Major Diseases and Causes of Death (Public Health, State of the South West 2011)

8.10.1.1 The National Centre for Health Outcomes Development (NCHOD) uses the standardised mortality ratio (SMR) to compare mortality within an aggregated three-year time period (2006–08) and across sub-populations: these are used in Table 8.10.2.1. England is used as the reference (index) population and consequently the SMR for England is always 100. If an SMR in one of the comparison (study) populations is below 100, then the study population has a lower rate of mortality, for a given cause of death than England as a whole.

8.10.1.2 Confidence intervals CIs provide information regarding the precision of estimated values since they take into account the variability of the SMR estimate. The narrower the confidence interval, the greater the degree of precision of the SMR estimate. Using 'accidents', and 'bronchitis and emphysema' as examples, if the ranges of the CI values, respectively 93–99 or 103–123 of the study populations, shown in Table 8.10.2.1, do not include 100, then the SMRs for those study populations can be considered significantly different (statistically) to those of England. An SMR is significantly higher than that of England if both lower and upper values of the CI of the study population are above 100, and significantly lower if both are below 100.

8.10.2.1 The ‘all cause’ mortality rate in the South West (Table 8.10.2.1) during the combined period 2006–08 was significantly lower than the average for England. However, there were variations within the South West. For example, Bristol Primary Care Trust (PCT) had rates significantly higher than those of England, whilst Somerset PCT had significantly lower rates (source: NCHOD).

Table 8.10.2.1 Number of deaths and age-standardised mortality ratios (SMRs) for selected
causes of death in the South West

Cause of death	Number of deaths aged 1+ in 2008	Age-Standardised Mortality Ratio (England = 100, 2006-08 pooled)	Confidence interval	Comparison to England
All causes	53,168	92	92-93	Lower
Circulatory	18,083	93	92-94	Lower
All Cancers	14,467	94	93-95	Lower
Accidents	1,228	96	93-99	Lower
Asthma	89	81	71-91	Lower
Bronchitis and Emphysema	196	113	103-123	Higher
Suicide and injury undetermined	442	104	98-109	Similar
Land transport accidents	274	106	99-114	Similar
Malignant Melanoma	245	129	120-139	Higher
Prostate Cancer	1,137	103	100-107	Similar
Source: Number of Deaths (aged 1+): 2008; SMRs: 2006-08 pooled, NCHOD

8.10.2.2 During the 1990s "There was a clear socioeconomic gradient in ‘all cause’ mortality for all countries of the United Kingdom and regions of England, with mortality increasing between Social Class I [professional occupations] and V [unskilled occupations]." (source: ONS Decennial Supplement DS16 Chapter 12).

8.10.2.3 The ONS publication Social Inequalities in Female Mortality by Region and by Selected Causes of Death, England and Wales 2001–03 shows a marked socioeconomic gradient, with those in the most deprived social class experiencing higher rates of mortality. There is little, if any, statistically significant difference in the gradient (Figure 2 of the ONS publication) however, when comparing Wales or the different sub-national areas to England and Wales as a whole. Figure 3, in contrast, shows that "most mortality rates in the South West are statistically significantly lower than the corresponding NS-SEC class rates for England and Wales." (source: Social Inequalities in Female Mortality by Region and by Selected Causes of Death, England and Wales 2001–03, p.9).

8.10.2.4 Age-standardised mortality rates by socioeconomic classification in the North East and South West, for men aged 25–64 during the period 2001–2003, may be found on page 44 of Fair Society, Healthy Lives. "Flattening the gradient is the ambition of proportionate universalism and of the recommended policies that we [The Marmot Review] outline in Chapters 4 and 5." (source: Fair Society, Healthy Lives, p.41).

Cancers are a group of diverse diseases which collectively accounted for around 27% of deaths from all causes in the South West in 2008. The mortality rate for all cancers combined in the South West is lower than in England as a whole, but is higher for malignant melanoma skin cancer (Table 8.10.2.1).

Cancers must be tackled on two fronts. The first is to reduce incidence, the number of people developing the disease. The second is to reduce mortality, the number of people dying from the disease. Different cancers are susceptible to different strategies, but it is recognised that giving up smoking is the single most useful strategy for the individual. Healthy eating, limiting sun exposure, and avoiding excessive alcohol consumption can also reduce the risk of cancer. Early detection is key to improving outcomes, so making people aware of the symptoms and encouraging attendance at screening programmes is important.

8.10.4.1 Lung Cancer

8.10.4.1.1 Lung cancer is the third most common cancer for both males and females in the South West (after excluding non-melanoma skin cancer) and equates to more than 3,100 new cases per year between 2004 and 2008. It is the leading cause of cancer deaths for males and the second most common cause of cancer deaths after breast cancer for females in the South West. Lung cancer has a poor prognosis. For people who develop lung cancer, the survival rate in the South West one year after diagnosis is 27.2%, a figure which drops to 8.3% after five years. Because of this, mortality trends closely mirror incidence trends, with more than 2,550 deaths per year between 2004 and 2008 in the South West (source: SWPHO).

8.10.4.1.2 South West male lung cancer incidence and mortality rates are among the lowest in England.

8.10.4.1.3 Incidence rates have decreased for males and increased for females over the last twenty years, while mortality rates have fallen for males and remained relatively stable for females.

8.10.4.1.4 It is projected that, if current national trends in lung cancer incidence continue to apply to the South West rates and demographics, then by 2030 the numbers of cases of lung cancer in males and females in the region will be approximately equal.

8.10.4.1.5 Lung cancer incidence and mortality rates are high in deprived populations of the South West. Rates in the most deprived areas are more than double that of the most affluent areas in the region.

8.10.4.1.6 In the South West, there is steady progress in reducing lung cancer mortality in patients aged under 75. Under-75 lung cancer mortality rates fell from 37.4 to 25.4 per 100,000 between 1996 and 2008 for males, but showed only a slight (though not statistically significant) decrease in females from 15.7 to 15.3 per 100,000 females.

8.10.4.1.7 This reduction in lung cancer mortality in males has not contributed to narrowing the inequalities between the most and least deprived populations in the South West, which have remained constant. The widening trend in lung cancer mortality between the most and least deprived populations in females has contributed to widening health inequalities among females in the South West.

8.10.4.1.8 The only way that significant impacts will be made on lung cancer incidence and mortality will be through reducing smoking prevalence in the population. There is a strong need to increase efforts to tackle the inequality gaps in smoking between the most and least deprived sections of the population.

8.10.4.2 Skin Cancer

8.10.4.2.1 Exposure to ultra-violet (UV) light is generally recognised as a risk factor associated with the development of skin cancer. Skin cancer is the most common form of cancer, and there are two main types: malignant melanoma and non-melanoma skin cancer. Malignant melanoma is the most serious type. Non-melanoma is rarely fatal and can be treated easily, but it is very common and can cause disfigurement.

8.10.4.2.2 The South West has the highest incidence of, and mortality from, malignant melanoma in the UK. It also has the highest incidence of non-melanoma skin cancer. Incidence rates for both types of skin cancer for males and females are rising. Mortality rates from malignant melanoma are rising for males. However, five-year relative survival rates from malignant melanoma showed no statistically significant difference between the South West and England for both males and females diagnosed in 2001–03. The survival rate for males was 81.7% in the South West and 82.7% in England, while for females the rates were 91% in the South West and 90.5% in England (source: UK Cancer Intelligence Service (UKCIS)).

8.10.4.2.3 The South West is one of the sunniest parts of the UK, and approximately a quarter of its population are beyond retirement age. People who enjoy spending time in the sun are believed to preferentially retire to coastal parts of the South West. This may result in a concentration of elderly people with a long history of UV exposure along the South West coast. Research by the SWPHO examining the geographic distribution of melanoma cases has shown that the incidence of melanoma is significantly higher on the South West coast, particularly in more rural regions.

8.10.4.2.4 Along with older people with a history of high sun exposure, melanoma also affects younger age-groups more than most other cancers. Deaths from melanoma – of which there were 245 in the South West in 2008 (Table
8.10.2.1) – are almost entirely preventable. Prevention and early diagnosis are possible either by taking precautions against exposure to excess UV or by seeking advice at the earliest opportunity about suspicious skin lesions. UV radiation was recently classified as a carcinogen category 1 (IARC 2009) and therefore sunbed use by younger people should be discouraged. In April 2010 the Sunbed (Regulation) Act was passed, which will come into force in April 2011, prohibiting the use of sunbeds by under 18s.

8.10.4.2.5 In 2010 the SWPHO undertook two research projects which aimed to: (i) describe current sun protection policy and practice in schools; and (ii) explore pupils’ sun protective knowledge attitudes and behaviour. The findings highlighted the lack of consistent policy and practice in schools in the South West, and it is hoped will contribute to the development of national policy and guidance. Some of the key findings from these projects are highlighted in the following two paragraphs.

8.10.4.2.6 Forty one percent of schools had either a dedicated sun protection policy or a section on sun protection in the general health and safety policy, while 35% had no policy and no plans to develop one. In addition, most schools (65%) do not provide sunscreen, but encourage their pupils to bring their own. Hat wearing was enforced in 17% of schools. A small number of schools had undertaken a shade assessment (8%).

8.10.4.2.7 The pupil questionnaire highlighted low protective behaviours being adopted by pupils. Many pupils reported never bringing sun protective items to school: sunscreen (48%), sunhats (34%) and sunglasses (61%). Under two-thirds (60%) apply sunscreen before going to school. Those most exposed in the school environment are the ‘physically active’ (23%), who play all lunchtime without seeking shade.

8.10.4.3 Prostate Cancer

Figure 8.10.4.3.1 Incidence and mortality for prostate cancer (directly age-standardised rate
per 100,000 males) in the South West, 1995 - 2008

[ Zoom ]

Incidence and mortality for prostate cancer (directly age-standardised rate per 100,000 males) in the South West, 1995 - 2008 (Fig 8.10.4.3.1). Source: National Cancer Information Service.

8.10.4.3.1 Prostate cancer is the second most common cancer in men. The most common is non-melanoma skin cancer, but this is rarely fatal. In 2008 there were 3,920 new cases of prostate cancer in the South West. This is equivalent to an age-standardised rate of 104 per 100,000 men (Figure 8.10.4.3.1). In 2008, the South West had the equal highest rate in England.

8.10.4.3.2 The age-standardised mortality rate from prostate cancer in the South West in 2008, 25 per 100,000 men, was the equal highest in England. This rate is steadily declining (Figure 8.10.4.3.1).

8.10.4.3.3 The sharp increase in incidence of prostate cancer evident from 1999 onwards is likely to be due to an increased uptake of Prostate Specific Antigen (PSA) testing, which detects asymptomatic prostate tumours.

8.10.4.3.4 Radical prostatectomy is the complete removal of the prostate and its surrounding capsule. It is an effective treatment in terms of added years of life, but can cause unpleasant side-effects. In 2002 the National Institute for Health and Clinical Excellence (NICE) published guidelines to improve the treatment of men with prostate cancer. It recommended that the treatment of patients be managed by multi-disciplinary teams incorporating surgeons, oncologists, radiologists and others, to ensure the best treatment for each patient.

8.10.4.3.5 Consistent with the publication of the guidance was a reduction in the numbers and rates of radical prostatectomies for men diagnosed in 2005, 2006 and 2007 compared to men diagnosed in 2004 (Figure 8.10.4.3.2). This could be the result of multi-disciplinary teams being more likely to recommend treatments other than surgery, compared to cases handled by surgeons alone, or of better informed consent. The 2002 guidelines also emphasised the option to postpone or forgo treatment, known as ‘Active Monitoring’ or ‘Watchful Waiting’, which may have caused a number of men to delay treatment until it was thought necessary. This would have the effect of temporarily reducing numbers in the short-term, with an associated rise in numbers of radical prostatectomies later.

Figure 8.10.4.3.2 Radical prostectomies for prostate cancer, total numbers and as a percentage
of all new patients diagnosed, by year of diagnosis, in the South West, 1997 - 2007

[ Zoom ]

Radical prostectomies for prostate cancer, total numbers and as a percentage of all new patients diagnosed, by year of diagnosis, in the South West, 1997 - 2007 (Fig 8.10.4.3.2). Source: National Cancer Information Service.