Around 5 million people live in the East Midlands, but are they all receiving the same standard of cancer detection and treatment? With such a huge population, stretched over five Integrated Care Systems, how do healthcare leaders identify and track inequalities? The Health Economics Unit was asked to help the East Midlands Cancer Alliance identify opportunities to improve cancer detection, treatment, and outcomes across the region.

The East Midlands Cancer Alliance (EMCA) aims to improve outcomes for cancer patients across the East Midlands. This area includes five Integrated Care Systems or Boards (ICSs/ICBs):  Lincolnshire, Leicester, Leicestershire and Rutland, Derby and Derbyshire, Northamptonshire and Nottingham and Nottinghamshire.

The Health Economics Unit (HEU) was commissioned by the EMCA to evaluate inequalities in colorectal cancer care across the East Midlands.

Using patient-level data to understand cancer pathways

Historical patient-level data (NHS Cancer Waiting Times dataset, NHS Secondary Uses Service dataset, the Emergency Care Services Dataset, and the Office for National Statistics Mortality dataset) covering a 6-year period was analysed as part of a health inequality assessment of colorectal cancer care pathways in the East Midlands.

To support the patient-level data, the HEU team used integrated care system-level data on colorectal cancer screening (covering a 10-year period), as well as reference data.

To be included in the analysis, patients must have been living in the East Midlands and diagnosed with colorectal cancer (based on ICD-10 codes). ​

Data related to community care, GP appointments, medication use, symptom management, and end-of-life care were excluded due to insufficient data availability.

To identify specific drivers of inequality (demographics, risk factors and sub-conditions) the HEU analysts compared data for the East Midlands to the national average for England. Metrics were normalised to reflect inequities in access, diagnosis, treatment, and outcomes driven by population, age, and gender differences.

The team investigated key metrics such as, screening, waiting times, diagnosis, treatment, and outcomes (survival, quality of life, and emergency attendances).

Understanding inequalities compared to national levels

Based on the HEU’s findings, it was clear that there are differences in the provision of colorectal cancer care across the East Midlands when compared to the rest of England.

Overall, there were fewer referrals under the 2-week wait priority and from GPs in the East Midlands compared to the rest of England. However, urgent referrals were higher in the East Midlands compared to the rest of England, particularly in more deprived areas such as in Derby and Derbyshire and Nottingham and Nottinghamshire. This highlights clear differences in the early stages of the care pathway. Further research is needed to improve early detection rates.

​Historically, screening coverage in the East Midlands has been marginally higher than in the rest of England. In our analysis, screening varied across the East Midlands with Leicester, Leicestershire and Rutland ICS having the lowest coverage but the highest rates of referral.

In terms of diagnosis, there were 9,251 cases of colorectal cancer in the East Midlands (8.5% of all cases in England). Lincolnshire ICS had a high number of patients diagnosed with colorectal cancer compared to other ICSs and England.

Leicester, Leicestershire, and Rutland ICS had a higher proportion of Stage 4 diagnoses than the rest of England, indicating a later-stage diagnosis for many patients.

The East Midlands was below the national average in England for the 31-day and
62-day targets for starting cancer treatment. Further research looking at the factors contributing to these delays is needed.

A higher proportion of patients required non-specialist palliative care and chemoradiotherapy in the East Midlands compared to the rest of England. This suggests that patients are entering the system later, with more advanced cancers requiring more intensive treatments or
end-of-life care compared to other areas.

​There was a higher proportion of white British individuals being diagnosed with colorectal cancer compared to the national average. This may either reflect better data recording in the East Midlands or a genuine demographic difference in the population.

​​There was some variation between ICSs in terms of survival; the East Midlands had marginally lower survival rates than in the rest of England. Overall, Derby and Derbyshire ICS had the worse 1-year, 5-year, and 10-year survival rates of all ICSs. ​

There was some variation in quality of life (QoL), particularly for people living in the most deprived areas and patients diagnosed with Stage 4 cancer. Lincolnshire ICS QoL scores were lower than other ICSs and the rest of England. In contrast, Northamptonshire QoL scores were higher than for the other ICSs.

Identifying areas for improvement

This project showed that differences due to geographic, demographic and healthcare system factors are affecting cancer care in the East Midlands.

Further research to understand and address these disparities will be important for improving the quality of colorectal cancer care across the East Midlands.

While there have been some successes in colorectal cancer care across the East Midlands, there remain opportunities to enhance early detection, reduce waiting times (for diagnosis/treatment), and improve outcomes.

By addressing inequalities, we can drive better colorectal cancer care outcomes for the people of the East Midlands.

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