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Introduction to Cancer JSNA for Cheshire and Merseyside (2021)

Cancer is a leading public health challenge – a condition that in all its forms (and there are over 200 different kinds of cancer), is likely to affect one in two during their lifetime. Over 40% of cancers are thought to be preventable however, so working with partners across the system to tackle inequalities, improve screening rates, increase awareness among the public of signs and symptoms (which in turn can improve earlier diagnosis and more effective treatment) and reduce the impact of the major risk factors such as smoking, obesity and alcohol, is crucial.

  • The COVID-19 pandemic has presented the NHS with perhaps its most challenging period in its 73 year history. Clinical and non-clinical healthcare professionals have gone to extraordinary lengths to maintain cancer services in Cheshire and Merseyside throughout the crisis.  

  • At the start of the pandemic the number of people seeking advice from their GP regarding symptoms that could be cancer, and hence the number of urgent suspected cancer referrals to hospitals, fell dramatically. Referrals were lower than expected between April and September 2020 but have since recovered and are now approximately 20% greater in number each week than before the pandemic.

  • This is positive because it means that the public’s confidence to seek medical advice from their GP about potential signs of cancer has, in general, been restored. However, there are some differences at tumour level. Referrals for suspected urological cancers (primarily suspected prostate cancer), suspected lung cancers and suspected haematological (blood) cancers remain lower than expected. 

  • Although referral rates have, in most cases, returned to at least pre-pandemic levels, the impact of the dramatic fall in referrals at the beginning of the crisis means that the total number of referrals received in the year from April 2020 to March 2021 was 8% lower than the previous 12 month period (i.e. the year before the pandemic).

  • The biggest shortfalls are in the tumour groups that still have not returned to normal referral levels, i.e. urological, lung and haematology and, to a lesser degree, skin (although skin referrals are now 28% higher than pre-COVID-19). Whilst 8% is the average shortfall in referrals in 2020/21 compared to 2019/20 across Cheshire and Merseyside

Key Messages

  • Smoking rates in Cheshire and Merseyside have fallen substantially and are now similar to England, but Halton, Knowsley and Liverpool Local Authorities have the highest rates in Cheshire and Merseyside  

  • However, successful smoking quit rates in all Local Authorities in Cheshire and Merseyside – except Cheshire East and Warrington – are higher than in England 

  • Of concern is the widening inequality in smoking behaviour, both nationally and locally. In some of our boroughs, residents are four times as likely to smoke if they are in routine and manual occupations, compared to those in managerial and professional occupations 

  • Smoking during pregnancy remains a significant issue. Even through smoking prevalence amongst pregnant women has fallen, rates generally are higher in Cheshire and Merseyside  than the England average 

  • 2019/20 data illustrates that between 43.8% and 55% of adults in Cheshire and Merseyside local authorities eat the recommended five or more daily portions of fruit and vegetables, compared with 51.2% in the North-West and 55.4% in England. Overall, there has been a slight decline in most recent years, between 2015/16 and 2019/20, both locally as well as regionally and nationally 

  • Data from the National Childhood Measurement Programme shows that Cheshire and Merseyside had a significantly higher prevalence of excess weight than England in both Reception-age children and in those in Year 6 in 2019/20. Overweight children and adolescents are around 5 times more likely to become obese adults than those who their non-obese peers. 

  • 2018/19 data shows between 64.9% - 73.7% of adults (aged 18+) are overweight or obese.  Rates are statistically significantly higher than the England average in Knowsley, Halton, St Helens, and Liverpool.  The other boroughs are statistically similar even though the England rate is lower than any of the Cheshire and Merseyside boroughs (62.3%) 

  • Only Cheshire East and Cheshire West & Chester have a higher percentage of adults who are physically active compared to the England average 

  • The rate of hospital admissions related to alcohol is high in Cheshire and Merseyside compared to England. For most local authorities it is statistically significantly higher 

  • Cervical screening declined during the course of the pandemic in both cohorts eligible (those aged 25-49 and 50-64); over the longer time period provided in this report however, (since 2017/18), coverage had increased in younger women in Cheshire and Merseyside overall 

  • Cervical screening was higher in the older cohort (50-64) compared to younger women (25-49); Liverpool CCG had the lowest coverage of all CCGs in Cheshire and Merseyside and also showed the largest declines over the time period shown (in both age cohorts) 

  • In 2019/20, more than two in three of all females in Cheshire and Merseyside eligible for breast screening (aged 50-71 were screened for breast cancer (70.5% coverage rate), just exceeding the 70% target 

  • Data from during the pandemic however (Quarter 3 of 2020/21) shows that compared to the same quarter the year before, breast screening coverage in Cheshire and Merseyside fell by just over 11% (all CCGs decreased) 

  • The proportion of people screened for bowel cancer in Cheshire and Merseyside between 2009/10 and 2019/20 improved; overall the national target of 60% coverage was exceeded in Cheshire and Merseyside (although coverage was still lower than the England average) 

  • Bowel screening coverage fell in Cheshire and Merseyside during the pandemic by just under 5% with all CCGs showing a decrease 

  • There are inequalities in screening uptake for those with severe mental illness (SMI) and those with learning disabilities (LD) compared to those without those conditions.  For people with LD the difference is most marked for cervical screening, remains for breast screening but is nearly identical or in some areas better for bowel screening compared to those with no LD 

  • Cancer incidence (newly diagnosed) rates are higher among men than women 

  • Newly diagnosed cancer rates are higher in nearly all local authorities in Cheshire and Merseyside than England 

  • Cancer incidence in Cheshire and Merseyside, as with England, have increased steadily in the last 2 decades 

  • A greater number of cancers in Cheshire and Merseyside are in the most deprived areas 

  • The majority of cancer in Cheshire and Merseyside are diagnosed early (stage 1 or 2) 

  • There are more women living with cancer than men, with the majority aged 45 and older 

  • There was a higher prevalence of diagnosed cancers in Cheshire and Merseyside compared to England overall in 2020/21 (3.21% in England compared to 3.62% in Cheshire and Merseyside)  

  • Prevalence has risen in Cheshire and Merseyside in recent years, from 3.40% in 2018-19, to 3.55% in 2019-20, to 3.62% in 2020/21 (prevalence has also risen in England, from 2.98% in 2018-19 to 3.13% in 2019-20, and then 3.21% in 2020/21) 

  • The majority of cancers are diagnosed through ‘managed routes’ (e.g., urgent GP referrals) 

  • Around 1 in 5 cancers were diagnosed via emergency presentations and relatively few via screening 

  • Cheshire and Merseyside has lower bowel, similar breast, and higher cervical screening rates than England (Halton, Knowsley and Liverpool CCGs broadly had the lowest screening rates in Cheshire and Merseyside) 

  • Cheshire and Merseyside continue to have a lower proportion of cancers diagnosed early than England 

  • Colonoscopy procedures increased between 2009/10 and 2019/20 (by 69% in Cheshire and Merseyside, versus 49% increase in England) and the majority Cheshire and Merseyside  CCGs had higher rates than the England average (only NHS Warrington CCG and NHS Liverpool CCG were lower) 

  • All but one Cheshire and Merseyside CCG (NHS Liverpool) had rates of sigmoidoscopy higher than the England average; Cheshire and Merseyside overall had rates higher than England and there was an 18% increase in sigmoidoscopy procedures in Cheshire and Merseyside between 2009/10 and 2019/20 (vs a 45% increase in England overall) 

  • The rate of in-patient or day-case upper GI endoscopy procedures in Cheshire and Merseyside overall was significantly higher than that of England in 2019/20 

  • All but one Cheshire and Merseyside  CCG improved the rate of In-patient or day-case upper GI endoscopy procedures between 2009/10 to 2019/20; the overall Cheshire and Merseyside  rate improved by 21% (22% in England) although it should be noted that improvements appear to have levelled off since 2015/16 (reasons for this are unclear) 

  • Between 2013 and 2018, Cheshire and Merseyside had a lower proportion of cancers diagnosed at an early stage (1 and 2) compared to England 

  • Cheshire and Merseyside showed a very similar picture to England overall in the proportion of treatment combinations for cancer between 2013-16; around a third of people received ‘Other Care’ in both England and Cheshire and Merseyside, while the next most common treatment option was ‘Tumour Resection’ (around 1 in 5 patients in both England and Cheshire and Merseyside had this treatment)  

New Cancer Diagnoses 

  • There was a fairly consistent number of estimated new cancer diagnoses recorded in the rapid cancer registrations dataset in the pre-COVID-19 period up to March 2020, for England and Cheshire and Merseyside 

  • Following the arrival of COVID-19, the estimated number of new cancer diagnoses per month dropped, to around 64% of the pre-COVID numbers for England and 60% of the pre-COVID numbers for Cheshire and Merseyside 

  • For June 2020 onwards, the estimated number of new cancer diagnoses increased again from their lowest levels for all cancer groups and by September 2020, the estimated number of diagnoses had reached 95% (for both England and Cheshire and Merseyside) of previous activity for all malignant cancers, excluding NMSC 

  • For all malignant cancers excluding NMSC, the pattern and size of changes in new cancer diagnoses were similar for most demographic factors, including for both men and women and for all income deprivation quintiles (refers to England level data only)  

Surgical tumour resection activity 

  • There was a reasonably consistent number of surgical tumour resection procedures before the arrival of COVID-19 

  • Following the arrival of COVID-19, surgical tumour resection activity was much lower than usual for all cancer groups 

  • The number of surgical tumour resection procedures per month subsequently decreased to around two-thirds of the previous activity for April to May 2020 for all included malignant cancers, to around 67% of the pre-COVID numbers for England and 65% of the pre-COVID numbers for Cheshire and Merseyside 

  • Since May 2020, surgical tumour resection activity increased for most cancer groups and by December 2020, had reached 91% of previous activity for England and 99% of previous activity for Cheshire and Merseyside for all cancer sites combined (some cancer groups had a higher proportion of previous activity for September or October) 

  • For all malignant cancers excluding NMSC, the pattern and size of changes in surgical tumour resection activity for all included malignant cancers were similar for most demographic factors (refers to England level data only) 

Treatment proportions

  • For diagnoses with complete follow-up between January 2018 and February 2021, around 36-39% of all malignant cancers excluding NMSC were recorded as receiving a tumour resection, around 28-31% chemotherapy and 26-28% radiotherapy at England level. Very similar proportions were seen at a Cheshire and Merseyside level with around 36-45% of all malignant cancers recorded as receiving a tumour resection, 26-34% chemotherapy and 25-31% radiotherapy 

  • For patients diagnosed between December 2019 and March 2020, there was a decrease in the proportion recorded as receiving chemotherapy with an increase for those diagnosed between April and June 2020. A similar pattern was seen for this period for most cancer groups

  • For all malignant cancers excluding NMSC and patients diagnosed in 2020, there was a steady decline in the proportion of patients recorded as receiving radiotherapy due to the current availability of follow-up data

  • There were similar changes to the patterns of treatment proportions by many demographic factors, including for men and women, for all deprivation quintiles and for all ethnicities (refers to England level data only) 



  • The gap in survival from cancer between England and Cheshire & Merseyside narrowed considerably between 2003 and 2018 (England historically had higher survival rates compared to Cheshire and Merseyside) 

  • In fact, in the case of 1 year survival, improvements in Cheshire and Merseyside mean survival rates are now in excess of England (as of 2018) 

  • Survival from all cancers in Cheshire and Merseyside improved drastically between 2003 and 2018: 

    • Around 75% of people survived at least 1 year beyond diagnosis 

    • More than 50% survived beyond 5 years beyond diagnosis 

    • More than 40% survived over 10 years beyond diagnosis 

  • Although 1 year survival has improved between 2003 and 2018 (15% improvement in Cheshire & Merseyside overall, compared to 10% improvement in England) in all local CCG areas; it was still however, lower in the more deprived local authorities of Cheshire and Merseyside (e.g., Liverpool, Knowsley and Halton) 

Palliative Care 

  • There were just over 15,000 (or 0.6% of the population of the Cheshire and Merseyside area) on GP palliative care registers in 2021; similar to national prevalence (0.5%) 

  • Those areas with higher prevalence of older people had the highest prevalence of people on palliative care registers (e.g., Southport & Formby CCG, Wirral CCG) 

  • Around 1 in 3 of people dying with cancer in Cheshire and Merseyside are died at home in 2016-18, slightly higher than England 

  • Recent research indicates there was public avoidance of hospital care for non-COVID-19 conditions, such as cancer during the pandemic and that this resulted in an increase in deaths at home and a reduction in hospital deaths in cancer patients 

  • The rate of deaths at home from cancer in Cheshire and Merseyside varied by Local Authority and gender (e.g., highest in Knowsley at 38.6%, lowest in Liverpool at 29.5% for menhighest in Knowsley at 38.4% and lowest in Cheshire East 27.9% for women) 

  • Avoidable mortality from cancer (deaths among those aged <75) fell all Cheshire and Merseyside Local Authorities between 2001-2003 to 2017-19 

  • Rates of avoidable mortality from all cancers were consistently higher in the more deprived areas of Merseyside, compared to those in Cheshire 

  • Rates of avoidable mortality from breast, colorectal and lung cancer mortality were also consistently higher in the more deprived areas of Merseyside, compared to those in Cheshire 

Previous content

Key findings (Published July 2015)

(Important please note: read this section in conjunction with the Wirral Right Care pack for Cancer (May 2016) 

  • 1 in 3 people will develop some form of cancer in their lifetime

  • Cancer causes 1 in 4 deaths every year in Wirral

  • Lung cancer continues to be the most common cause of death in both males and females in Wirral. Death rates in males were 20% higher than the national average and in females, they were 30% higher. Smoking is the main risk factor for lung cancer

  • The economic cost of cancer has been estimated at £15.8bn for the UK, which would equate to around £93.5million per annum for Wirral

  • In Wirral breast, lung, bowel and prostate cancer account for half of all new cancers diagnosed

  • The two most commonly diagnosed cancers in Wirral are prostate and lung (in men) and breast and lung (in women)

  • Breast cancer incidence has increased by 40% since 1993. New cases of lung cancer in woman are continuing to rise, with rates 30% higher in Wirral than the national average

  • Rates of lung cancer in men are showing signs of improvement with a 25% reduction in new cases since 1993. However cases diagnosed via emergency presentation are a third higher in Wirral than the national average

  • Historical data on cancer deaths for the EU region (1970-2009)  predicted the numbers of deaths in women from lung cancer will continue to increase and it may become the most common cancer amongst women by 2040

  • Deaths in those aged under 75 years from cancer (classed as premature mortality) have reduced by more than a third (36%) since 1993 (up to 2012)

  • Deaths from breast cancer accounted for 14% of all Wirral cancer deaths in 2012

  • More than two in three people diagnosed with cancer survive beyond the first year after diagnosis

  • Almost half (46%) of all people diagnosed with cancer now survive for at least 5 years and 92% rated their cancer care as either excellent or very good

  • Wirral’s breast screening coverage is slightly higher than the national average at 77% in 12/13

  • Bowel screening uptake is 53%% within the Merseyside & North Cheshire Screening Centre (M&NCSC) area (2012/13). The national target is 60%

  • Cervical screening coverage was better in older women (50-64) compared to younger women in Wirral in 2010/11 

Cancer JSNA (July 2015)

  • National Cancer Intelligence Network Cancer and equality groups (2015)
    This third edition key metrics report builds on previous reports to give a picture of differences between groups in diagnosis, care and outcomes. Although there have been gains in cancer survival, the report highlights stark health inequalities in cancer.

  • Geographic Patterns of Cancer Survival in England, Adults diagnosed 2004 to 2008 and followed up to 2013 - Office for National Statistics (May 2015) 
    (Overview) (Data)
    This release highlighted some Cancer survival statistics in Cheshire, Warrington & Wirral Local Area Team for colon cancer that were below the England average.