdale *                    318     271    277         -12.9        185      180       206          11.4
      Rossendale *                   65      80     66           1.5         68       58        72           5.9
      Salford *                     447     366    360         -19.5        291      281       313           7.6
      Sefton                        516     469    388         -24.8        317      320       386          21.8
      South Lakeland                136     108    103         -24.3         83       71        79          -4.8
      South Ribble                  114     133     99         -13.2         86       83       105          22.1
      St Helens *                   284     245    242         -14.8        151      184       185          22.5
      Stockport                     393     361    345         -12.2        212      224       241          13.7
      Tameside *                    359     330    290         -19.2        196      197       218          11.2
      Trafford                      313     267    278         -11.2        184      193       211          14.7
      Vale Royal                    148     144    140          -5.4         76       88        78           2.6
      Warrington *                  252     241    219         -13.1        135      151       165          22.2
      West Lancashire               148     135    126         -14.9         96      104        84         -12.5
      Wigan *                       445     438    397         -10.8        273      264       300           9.9
      Wirral *                      509     499    447         -12.2        389      386       374          -3.9
      Wyre                          178     167    158         -11.2        101      106       110           8.9
      North West                  10462    9742    9101         -13        6328     6694      7049          11.4
      LSCCN                        2063   1975    1934          -6.3       1193     1294      1409         18.1
      GMCCN                        4550   4149    3865         -15.1       2601     2703      2897         11.4
      MCCN                         3415   3188    2908         -14.8       2286     2417      2473          8.2
      England                     62493   58122   54658        -12.5      11,756   12,308    12,834         9.2




54
Table A2.4: Lung cancer incidence rates in under 75 year olds (per 100,000) and difference to
England average (%). (*=spearhead local authority)
                                              Change     Difference   Difference   Change in difference to
                             1995-   2003-
 Place                                        95-97 to   to England   to England   England 95-97 to 03-05
                             1997    2005
                                             03-05 (%)    95-97 (%)    03-05 (%)            (%)
 Allerdale                   43.2    34.4      -20.5         7.1          2.6                -4.4
 Barrow-in-Furness *         46.3    40.9      -11.5        14.6         22.1                 7.5
 Blackburn with Darwen *     49.1    45.7        -7         21.6         36.3                14.7
 Blackpool *                 51.3    47.3       -7.7        26.9         41.2                14.2
 Bolton *                    47.3    37.8      -20.2        17.2         12.7                -4.5
 Burnley*                    49.6    48.2       -2.9        22.8         43.8                20.9
 Bury *                      44.2    41.5       -6.2         9.5         23.8                14.3
 Carlisle*                   43.4    36.5      -15.9         7.4          8.8                 1.5
 Chester                     38.4    32.8      -14.7        -4.9         -2.2                 2.7
 Chorley                     44.3    35.1      -20.9         9.7          4.6                -5.1
 Congleton                   29.5    31.3        5.9        26.9         -6.7                20.2
 Copeland                    42.5    35.1      -17.3         5.2          4.8                -0.4
 Crewe and Nantwich          31.3    35.8       14.2        22.5          6.6                29.2
 Eden                        31.4    28.1      -10.5        22.3         16.3                6.1
 Ellesmere Port and Neston   50.2    36.1       -28         24.3          7.8               -16.5
 Fylde                       30.6     29        -5.2        24.1         13.4                10.8
 Halton *                    63.2    53.7      -15.1        56.6         60.2                 3.6
 Hyndburn *                  46.5    44.6       -4.1        15.1          33                 17.9
 Knowsley *                  74.6    60.7      -18.7        84.8          81                 -3.8
 Lancaster                    42     36.9      -12.3         4.1          10                   6
 Liverpool *                 74.3    65.9      -11.3        84.1         96.7                12.6
 Macclesfield                  38      24       -36.8         -6          28.4               -22.4
 Manchester *                75.8    62.4      -17.6        87.7         86.3                -1.4
 Oldham *                    50.2    41.7      -16.9        24.3         24.4                 0.1
 Pendle *                    43.7    35.2      -19.3         8.2          5.1                -3.1
 Preston *                   46.4    45.4       -2.2        14.8         35.3                20.5
 Ribble Valley                29     29.3        0.8        28.1         12.7                15.4
 Rochdale *                  55.6    46.5      -16.4        37.6         38.6                  1
 Rossendale *                46.7    38.9      -16.7        15.6          16                  0.4
 Salford *                   67.4     57       -15.5        66.9         69.9                 3.1
 Sefton                      53.7    39.5      -26.5         33          17.7               -15.2
 South Lakeland              29.3    20.4      -30.5        27.5         39.3               -11.8
 South Ribble                43.6    34.3      -21.3          8           2.4                -5.6
 St Helens *                  48     37.9       -21         18.8         13.1                -5.7
 Stockport                   38.3    35.8       -6.7        -5.1          6.7                11.8
 Tameside *                  53.2    45.6      -14.3        31.7         35.9                 4.3
 Trafford                    45.5    41.1       -9.8        12.7         22.6                 9.8
 Vale Royal                  35.9    27.8      -22.6        11.2         17.2                 -6
 Warrington *                43.5    36.3      -16.6         7.7          8.2                 0.5
 West Lancashire             48.4    32.2      -33.5        19.8          -4                -23.7
 Wigan *                     48.7    43.4       -11         20.6         29.4                 8.8
 Wirral *                    52.6    41.5      -21.2        30.3         23.7                -6.6
 Wyre                        37.9    31.5      -16.9        -6.2         -6.1                 0.1
 North West                  50.1    41.9      -16.4        24.1          25                  0.9
 LSCCN                       39.9    34.7      -12.8        -1.3          3.6                 4.9
 GMCCN                       49.9    42.4      -15.1        23.5         26.3                 2.8
 MCCN                        59.9    48.3      -19.4        48.3         44.1                -4.2
 England                     40.4    33.5       -17         n.a.         n.a.                n.a.




                                                                                                             55
     Figure A2.1: Change (%) in age-standardised lung cancer incidence rates in patients under 75
     years at diagnosis from 1995-97 to 2003-05, by local authority in the North West.

                                                             Macclesfield
                                                       West Lancashire
                                                           South Lakeland
                                              Ellesmere Port and Neston
                                                                  Sefton
                                                               Vale Royal
                                                             South Ribble
                                                                  Wirral *
                                                               St Helens *
                                                                 Chorley
                                                                Allerdale
                                                                 Bolton *
                                                                 Pendle *
                                                               Knowsley *
                                                             Manchester *
                                                               Copeland
                                                                Oldham *
                                                                    Wyre
                                                             Rossendale *

              Decrease                                       Warrington *
                                                               Rochdale *        Increase
                                                                 Carlisle*
                                                                 Salford *
                                                                  Halton *
                                                                 Chester
                                                               Tameside *
                                                               Lancaster
                                                    Barrow-in-Furness *
                                                               Liverpool *
                                                                  Wigan *
                                                                    Eden
                                                                 Trafford
                                                              Blackpool *
                                                Blackburn with Darwen *
                                                               Stockport
                                                                   Bury *
                                                                   Fylde
                                                              Hyndburn *
                                                                 Burnley*
                                                                Preston *
                                                            Ribble Valley
             * = spearhead local                               Congleton
                 authority
                                                    Crewe and Nantwich

       -40                -30       -20              -10                     0    10            20
                                            Percentage change




56
Figure A2.2: Change (%) in the gap in incidence between the national average in patients under
75 years at diagnosis from 1995-97 to 2003-05 by local authority in the North West.

                                West Lancashire
                                       Macclesfield
                     Ellesmere Port and Neston
                                            Sefton
                                  South Lakeland
                                            Wirral *
                                        Vale Royal
                                         St Helens *
                                       South Ribble
                                           Chorley
                                           Bolton *
                                          Allerdale
                                        Knowsley *
                                           Pendle *
                                       Manchester *
                                         Copeland
                                              Wyre
                                          Oldham *
                                       Rossendale *
                                       Warrington *
                                         Rochdale *
        Decrease                           Carlisle*
                                                                       Increase
                                           Chester
                                           Salford *
                                            Halton *
                                        Tameside *
                                         Lancaster
                                              Eden
                              Barrow-in-Furness *
                                            Wigan *
                                           Trafford
                                             Fylde
                                         Stockport
                                         Liverpool *
                                        Blackpool *
                                             Bury *
                          Blackburn with Darwen *
                                    Ribble Valley
                                        Hyndburn *
                                         Congleton
                                          Preston *
    * = spearhead local                    Burnley*
        authority            Crewe and Nantwich

  -30          -20               -10                   0         10    20         30     40
                                                   Percentage change




                                                                                                 57
     Table A2.5: Results of joinpoint analysis of time trends in lung cancer incidence rates in 30-49
     year old women in the North West and in cancer networks in the North West.

                                                                 APC       APC
                               Segment     Segment                                   APC Significant
      Place       Joinpoint                             APC      95%       95%
                                 Start       End                                     (1= significant)
                                                                 LCL       UCL
      North
                                 1986         2004      -0.71    -1.22    -0.19             1
      West
      North
                                 1986         1994      -2.25    -3.69    -0.80             1
      West
      North
                    1994         1994         2004      0.43     -0.63     1.49             0
      West
      LSCCN                      1986         2004      2.07     0.79      3.37             1
      GMCCN                      1986         2004      -1.27    -2.19    -0.33             1
      MCCN                       1986         2004      -1.65    -2.27    -1.03             1
      MCCN                       1986         1992      -3.90    -6.57    -1.16             1
      MCCN          1992         1992         2004      -0.76    -1.76     0.24             0




58
Appendix 3 - Mortality
  Table A3.1: Age standardised lung cancer mortality rates in women (per 100,000) relative
  change and difference to England. (*=spearhead local authority)
                                                                    Change         03-05       Change in difference to
   Place                       1995-1997   1999-2001   2003-2005    95-97 to   difference to   England 95-97 to 03-05
                                                                   03-05 (%)   England (%)              (%)
   Allerdale                     25.7        30.4        33.5        30.6          17.8                  29.4
   Barrow-in-Furness *           36.3        26.4        31.5       -13.2          10.7                 -14.2
   Blackburn with Darwen *       31.4        34.2        42.4        34.8          49.1                  40.7
   Blackpool *                   33.8        39.2        41.6        23.1          46.2                  29.8
   Bolton *                      31.8        32.4        35.3        11.1          24.2                  14.7
   Burnley*                      29.6        42.3        43.1        45.5          51.7                  49.5
   Bury *                        39.3        29.9        36.3        -7.7          27.5                  -7.8
   Carlisle*                     32.7        45.5        38.5        17.8          35.4                  22.8
   Chester                       28.7        34.8        20.2       -29.8          -29                   -28
   Chorley                       26.8        29.8        30.5        13.8           7.1                  14.9
   Congleton                     11.8        25.5        26.3       124.2          -7.4                  52.1
   Copeland                       35         23.4         30        -14.4           5.4                 -15.3
   Crewe and Nantwich            17.7        20.1        27.3        54.3          -4.1                   35
   Eden                          32.2        24.1        27.7       -14.1          -2.7                 -13.7
   Ellesmere Port and Neston     29.5        36.4        32.3         9.2          13.5                  11.7
   Fylde                         19.5        19.6        22.9        17.6         -19.3                  13.5
   Halton *                      43.2        47.9        49.6        14.9          74.5                  25.6
   Hyndburn *                    34.2        35.2        35.1         2.6          23.3                   5.6
   Knowsley *                    61.3         60         56.3        -8.2          97.8                 -13.4
   Lancaster                     29.6        30.2        28.9        -2.3           1.7                  -0.3
   Liverpool *                    63         60.8        61.8        -1.9         117.2                   0.2
   Macclesfield                   24.9        20.5        21.8       -12.5         -23.3                  -9.2
   Manchester *                  49.9        52.9        46.6        -6.5           64                    -8
   Oldham *                      37.6        37.8        34.3        -8.7          20.6                  -8.9
   Pendle *                      32.8        34.6        31.2         -5            9.6                  -3.4
   Preston *                     27.5        35.2        33.9        23.2          19.1                  24.4
   Ribble Valley                 31.3        26.4        28.7        -8.4           0.9                   -7
   Rochdale *                    37.5        39.7        43.2        15.2          51.9                  22.7
   Rossendale *                  49.8        34.3        40.3        -19           41.8                 -29.8
   Salford *                      52         54.9        55.7         7.1          95.9                  16.7
   Sefton                        38.9        35.4        40.1         2.9          40.8                   6.7
   South Lakeland                22.4        22.7        20.9        -6.7         -26.6                  -3.7
   South Ribble                  33.7        30.8         31          -8            9.1                  -7.1
   St Helens *                   36.4        36.2         34         -6.7          19.4                  -5.9
   Stockport                     30.7        24.8        31.3         2.2          10.1                   4.5
   Tameside *                    38.6        38.8        37.7        -2.3          32.5                  -0.3
   Trafford                      32.5        33.5        35.7         9.9          25.7                  13.6
   Vale Royal                    23.7        28.5         22         -7.3         -22.6                  -4.5
   Warrington *                  30.2        30.7        32.2         6.7          13.2                   9.2
   West Lancashire               31.6        35.1        26.3       -16.7          -7.4                 -16.3
   Wigan *                       35.5        35.1        34.6        -2.4          21.7                  -0.5
   Wirral *                      43.1        42.3        36.6       -14.9          28.8                 -19.6
   Wyre                          26.4        29.5        27.8          5           -2.3                   6.5
   North West                    36.8         37         36.9         0.3          29.7                   2.9
   LSCCN                         28.3        29.5        30.2         6.7           6.2                   8.6
   GMCCN                         35.6        35.5        36.3          2           27.7                    5
   MCCN                          46.1        45.7        43.6        -5.5          53.1                  -5.6
   England                        29         28.5        28.4         -2           n.a.                  n.a.




                                                                                                                         59
     Table A3.2: Age standardised lung cancer mortality rates in men (per 100,000) relative change
     and difference to England. (*=spearhead local authority)
                                                                       Change         03-05       Change in difference to
      Place                       1995-1997   1999-2001   2003-2005    95-97 to   difference to   England 95-97 to 03-05
                                                                      03-05 (%)   England (%)              (%)
      Allerdale                      76.2        61.3       56.2        -26.2           7.9                 -3.9
      Barrow-in-Furness *            73.2        64.2       68.6         -6.3          31.5                 24.2
      Blackburn with Darwen *         84          79        72.1        -14.1          38.3                 15.1
      Blackpool *                    79.6        80.2       63.8        -19.9          22.3                  5.5
      Bolton *                       75.9       69.6        58.3        -23.2          11.8                  0.5
      Burnley*                       78.8        69.4       72.4         -8.1           39                  23.4
      Bury *                         76.9       64.4        62.8        -18.4          20.4                  7.6
      Carlisle*                      73.1        67.1       59.8        -18.2          14.8                  7.5
      Chester                        65.7       57.4        46.8        -28.8         -10.3                 -6.7
      Chorley                        70.7        73.9       57.8        -18.3          10.9                  7.1
      Congleton                       56         47.2       50.1        -10.5          -3.9                  14
      Copeland                       66.5       63.3        51.8        -22.1          -0.6                  1.8
      Crewe and Nantwich             67.2        59.1       50.4        -25.1          -3.4                  -2
      Eden                           55.3        55.4       34.6        -37.4         -33.6                -14.7
      Ellesmere Port and Neston      80.2        66.2       47.5        -40.7          -8.8                -26.5
      Fylde                          45.2        52.8       43.3         -4.2         -16.9                 16.7
      Halton *                       114         72.8        75         -34.2          43.9                -23.4
      Hyndburn *                     79.8        76.4        73          -8.5          40.1                  23
      Knowsley *                    126.7       101.2       84.2        -33.6          61.5                -24.4
      Lancaster                      74.7        59.8        59          -21           13.2                  3.6
      Liverpool *                    113        102.9       93.9        -16.9          80.2                 14.4
      Macclesfield                    66.3       48.6        42.8        -35.3         -17.8                 -15
      Manchester *                   114         99.9       86.5        -24.1           66                  -1.3
      Oldham *                       80.9        77.1       64.5        -20.2          23.8                  5.1
      Pendle *                       68.5         56         63          -8.1          20.9                 20.3
      Preston *                      78.7        59.7       66.4        -15.6          27.4                 11.9
      Ribble Valley                  44.8        52.6       52.2         16.4           0.1                 34.3
      Rochdale *                     82.2       76.1        68.5        -16.6          31.5                 10.9
      Rossendale *                   62.6       59.4         62          -1.1          18.9                  27
      Salford *                     108.4        87.7       79.7        -26.4          52.9                 -6.1
      Sefton                         87.9        71.8       56.5        -35.7           8.4                -20.6
      South Lakeland                 54.8        39.9       38.8        -29.1         -25.5                 -5.9
      South Ribble                   67.8       78.7        46.6        -31.2         -10.5                -10.1
      St Helens *                    92.5       67.7        58.5        -36.8          12.2                -23.6
      Stockport                      67.5       59.2         54          -20            3.7                  4.6
      Tameside *                     98.2         77        68.3        -30.4          31.1                 -13
      Trafford                       76.1        53.5       54.2        -28.8           3.9                 -7.7
      Vale Royal                     63.3        52.7       45.7        -27.9         -12.3                 -5.3
      Warrington *                   78.1       63.2        56.3        -27.9            8                  -6.6
      West Lancashire                73.8        66.2       55.4        -24.9           6.4                  -2
      Wigan *                        83.7       77.4        62.5        -25.3           20                  -2.9
      Wirral *                       77.3         77        61.5        -20.5           18                   4.5
      Wyre                           67.4        53.1       51.2         -24           -1.8                 -0.6
      North West                     82.2         71        62.2        -24.3          19.4                 -1.2
      LSCCN                          65.4       59.6        54.5        -16.7           4.6                  8.6
      GMCCN                          83.1       70.7        62.4        -24.9          19.7                 -2.2
      MCCN                           96.8         82        69.8        -27.8           34                   -8
      England                        68.1        58.9       52.1        -23.5          n.a.                 n.a.




60
 Table A3.3: Number of lung cancer deaths in women and men and change 95-97 to 03-05 (%).
(*=spearhead local authority)
                                             Women                                    Men
                                                         Relative                                 Relative
                             1995-   1999-    2003-                   1995-   1999-    2003-
 Place                                                change 95-97                             change 95-97
                             1997    2001     2005                    1997    2001     2005
                                                       to 03-05 (%)                             to 03-05 (%)
 Allerdale                      56     71        82         46.4        136     117     116         -14.7
 Barrow-in-Furness *            56     41        51         -8.9         92      84      93           1.1
 Blackburn with Darwen *        83      89      108         30.1        163     156     150           -8
 Blackpool *                   120    149      154          28.3       225      232     192         -14.7
 Bolton *                      174    174      202          16.1       306      294     262         -14.4
 Burnley*                       56     75       87          55.4       112      102     113           0.9
 Bury *                        150    120      147           -2        217      191     190         -12.4
 Carlisle*                      81    115       99          22.2       132      128     126          -4.5
 Chester                        78    100       64         -17.9       140      127     113         -19.3
 Chorley                        51     60       68          33.3       103      119     105           1.9
 Congleton                      25     51       54          116         82       78      90           9.8
 Copeland                       53     36       51          -3.8        77       81      70          -9.1
 Crewe and Nantwich             42      51       68         61.9        126     116     108         -14.3
 Eden                           37     31       37            0         51       56      41         -19.6
 Ellesmere Port and Neston      50     70        65          30         105      95      73         -30.5
 Fylde                          43     43       61          41.9        76       91      77           1.3
 Halton *                       95    110      117          23.2       196      127     144         -26.5
 Hyndburn *                     59     63       57          -3.4       104       98      99          -4.8
 Knowsley *                    183    190      186           1.6       273      229     200         -26.7
 Lancaster                      95    102       96           1.1       183      145     153         -16.4
 Liverpool *                   609     568      574         -5.7        797     729     673         -15.6
 Macclesfield                    95     87       98           3.2       181      147     141         -22.1
 Manchester *                  379    387      349          -7.9       683      578     499         -26.9
 Oldham *                      161    171      153           -5        268      259     227         -15.3
 Pendle *                       61     60       64           4.9        95       84      98           3.2
 Preston *                      71     94       89          25.4       156      124     142           -9
 Ribble Valley                  38     33        41          7.9         43      54      57          32.6
 Rochdale *                    149    164      178          19.5       253      246     231          -8.7
 Rossendale *                   63     44       59          -6.3        62       62      67           8.1
 Salford *                     244    252      265           8.6       400      326     294         -26.5
 Sefton                        280    268      325          16.1       456      391     327         -28.3
 South Lakeland                 65     69       70           7.7       122       89      93         -23.8
 South Ribble                   67     70       76          13.4       112      140      91         -18.8
 St Helens *                   135    144      149          10.4       263      204     184          -30
 Stockport                     205    166      213           3.9       328      298     280         -14.6
 Tameside *                    174    180       174           0         332     264     243         -26.8
 Trafford                      150     170      176         17.3        278     196     208         -25.2
 Vale Royal                     62      78       64          3.2        125     114     109         -12.8
 Warrington *                  115    122      135          17.4       224      192     186          -17
 West Lancashire                68     84        74          8.8        129     127     112         -13.2
 Wigan *                       221    226      225           1.8       390      380     323         -17.2
 Wirral *                      337    322      303         -10.1       439      452     372         -15.3
 Wyre                           81     92       93          14.8       156      136     135         -13.5
 North West                   5417    5592     5801          7.1       9191    8258    7607         -17.2
 LSCCN                        1009   1084     1174          16.4      1804     1716    1665          -7.7
 GMCCN                        2218   2263     2356           6.2      3934     3456    3181         -19.1
 MCCN                         1963   1991     2002            2       3057     2703    2408         -21.2
 England                     31071   31246    32641          5.1      55698   50543   47286         -15.1




                                                                                                               61
     Table A3.4: Lung cancer mortality rates in under 75 year olds (per 100,000) and difference to
     England average (%). (*=spearhead local authority)
                                  1995-   1999-   2003-   Change 95-97    03-05 difference    Change in difference to
      Place
                                  1997    2001    2005     to 03-05 (%)   to England (%)     England 95-97 to 03-05 (%)
      Allerdale                   39.3    31.1    -20.9       14.6             15.3                     0.7
      Barrow-in-Furness *         42.6    34.4    -19.3       24.3             27.5                     3.2
      Blackburn with Darwen*      42.9    40.3    -6.1         25              49.3                     24.3
      Blackpool *                 43.8    36.3    -17.2       27.7             34.5                     6.8
      Bolton *                    39.8    30.6    -23.1        16              13.5                     -2.6
      Burnley*                    42.2    38.8    -8.1         23              43.7                     20.6
      Bury *                      39.6     34     -14.3       15.6              26                      10.4
      Carlisle*                   37.8    33.8    -10.5       10.1             25.3                     15.2
      Chester                     34.6    21.8     -37         1               -19.1                    -20
      Chorley                     35.3     27     -23.5        2.8               0                      -2.8
      Congleton                   26.4     25     -5.2        -23.1             -7.4                    15.8
      Copeland                    32.7    27.2    -16.9       -4.8              0.7                     5.4
      Crewe and Nantwich          29.6    28.3    -4.4        -13.8             4.8                     18.6
      Eden                        32.5    22.3    -31.3       -5.1             -17.2                    -12
      Ellesmere Port and Neston   38.6    27.6    -28.4       12.5              2.4                    -10.2
      Fylde                       23.3    22.5    -3.2        -32.2            -16.6                    15.6
      Halton *                    57.6     44     -23.6       67.9              63                      -4.9
      Hyndburn *                  39.4     42      6.4         15              55.5                     40.6
      Knowsley *                  67.9    47.5    -30.1        98               76                      -22
      Lancaster                   37.3    31.3    -16.2        8.8              16                      7.2
      Liverpool *                 63.8     53     -16.9       85.9             96.5                     10.6
      Macclesfield                 30.8    17.6    -42.9       -10.1            -34.7                   -24.6
      Manchester *                62.1    47.8     -23        80.9             77.2                     -3.7
      Oldham *                    45.4    35.1    -22.6       32.3             30.1                     -2.2
      Pendle *                    38.5    32.6    -15.4       12.3             20.8                     8.4
      Preston *                   38.1    35.4     -7          11              31.2                     20.2
      Ribble Valley               30.1    23.9    -20.7       -12.2            -11.5                    0.7
      Rochdale *                  44.8     39     -12.9       30.5             44.5                     14
      Rossendale *                42.4    36.5    -13.8       23.6             35.5                     11.9
      Salford *                   60.9    46.9    -22.9       77.5             73.9                     -3.6
      Sefton                      47.5    32.1    -32.3       38.4             19.1                    -19.3
      South Lakeland              25.9    18.8    -27.5       -24.5            -30.4                    -5.9
      South Ribble                39.5    29.7    -24.9       15.1              9.9                     -5.2
      St Helens *                  46     29.7    -35.4       34.2             10.2                     -24
      Stockport                   33.1    29.4    -11.3       -3.4              8.9                     12.3
      Tameside *                  48.8    37.8    -22.7       42.4             39.9                     -2.5
      Trafford                     39     30.1    -22.9       13.8             11.6                     -2.2
      Vale Royal                  29.5    21.6    -26.7        -14             -19.8                    -5.8
      Warrington *                37.5     29     -22.5        9.3              7.6                     -1.7
      West Lancashire              38     24.7     -35        10.7              -8.6                   -19.3
      Wigan *                     41.6    32.8    -21.3       21.4             21.4                      0
      Wirral *                    44.2    34.1    -22.8       28.8             26.3                     -2.5
      Wyre                        32.7    27.8    -15.1       -4.6               3                      7.6
      North West                  43.4    33.9    -21.9       26.6             25.6                     -0.9
      LSCCN                       34.5    29.3    -15.2        0.6              8.5                     7.9
      GMCCN                        43     33.8    -21.4       25.3             25.2                     -0.1
      MCCN                        52.1    38.4    -26.4       51.9             42.2                     -9.7
      England                     34.3     27     -21.3       n.a.              n.a.                    n.a.




62
Appendix 4 - Survival

  Table A4.1: Five year survival in cancer networks in the North West and the North West
  1989-91 to 1998-00.

             Place                        1989-1991     1992-1994       1995-1997      1998-2000
             LSCCN                           4.8           7.1             6.2            6.7
             GMCCN                           6.2           7.1             6.4            6.4
   Men
             MCCN                            7.3           8.3             8.5            9.9
             North West                      6.2           7.3             7.1            7.5
             LSCCN                           5.5           6.6             5.4            6.7
             GMCCN                           6.1           6.3             6.5            8.3
   Women
             MCCN                            7.7           9.3             7.6            9.6
             North West                      6.5           7.4             6.6            8.3
             LSCCN                           5.0           6.9             5.9            6.7
             GMCCN                           6.2           6.8             6.4            7.2
   Persons
             MCCN                            7.5           8.7             8.1            9.8
             North West                      6.3           7.4             6.9            7.9

  Table A4.2: One year survival in cancer networks in the North West and the North West
  1989-91 to 2004-05.

             Place         1989-1991   1992-1994   1995-1997   1998-2000   2001-2003    2004-2005
             LSCCN           19.1        19.3         20.3       22.7        22.7         25.3
             GMCCN           20.5        21.0         21.1       21.6        25.5         28.6
   Men
             MCCN            23.1        27.4         25.0       27.6        31.4         29.5
             North West      21.0        22.8         22.1       23.6        26.6         28.0
             LSCCN           17.0        19.6         20.0       19.8        25.0         23.4
             GMCCN           19.3        21.1         21.1       24.5        26.9         30.6
   Women
             MCCN            21.6        25.5         26.4       27.3        32.2         32.9
             North West      20.2        22.4         22.8       24.4        28.2         29.6
             LSCCN           18.4        19.4         20.1       21.6        23.7         24.4
             GMCCN           20.4        21.0         21.1       22.8        26.1         29.5
   Persons
             MCCN            23.2        26.7         25.6       27.4        31.8         31.2
             North West      20.6        22.7         22.4       24.0        27.3         28.7

  Table A4.3: Five year survival in under 75 year olds in cancer networks in the North West and
  the North West 1989-91 to 1998-00.
             Place                        1989-1991      1992-1994      1995-1997      1998-2000
             LSCCN                           5.8             8.0           7.1             7.6
             GMCCN                           6.8             8.0           7.1             6.9
   Men
             MCCN                            8.5             8.9           9.6            10.6
             North West                      7.1             8.1           8.0             8.2
             LSCCN                           6.6             8.0           6.6             7.8
             GMCCN                           6.8             7.1           7.9            10.1
   Women
             MCCN                            9.1            11.1           9.8            10.7
             North West                      7.5             8.7           8.2             9.7
             LSCCN                           6.1             8.0           6.9             7.7
             GMCCN                           6.8             7.7           7.4             8.2
   Persons
             MCCN                            8.7             9.7           9.7            10.6
             North West                      7.2             8.3           8.1             8.8




                                                                                                    63
     Figure A4.1: One and five year relative survival in under 75 year olds in cancer networks in the
     North West and the North West 1989-91 to 04-05.
                                 40


                                 35
                                                                     1 year
                                 30
             Relative survival (%)




                                 25


                                 20


                                 15
                                                            5 year
                                 10
                                                                                                                  LSCCN
                                                                                                                  GMCCN
                                     5                                                                            MCCN
                                                                                                                  North West

                                     0
                                         1989-1991   1992-1994           1995-1997        1998-2000   2001-2003    2004-2005
                                                                              Year of diagnosis



     Figure A4.2: One and five year relative survival in over 75 year olds in cancer networks in the
     North West and the North West 1989-91 to 04-05.
                           30



                           25
                                                                     1 year
       Relative survival (%)




                           20



                           15



                           10
                                                            5 year



                                     5                                                                            LSCCN
                                                                                                                  GMCCN
                                                                                                                  MCCN
                                                                                                                  North West

                                     0
                                         1989-1991   1992-1994          1995-1997        1998-2000    2001-2003    2004-2005
                                                                              Year of diagnosis




64
Table A4.4: One year survival in under 75 year olds in cancer networks in the North West and
the North West 1989-91 to 2004-05.

           Place         1989-1991   1992-1994       1995-1997    1998-2000     2001-2003    2004-2005
           LSCCN           21.6        20.9            22.0            24.1        26.9         26.7
           GMCCN           23.4        23.0            23.8            23.9        28.3         34.0
 Men
           MCCN            25.3        29.2            27.9            29.7        34.6         32.5
           North West      23.7        24.7            24.7            25.7        29.8         31.6
           LSCCN           19.9        23.0            23.1            22.9        28.0         26.8
           GMCCN           23.8        23.5            24.8            28.8        31.6         35.7
 Women
           MCCN            26.9        28.6            30.0            31.1        37.9         39.4
           North West      24.1        25.2            26.3            28.1        33.0         34.8
           LSCCN           21.0        21.6            22.4            23.6        27.3         26.8
           GMCCN           23.5        23.2            24.1            25.8        29.6         34.7
 Persons
           MCCN            25.9        29.0            28.7            30.3        36.0         35.6
           North West      23.8        24.9            25.3            26.7        31.1         33.0

Table A4.5: Five year survival in over 75 year olds in cancer networks in the North West and
the North West 1989-91 to 1998-00
           Place                        1989-1991         1992-1994           1995-1997      1998-2000
           LSCCN                                             4.0                 3.7            4.3
           GMCCN                               4.0           3.5                 4.4            5.0
 Men
           MCCN                                2.8           5.7                 4.7            7.9
           North West                          2.9           4.3                 4.2            5.5
           LSCCN                                                                 2.6            4.2
           GMCCN                               3.8               3.8             3.1            4.5
 Women
           MCCN                                3.3               3.9             1.9            7.2
           North West                          3.2               3.5             2.4            5.3
           LSCCN                               1.6               3.5             3.2            4.3
           GMCCN                               3.9               3.6             3.8            4.8
 Persons
           MCCN                                3.0               4.9             3.4            7.6
           North West                          3.1               4.0             3.4            5.4

Table A4.6: One year survival in over 75 year olds in cancer networks in the North West and
the North West 1989-91 to 2004-05.

            Place        1989-1991   1992-1994       1995-1997     1998-2000     2001-2003    2004-2005
            LSCCN           13.3        15.7            16.6           19.9        15.4         22.9
            GMCCN           13.5        15.8            15.4           16.9        20.1         18.3
 Men
            MCCN            17.0        22.4            17.8           23.1        24.6         24.0
            North West      14.4        17.8            16.3           19.3        20.4         21.0
            LSCCN           11.0        12.0            14.0           14.8        20.8         18.7
            GMCCN           11.9        15.6            14.0           17.4        20.2         23.0
 Women
            MCCN            14.7        18.3            19.0           20.6        23.4         23.4
            North West      12.5        15.9            16.0           18.2        21.1         22.1
            LSCCN           12.5        14.4            15.6           17.8        17.8         20.9
            GMCCN           13.0        15.7            14.9           17.1        20.1         20.5
 Persons
            MCCN            16.1        20.7            18.3           22.0        24.0         23.7
            North West      13.7        17.1            16.2           18.8        20.7         21.6




                                                                                                          65
     Table A4.7: One and five year survival by age bands (based on 2004-05 data for one year
     survival and 1998-00 data for five year survival analysis).
                                30-54         55-64         65-74        75-84          85+
      Men        5 Year           9.1           9.2           7.4          5.7           -
      Women      5 Year          13.5          12.6           7.2          5.6           -
      Men        1 Year          38.0          30.8          29.0         22.3          13.5
      Women      1 Year          39.5          41.2          31.8         23.8          14.7




66
Appendix 5 - Histological type and treatment
  Table A5.1: ICD 02 codes for the analysis by histological types of lung cancer.
   Lung cancer morphology codes
   Small Cell
   M80413 - M80453
   Squamous
   M80500 - M80899
   Large Cell
   M80120 - M80149
   Adenocarcinoma
   M81400 - M83800, M80463, M84303, M85500 - M85510
   excluding:
   M81440 - M81459
   M81500 - M81549
   M81600 - M81809
   M82143 - M82302
   M82400 - M82459
   M82470 - M82479
   M82610 - M83009
   M83120 - M83149
   M83160 - M83199
   M83210 - M83229
   M83250 - M83849




  Table A5.2: Distribution of histological types of lung cancer by cancer network, 03-05;
  percentage and total.

                                           GMCCN          LSCCN           MCCN          Total
   small cell                                826            444            678         1,948
   %                                         12.1           12.5           13.1         12.5
   squamous cell carcinoma                  1,402           721           1,020        3,143
   %                                         20.6           20.3           19.7         20.2
   adenocarcinoma                           1,027           441           1,234        2,702
   %                                         15.1           12.4           23.9         17.4
   large cell                                 43             61             25          129
   %                                         0.63           1.72           0.48         0.83
   NOS                                      3,522          1,888          2,215        7,625
   %                                         51.6           53.1           42.8         49.0
   total                                    6,820          3,555          5,172        15,547
   %                                         100            100            100          100




                                                                                                67
     Table A5.3: Distribution of histological types of lung cancer by sex, North West 03-05 ;
     percentage and total.
                                                          Male           Female            Total
      small cell                                           974             974             1,948
      %                                                    11.2            14.3             12.5
      squamous cell carcinoma                             2,110           1,033            3,143
      %                                                    24.1            15.2             20.2
      adenocarcinoma                                      1,447           1,255            2,702
      %                                                    16.6            18.4             17.4
      large cell                                            78              51              129
      %                                                     0.9             0.8              0.8
      NOS                                                 4,130           3,495            7,625
      %                                                    47.3            51.3             49.0
      total                                               8,739           6,808           15,547
      %                                                    100             100              100

     Table A5.4: Distribution of histological types of lung cancer by age, North West 03-05;
     percentage and total.
                                                        under 75         over 75           Total
      small cell                                         1,424             524             1,948
      %                                                   15.7              8.1             12.5
      squamous cell carcinoma                            2,011            1,132            3,143
      %                                                   22.1             17.5             20.2
      adenocarcinoma                                     1,908             794             2,702
      %                                                   21.0             12.3             17.4
      large cell                                           85               44              129
      %                                                    0.9              0.7              0.8
      NOS                                                3,665            3,960            7,625
      %                                                   40.3             61.4             49.0
      total                                              9,093            6,454           15,547
      %                                                   100              100              100

     Table A5.5: Distribution of lung cancer treatment in cancer networks in the North West 03-05;
     percentage and total.
      Treatment                                 GMCCN         LSCCN          MCCN          Total
      surgery only                                394           117           457            968
      %                                           6.0           3.4           9.1            6.5
      chemotherapy only                           766           363           343           1472
      %                                          11.7          10.5           6.9            9.8
      radiotherapy only                           831           816           352           1999
      %                                          12.7          23.7           7.0           13.3
      surgery & any other treatment               163            64            64            291
      %                                           2.5           1.9           1.3            1.9
      radiotherapy & chemotherapy                 993           277           231           1501
      %                                          15.2           8.0           4.6           10.0
      other treatment                              23            11            18             52
      %                                           0.4           0.3           0.4            0.3
      no treatment                               3372          1793          3540           8705
      %                                          51.5          52.1          70.7           58.1
      total                                      6542          3441          5005          14988
      %                                           100           100           100            100




68
Table A5.6: Distribution of lung cancer treatment by histological type in the North West 03-05;
percentage and total.

                                                                Squamous
                                                     Large                    Small
 Treatment                       Adenocarcinoma                     cell                   Other
                                                      cell                     cell
                                                                carcinoma
 surgery only                           405            12             411      17          123
 %                                     15.2           9.3             13.2     0.9          1.7
 chemotherapy only                      283            14             261      564         350
 %                                     10.6           10.9            8.4     29.5          4.9
 radiotherapy only                      302            25             611      72          989
 %                                     11.3           19.4            19.7     3.8         13.8
 surgery & any other treatment          123            6              113      15           34
 %                                      4.6           4.7             3.6      0.8          0.5
 radiotherapy & chemotherapy            248            9              412      332         500
 %                                      9.3           7.0             13.3    17.3          7.0
 other treatment                        15             1               8        8           20
 %                                      0.6           0.8             0.3      0.4          0.3
 no treatment                          1294            62             1292     907         5150
 %                                     48.5           48.1            41.6    47.4         71.9
 total                                 2670           129             3108    1915         7166
 O%                                     100           100             100      100         100

Table A5.7: Distribution of lung cancer treatment by age groups, North West 03-05;
percentage and total.

 Treatment                                                   under 75           over 75
 surgery only                                                  756                   212
 %                                                             8.5                   3.5
 chemotherapy only                                            1206                   266
 %                                                             13.6                  4.3
 radiotherapy only                                            1115                   884
 %                                                             12.6                 14.4
 surgery & any other treatment                                 270                   21
 %                                                             3.0                   0.3
 radiotherapy & chemotherapy                                  1199                   302
 %                                                             13.5                  4.9
 other treatment                                               37                    15
 %                                                             0.4                   0.2
 no treatment                                                 4279                  4426
 %                                                             48.3                 72.2
 total                                                        8862                  6126
 %                                                             100                   100




                                                                                                   69
     Table A5.8: Distribution of lung cancer treatment by age groups in cancer networks in the
     North West 03-05; percentage and total.

                                                                over 75
      Treatment                          GMCCN           LCCN              MCCN         Total
      surgery only                          79             26               107          212
      %                                    3.0            1.8               5.1          3.5
      chemotherapy only                    135             59                72          266
      %                                    5.2            4.1               3.5          4.3
      radiotherapy only                    383            349               152          884
      %                                   14.7           24.2               7.3         14.4
      surgery & any other treatment         11              4                 6           21
      %                                    0.4            0.3               0.3          0.3
      radiotherapy & chemotherapy          244             32                26          302
      %                                    9.4            2.2               1.3          4.9
      other treatment                        8              4                 3           15
      %                                    0.3            0.3               0.1          0.2
      no treatment                        1745            967              1714         4426
      %                                   67.0           67.1              82.4         72.2
      total                               2605           1441              2080         6126
      %                                   100             100               100          100

                                                                under 75
      Treatment                          GMCCN           LCCN              MCCN         Total
      surgery only                        315             91                350          756
      %                                    8.0            4.6              12.0          8.5
      chemotherapy only                    631            304               271         1206
      %                                   16.0           15.2               9.3         13.6
      radiotherapy only                    448            467               200         1115
      %                                   11.4           23.4               6.8         12.6
      surgery & any other treatment        152             60                58          270
      %                                    3.9            3.0               2.0          3.0
      radiotherapy & chemotherapy          749            245               205         1199
      %                                   19.0           12.3               7.0         13.5
      other treatment                       15             7                 15           37
      %                                    0.4            0.4               0.5          0.4
      no treatment                        1627            826              1826         4279
      %                                   41.3           41.3              62.4         48.3
      total                               3937           2000              2925         8862
      %                                    100            100               100          100




70
Table A5.9: Percentage difference in lung cancer treatment by age groups (under 75 and over
75) in cancer networks in the North West 03-05.

                                               Difference between age groups
 Treatment                          GMCCN             LSCCN           MCCN          Total
 surgery only                         -5.0              -2.7          -6.8          -4.8
 chemotherapy only                    -10.8            -11.1          -5.8          -9.3
 radiotherapy only                     3.3              0.9            0.5          1.5
 surgery & any other treatment        -3.4              -2.7          -1.7          -2.7
 radiotherapy & chemotherapy          -9.7             -10.0          -5.8          -8.5
 other treatment                      -0.1              -0.1          -0.4          -0.2
 no treatment                         25.7              25.8          20.0          24.8


Table A5.10: Percentage lung cancer treatment by deprivation quintile in the North West
03-05.

 Treatment                            1           2             3             4        5
 surgery only                         7.7        6.7           6.0           5.8      6.5
 chemotherapy only                   11.4        9.8           11.3          9.1      9.2
 radiotherapy only                   15.5        13.5          13.8          14.7    11.8
 surgery & any other treatment        2.8        2.1           2.2           1.8      1.7
 radiotherapy & chemotherapy          9.5        11.2          10.2          10.6     9.4
 other treatment                      0.3        0.4           0.4           0.3      0.3
 no treatment                        52.7        56.2          55.9          57.6    61.0




                                                                                              71
     Appendix 6 - Deaths attributable to active and passive smoking

      Table A6.1: Smoking prevalence (1980) and ex-smokers (1982) in the North West.
                                               Male                                    Female
                                  current                  ex               current                   ex
            1980/82                 42                     31                 36                      17

      Table A6.2: Current and ex smoking prevalence, England 2004.
                                                       Male                                 Female
                age groups                  current               ex              current               ex
                  all > 35                   0.236              0.352              0.212              0.235
                   35-54                     0.301              0.223              0.273              0.191
                   55-64                     0.221              0.413              0.213              0.281
                   65-74                     0.162              0.507              0.148              0.272
                  75 plus                    0.076              0.586              0.072              0.285
                   35-64                     0.276              0.283              0.255              0.217
                  65 plus                    0.126               0.54               0.11              0.279

      Table A6.3: Relative risk ratios used for the calculation of smoking attributable mortality.
                                                                                 Male               Female
                                                                   age     current    ex                  ex
                     disease                          ICD 10      group    smoker smoker       current smoker
       cancer        lung                             C33-34     35 plus    26.6      8.2       13.6     4.1
                                                       C00-
                     upper respiratory sites          C14,C32    35 plus   10.6         3       6.1        1.5
                     oesophagus                         C15      35 plus    5.3         4       9.3        3.1
                     bladder                            C67      35 plus    2.9        2.1      1.6        1.5
                                                       C64-
                     kidney                           C66,C68    35 plus    2.8        1.6      1.3           1
                     stomach                            C16      35 plus    2.1        1.6      1.2        1.3
                     pancreas                           C25      35 plus    2.2        1.1      2.3        1.5
                     unspecified site                    C80      35 plus    4.4        2.3      2.1        1.2
                     myeloid leukemia                   C92      35 plus    1.4        1.3      1.2        1.3
                     chronic obstructive lung
       respiratory                                    J40-44     35 plus   14.1        8.4      14         8.6
                     disease
                     pneumonia                        J10-18     35-64      2.3        1.3      4.6        1.1
                     pneumonia                        J10-18     65 plus    1.9        1.3       2         1.1
       circulatory   IHD                              I20-25     35-54      4.2        1.9      5.2        2.9
                     IHD                              I20-25     55-64      2.6        1.6       3         1.1
                     IHD                              I20-25     65-74      1.7        1.4      2.1        1.2
                     IHD                              I20-25      75+       1.4        1.1      1.4        1.1
                     cerebrovascular disease          I60-69     35-54      5.1        1.1      4.5        1.1
                     cerebrovascular disease          I60-69     55-64      2.8        1.1      3.2        1.1
                     cerebrovascular disease          I60-69     65-74      2.1         1        3         1.6
                     cerebrovascular disease          I60-69      75+       1.4         1       1.2         1
                     aortic aneurysm                    I71      35 plus    5.3        2.6      8.2        1.6
                     myocardial degeneration            I51      35 plus    2.1        1.2      1.7        1.2
                     atherosclerosis                    I70      35 plus    1.9        1.1      2.2        0.8
       digestive     stomach/duodenal ulcer           K25-27     35 plus    4.5        1.6      6.4        1.4




72
Appendix 7 - Smoking cessation

 Table A7.1: Estimated number of quitters at 52 weeks (absolute and per 100 population over
 16) treated by the NHS smoking cessation service.
                                         06-07                      05-06                      04-05                      03-04
                              Absolute       Per 100     Absolute       Per 100     Absolute       Per 100     Absolute       Per 100     Average 03-04
                                            population                 population                 population                 population    to 06-07 per
                                               >16                        >16                        >16                        >16       100 population
                                                                                                                                               >16
  Ashton, Leigh & Wigan         283              0.11      397              0.16      414              0.17      117              0.049       0.124
  Bebington & West Wirral       42               0.04      71               0.07      71               0.07      68               0.069       0.064
  Birkenhead & Wallasey         217              0.14      275              0.18      305              0.2       263              0.176       0.175
  Blackburn & Darwen            247              0.23      266              0.25      255              0.24      178              0.173       0.225
  Blackpool                     203              0.17      195              0.17      177              0.15      118              0.102       0.149
  Bolton                        331              0.16      324              0.15      262              0.13      149              0.073       0.128
  Burnley, Pendle & Ros-        286              0.15      309              0.16      288              0.15      222              0.118       0.145
  sendale
  Bury                          233              0.16      130              0.09      131              0.09      131              0.092       0.108
  Carlisle & District           69               0.07      97               0.1       111              0.12      86               0.093       0.096
  Central Cheshire              249              0.12      330              0.16      250              0.12      132              0.065       0.117
  Central Liverpool             393              0.2       385              0.19      438              0.23      336              0.179       0.199
  Central Manchester            234              0.18      237              0.18      179              0.14      99               0.089       0.147
  Cheshire West                 96               0.08      153              0.12      153              0.12      72               0.058       0.095
  Chorley & South Ribble        203              0.12      227              0.13      215              0.13      155              0.095       0.12
  Eastern Cheshire              135              0.09      159              0.1       134              0.09      91               0.06        0.085
  Eden Valley                   51               0.08      57               0.1       57               0.1       53               0.093       0.093
  Ellesmere Port & Neston       74               0.11      88               0.14      90               0.14      62               0.096       0.121
  Fylde                         53               0.08      73               0.11      76               0.12      61               0.101       0.105
  Halton                        157              0.17      157              0.17      142              0.15      126              0.136       0.155
  Heywood & Middleton           97               0.16      121              0.21      84               0.14      33               0.057       0.143
  Hyndburn & Ribble Valley      171              0.17      222              0.22      170              0.17      131              0.134       0.174
  Knowsley                      215              0.18      199              0.17      161              0.14      158              0.136       0.156
  Morecambe Bay                 241              0.09      282              0.11      345              0.14      174              0.069       0.103
  North Liverpool               180              0.21      145              0.18      161              0.2       132              0.162       0.188
  North Manchester              246              0.23      276              0.26      300              0.28      122              0.135       0.226
  Oldham                        308              0.18      285              0.17      213              0.13      122              0.073       0.137
  Preston                       152              0.13      139              0.12      156              0.14      103              0.093       0.121
  Rochdale                      146              0.14      173              0.17      168              0.16      86               0.086       0.14
  Salford                       286              0.16      285              0.16      263              0.15      247              0.144       0.155
  South Liverpool               134              0.16      133              0.16      140              0.17      114              0.14        0.157
  South Manchester              182              0.15      192              0.17      156              0.14      79               0.073       0.132
  South Sefton                  184              0.14      188              0.14      199              0.15      159              0.121       0.138
  Southport & Formby            72               0.08      105              0.11      112              0.12      108              0.115       0.105
  St Helens                     230              0.16      190              0.13      129              0.09      117              0.083       0.118
  Stockport                     278              0.12      311              0.14      254              0.11      126              0.056       0.107
  Tameside & Glossop            278              0.14      289              0.15      208              0.11      122              0.063       0.114
  Trafford North                88               0.12      90               0.12      106              0.15      112              0.156       0.137
  Trafford South                85               0.09      99               0.1       110              0.11      107              0.111       0.102
  Warrington                    169              0.11      159              0.1       173              0.11      101              0.067       0.098
  West Cumbria                  106              0.1       127              0.12      139              0.13      137              0.131       0.119
  West Lancashire               110              0.13      93               0.11      99               0.11      88               0.102       0.112
  Wyre                          144              0.16      142              0.16      152              0.17      116              0.136       0.156
  Cheshire & Merseyside SHA    2548              0.13     2736              0.14     2657              0.14     2038              0.108       0.132
  Greater Manchester SHA       3075              0.15     3207              0.16     2846              0.14     1652              0.082       0.132
  Cumbria & Lancashire SHA     2037              0.13     2229              0.14     2240              0.15     1622              0.105       0.131
  Northwest                    7659              0.14     8173              0.15     7743              0.14     5313              0.098       0.131
  England                      47801             0.12     49452             0.12     44719             0.11     30731             0.077       0.107




                                                                                                                                                           73
     Table A7.2: Smoking HDA (based on 2001 census and 98-01 health survey for England data)
     and ONS (based on 2001 census and 2001-02 health survey for England data) smoking
     prevalence estimates at PCT level.
      PCT                                            HDA estimates    ONS synthetic estimate
      Bebington and West Wirral                           21                  19.3
      Trafford South                                      23                  19.6
      Eastern Cheshire                                    22                  20.5
      Fylde                                               22                  21.7
      Southport and Formby                                22                  21.8
      Cheshire West                                       24                  22.0
      Warrington                                          27                  23.1
      Chorley and South Ribble                            26                  23.6
      Bury                                                28                  23.8
      West Lancashire                                     27                  24.5
      Stockport                                           26                  24.6
      Morecambe Bay                                       27                  24.6
      Wyre                                                24                  24.7
      Eden Valley                                         25                  25.0
      Hyndburn and Ribble Valley                          27                  25.0
      Bolton                                              30                  25.2
      Central Cheshire                                    26                  25.3
      Trafford North                                      30                  25.6
      Ashton, Leigh and Wigan                             31                  26.4
      Blackburn with Darwen                               29                  26.5
      Burnley, Pendle and Rossendale                      29                  26.6
      Rochdale                                            30                  26.8
      St Helens                                           32                  27.0
      Ellesmere Port and Neston                           29                  27.2
      Tameside and Glossop                                32                  27.6
      West Cumbria                                        31                  27.6
      Oldham                                              31                  27.9
      Preston                                             28                  28.0
      South Liverpool                                     31                  28.4
      South Sefton                                        31                  29.1
      Halton                                              34                  29.1
      Carlisle and District                               29                  29.5
      Salford                                             35                  29.7
      South Manchester                                    37                  30.4
      Birkenhead and Wallasey                             31                  31.5
      Heywood and Middleton                               35                  31.9
      Blackpool                                           31                  32.9
      Central Manchester                                  35                  32.9
      Central Liverpool                                   37                  34.3
      Knowsley                                            36                  35.4
      North Liverpool                                     40                  35.5
      North Manchester                                    40                  37.2




74
Literature
1   Möller H, Shack L, Ashraf A (2006): Lung cancer in Cheshire and Merseyside. North West Cancer
    Intelligence Service. (http://www.nwph.net/NWCIS/Publications_and_Outputs/Forms/Detail%20View.
    aspx; visited May 2008).
2   Tyczynski JE, Berkel HJ (2005): Mortality from lung cancer and tobacco smoking in Ohio (U.S.): Will
    increasing smoking prevalence reverse current decrease in mortality? Cancer Epidemiology, Biomarkers
    and Prevention 14 (5): 1182-1187.
3   Jemal A, Cokkinides VE, Shafey O, Thun M (2003): Lung cancer trends in young adults: an early indicator
    of progress in tobacco control (United States). Cancer Causes and Control14: 579-585.
4   Wynder EL, Graham EA (1950): Tobacco smoking as a possible etiologic factor in bronchogenic carcinoma:
    A study of six hundred and eighty-four proved cases. Journal of the American Medical Association 143:
    329-336.
5   Doll R, Hill AB (1950): Smoking and carcinoma of the lung: preliminary report. British Medical Journal
    2:739-748.
6   Levin M, Goldstein H, Gerhardt P (1950): Cancer and tobacco smoking: A preliminary report. Journal of
    the American Medical Association 143: 336-338.
7   Schrek R, Baker LA, Ballard GP, Dolgoff S (1950): Tobacco smoking as an etiologic factor in disease. I.
    Cancer. Cancer Research 10: 49-58.
8   Mills C, Porter M (1950): Tobacco smoking habits, and cancer of the mouth and respiratory system.
    Cancer Research 10:539-542.
9   Quinn M, Babb P, Brock A, Kirby L, Jones J (2001): Cancer trends in England and Wales 1950-1999.
    Studies on medical and population subjects No. 66. London, the Stationery Office.
10 Goddard E. (2008): Smoking and drinking among adults 2006, General household survey 2006. Office
   for National Statistics, London, January 2008.
11 Kelly P M, Crombie H, Owen L (2004): The contribution of smoking, diet, screening and treatment to
   cancer mortality in the under-75s. Briefing paper, NHS, Health Development Agency.
12 Office for National Statistics (2006): Cancer survival. Rates improved during 1996-2001. ONS, Health.
   (http://www.statistics.gov.uk/CCI/nugget.asp?ID=861&Pos=3&ColRank=1&Rank=374; visited June 2008).
13 Khuder SA (2001): Effect of cigarette smoking on major histological types of lung cancer: A meta analysis.
   Lung cancer 31: 139-148.
14 Department of Health (2001): The National Health Inequalities Targets. March, 2001.
15 Department of Health (2004): National Standards, Local Action. Health and Social Care Standards &
   Planning Framework.
16 Twigg L, Moon G, Walker S (2004): The smoking epidemic in England. Health Development Agency,
   London.
17 The Information Centre for Health and Social Care (2007): Neighbourhood Statistics: LA Model-Based
   Estimates of Healthy Lifestyles Behaviours, 2003-05. (http://www.ic.nhs.uk/statistics-and-data-collections/
   population-and-geography/neighbourhood-statistics/neighbourhood-statistics:-model-based-estimates-
   of-healthy-lifestyles-behaviours-at-la-level-2003-05 ; visited June 2008).
18 Tobacco Advisory Group of the Royal College of Physicians (2005): Going smoke-free. The medical case
   for clean air in the home, at work and in public places. A report on passive smoking. July, 2005.
19 Ludbrook A, Bird S, van Teijlingen E (2005): International Review of the Health and Economic Impact
   of the Regulation of Smoking in Public Places. NHS Health Scotland. (http://www.healthscotland.com/
   documents/447.aspx; visited September 2007).




                                                                                                                 75
     20 Action on Smoking and Health (ASH) (2006): Smoking statistics: Illness and death; factsheet no:2.
        September 2006 (http://www.ash.org.uk/; visited May 2007).
     21 Action on Smoking and Health (ASH) (2006): Secondhand smoke; factsheet no:8. March 2006 (http://
        www.ash.org.uk/; visited May 2007).
     22 Centfiguregers for Disease Control and Prevention (CDC) (2006): Health effects of cigarette smoking;
        fact sheet, updated December 2006. (http://www.cdc.gov/tobacco/data_statistics/Factsheets/index.htm;
        visited May 2007).
     23 Centres for Disease Control and Prevention (CDC) (2006): Secondhand smoke; fact sheet, updated
        September 2006. (http://www.cdc.gov/tobacco/data_statistics/Factsheets/index.htm; visited May 2007).
     24 Centres for Disease Control and Prevention (CDC) (2007): Economic facts about U.S. Tobacco use
        and tobacco production; fact sheet, updated April 2007. (http://www.cdc.gov/tobacco/data_statistics/
        Factsheets/index.htm; visited May 2007).
     25 U.S. Department of Health and Human Services (2004). The Health Consequences of Smoking: A Report
        of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centres for Disease
        Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office on
        Smoking and Health. (http://www.cdc.gov/tobacco; visited May 2007).
     26 U.S. Department of Health and Human Services (2006): The Health Consequences of Involuntary Exposure
        to Tobacco Smoke: A Report of the Surgeon U.S. Department of Health and Human Services, Centres for
        Disease Control and Prevention, Coordinating Centre for Health Promotion, National Centre for Chronic
        Disease Prevention and Health Promotion, Office on Smoking and Health. (http://www.cdc.gov/tobacco;
        visited May 2007).
     27 Doll R, Peto R, Boreham J, Sutherland I (2004): Mortality in relation to smoking: 50 years observations on
        male British doctors. British Medical Journal 328 (7455):1519. doi:10.1136/bmj.38142.554479.AE
     28 Peto R, Lopez AD, Boreham J, Thun M, Heath JR C (1992): Mortality from tobacco in developed countries:
        indirect estimation from national vital statistics. Lancet 339: 1268-1278.
     29 International Agency for Research on Cancer, Working Group on the Evaluation of Carcinogenic Risks
        to Humans (2004): Tobacco smoke and involuntary smoking. IARC Monographs on the evaluation of
        carcinogenic risks to humans (83). Lyon, France.
     30 Law MR, Morris JK, Wald NJ (1997): Environmental tobacco smoke and ischaemic heart disease: an
        evaluation of the evidence. British Medical Journal 315: 973–80.
     31 Jamrozik K (2005): Estimate of death attributable to passive smoking among UK adults: database analysis.
        British Medical Journal. doi:10.1136/bmj.38370.496632.8F.
     32 Law MR, Hackshaw AK (1996): Environmental tobacco smoke. In: Doll R, Crofton J (eds),Tobacco and
        health. British Medical Bulletin 52 (1): 22–34.
     33 US Department of Health and Human Services (1989): Reducing the health consequences of smoking: 25
        years of progress. A report of the Surgeon General. DHHS Publication No. CDC 89–8411. Rockville MD:
        US DHHS, Public Health Service, Centres for Disease Control, Centre for Chronic Disease Prevention and
        Health Promotion, Office on Smoking and Health.
     34 Garfinkel L (1981): Time trends in lung cancer mortality among non smokers and a note on passive
        smoking. Journal of the National Cancer Institute 66:1061–1066.
     35 Haw SJ, Gruer L, Amos A, Currie C, Fischbacher C, Fong GT, Hastings G, Malam S, Pell J, Scott C, Semple
        S (2006): Legislation on smoking in enclosed public places in Scotland: How will we evaluate the impact?
        Journal of Public Health 28 (1): 24–30. doi:10.1093/pubmed/fdi080
     36 Barone-Adesi F, Vizzini L, Merletti F, Richiardi L (2006): Short-term effects of Italian smoking regulations
        on rates of hospital admissions for acute myocardial infarction. European Heart Journal 27 (20):
        2385-2386.



76
37 Khuder SA, Milz S, Jordan T, Price J, Silvestri K, Butler P (2007): The impact of a smoking ban on hospital
   admissions for coronary heart disease. Preventive Medicine April 4, 2007 Electronic publication ahead of
   print.
38 Bartecchi C, Alsever RN, Nevin-Woods C, Thomas CH, Estacio RO, Bucher Bartelson B, Mori J, Krantz MJ
   (2006): Reduction in the Incidence of acute myocardial infarction associated with a citywide smoking
   ordinance. Circulation 114: 1490-1496.
39 Sargent RP, Shepard RM, Glantz SA (2004): Reduced incidence of admissions for myocardial infarction
   associated with public smoking ban: Before and after study. British Medical Journal 328: 977–980.
40 Goodman P, Agnew M, Mc Caffrey M, Paul G, Clancy L (2007): Effects of the Irish smoking ban on
   respiratory health of bar workers and air quality in Dublin pubs. American Journal of Respiratory and
   Critical Care Medicine175: 840-845.
41 Eagan TM, Hetland J, Aaro LE (2006): Decline in respiratory symptoms in service workers five month after
   a public smoking ban. Tobacco Control 15 (3): 242-246.
42 Menzies D, Nair A, Williamson PA, Schembri S, Al-Khairalla MZ, Barnes M, Fardon TC, McFarlane L, Magee
   GJ, Lipworth BJ (2006): Respiratory symptoms, pulmonary function, and markers of inflammation among
   bar workers before and after a legislative ban on smoking in public places. Journal of the American
   Medical Association 296 (14): 1778-1779.
43 Eisner MD, Smith AK, Blanc PD (1998): Bartenders respiratory health after establishment of smoke-free
   bars and taverns. Journal of the American Medical Association 280 (22): 1909-1914.
44 National Centre for Health Outcomes Development (NCHOD) (2006): Clinical and Health Outcomes
   Knowledge Base. (http://nww.nchod.nhs.uk/; visited June 2008).
45 Office for National Statistics (2006): Sub national Population Projections – England. (http://www.statistics.
   gov.uk/statbase/Product.asp?vlnk=997; visited June 2008).
46 Kim HJ, Fay MP, Feuer EJ, Midthune DN (2000): Permutation tests for joinpoint regression with applications
   to cancer rates. Stat Med 19: 335-51.
47 Callum C (1998): The UK Smoking Epidemic: Deaths in 1995. The Health Education Authority, London.
48 The Information Centre for Health and Social Care (2006): Statistics on Smoking: England, 2006. (http://
   www.ic.nhs.uk/webfiles/publications/smokingeng2006/Smoking%20bulletin%202006%20-%20
   Finalv3.pdf, visited June 2008).
49 Goddard E, Green H (2005): Smoking and drinking among adults 2004, General household survey 2004.
   Office for National Statistics, London, December 2005.
50 International Agency for Research on Cancer, Working Group on the Evaluation of Carcinogenic Risks
   to Humans (2004): Tobacco smoke and involuntary smoking. IARC Monographs on the evaluation of
   carcinogenic risks to humans (83). Lyon, France.
51 Action on smoking and Health (ASH) (2004): Smoking at work. (http://www.ash.org.uk/html/factsheets/
   html/onsworkplacefigures2004.html, visited: July 2007).
52 Office for National Statistics (2008): Labour market statistics, North West 2008. (http://www.statistics.
   gov.uk/pdfdir/lmsnwest0508.pdf visited August 2008)
53 West R (2008): Key performance indicators: Findings from the Smoking Toolkit Study. (http://www.
   smokinginengland.info/ visited August 2008).
54 O’Dowd A (2005): Smoking ban in public places also cuts smoking at home. British Medical Journal 331:
   129. doi:10.1136/bmj.3317509.129-b
55 Woodward A, Laugensen M (2001): How many death are caused by second hand cigarette smoke?
   Tobacco Control 10: 383-388.
56 BBC News (10.09.07): Scots smoke ban improved health. (http://news.bbc.co.uk/1/hi/scotland/
   edingburgh_and_east/6986554.stm; visited September 2007).

                                                                                                                  77
     57 HM Treasury (2004): SR 2004. Public service agreements 2005/2008. (http://www.hm-treasury.gov.uk/
        spending_review/spend_sr04/psa/spend_sr04_psaindex.cfm, visited Mach 2008).
     58 Raw M, Mc Neill A, Coleman T (2005): Lessons from the English smoking treatment services. Addiction
        100 (supplement 2): 84-91.
     59 The Information Centre for Health and Social Care (2003-2007): Statistics on NHS stop smoking services
        in England. (http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/nhs-stop-smoking-
        services; visited January 2008).
     60 Milne E (2005): NHS smoking cessation services and smoking prevalence: Observational study. British
        Medical Journal 330: 760.
     61 West R (2006): Background smoking cessation rates in England. (http://www.aspsilverbackwebsites.co.uk/
        smokinginengland/ref/paper2.pdf; visited May 2008).
     62 Goddard E (2006): Smoking and drinking among adults 2005, General household survey 2005. Office for
        National Statistics, London, November 2006.
     63 National Cancer Institute: Statistical Research and applications. Joinpoint regression program. Version
        3.0, April 2005. (http://srab.cancer.gov/joinpoint/; visited June 2008).
     64 Estève J, Benhaumou E, Croasdale M, Raymond L (1990) Relative survival and the estimation of net
        survival: elements for further discussion. Stat Med 9: 529-539.
     65 Coleman MP, Babb P, Damiecki P, Grosclaude P, Honjo S, Jones J, KnererG, Pitard A, Quinn MJ, Sloggett
        A, De Stavola BL (1999). Cancer survival Trends in England and Wales 1971-1995: Deprivation and NHS
        Region, Series SMPS No. 61. London: The Stationary Office.
     66 StataCorp. STATA statistical software (8.2). 2001. Stata Corporation: College Station TX.




78
North West Cancer Intelligence Service (NWCIS)
                             Information Requests:
                                      Liverpool Office
                         2nd Floor, Muspratt Building
                               University of Liverpool
                                             Liverpool
                                             L69 3GB
             Tel: 0151 794 5691 Fax: 0151 794 5700
                            Email: info@nwcis.nhs.uk

                                   General Enquiries:
                                     Manchester Office
                       Centre for Cancer Epidemiology
                Christie Hospital NHS Foundation Trust
                                        Kinnaird Road
                                          Manchester
                                             M20 4QL
             Tel: 0161 446 8080 Fax: 0161 446 3590
                             Email: info@nwcis.nhs.uk
                                  www.nwcis.nhs.uk

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:9/21/2012
language:English
pages:88