all cancer jsna - kingston...
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All Cancer JSNA November 2016
Overview There are more than 200 types of cancer, each with different causes, symptoms and
treatments. Although survival is improving, more than a quarter of deaths in the UK are
caused by cancer. An individual's risk of developing cancer depends on many factors,
including age, lifestyle and genetic make-up. Some of these factors can be changed to
reduce the chance that someone develops cancer. The single most important thing someone
can do to reduce their chance of getting cancer is to stop smoking.
According to the latest data, around one in 70 people in Kingston are living with cancer. On
average more than 12 people a week are diagnosed with cancer in Kingston. Men are
slightly more likely to develop, and die from, cancer than women. The number of people
diagnosed with cancer is going up over time; however the death rate is falling. This is likely
to be related to earlier detection and better treatment.
Prostate cancer is the most common type of cancer in men in Kingston, while breast
cancer is the most common type in women. Lung cancer is relatively common in both men
and women, and because survival with the disease is low, it is Kingston’s biggest cancer
killer.
The earlier that cancer is detected, the better chance a patient has of a cure. Survival rates
in the UK are lower than other countries in Europe, so we know that there is definite potential
to improve our cancer services. Education campaigns to encourage patients to see their
doctor with the very first signs of cancer are underway and there are currently three NHS
cancer screening programmes (breast cancer screening, cervical cancer
screening and bowel cancer screening). Excellent cancer care requires that community
health providers and hospital team’s work together to ensure that patients with cancer are
tested, diagnosed and given appropriate treatment for their disease as quickly as possible.
Introduction Cancer is not just one disease but a group of conditions. In fact there are more than
200 types of cancer, each with different causes, symptoms and treatments. Cancer
is important because these diseases when grouped together are a large cause of
disability and death. More than 331,000 people were diagnosed with cancer in 2011
in the UK, one person every two minutes.
More than one in three people in the UK will develop some form of cancer
during their lifetime
Cancer survival rates in the UK have doubled in the last 40 years
Half of people diagnosed with cancer now survive their disease for at least ten
years
However, more than a quarter of deaths in the UK (29%) were caused by
cancer in 20111.
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Risk factors
An individual's risk of developing cancer depends on many factors, including age,
lifestyle and genetic make-up.
More than 40% of all cancers in the UK are linked to tobacco, alcohol, diet,
being overweight, inactivity, infection, radiation, occupation, post-menopausal
hormones, or breastfeeding for less than six months1
Cigarette smoking is the single most important cause of preventable death in
the UK1.
Key drivers for change
Improving results for cancer patients and reducing the number of cancer deaths was
the focus of the Department of Health Cancer Strategy 20112. Several indicators
related to cancer are available to assess performance at a national and local level
within the NHS3, The Public Health Outcomes Framework 2013 and the Clinical
Commissioning Group Outcomes Indicator Set4.
The Five-Year Cancer Commissioning Strategy For London states cancer as a
commissioning priority because of:
variation in outcomes across the capital
poor reported patient experience
survival times which lag behind our European counterparts.
1Cancer Research UK. All cancers combined key facts . 2014 . Available
from http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/Allcancerscombined/
2 Department of Health. Improving outcomes: a strategy for cancer. London: Department of Health; 2011.
Available
fromhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213785/dh_123394.pdf
3 Department of Health. NHS Outcomes Framework;Available
from: https://www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015. Accessed 21-Apr-14
4NHS England. CCG Outcomes Indicator Set 2014/15-at a glance. NHS England. December 2013. Available
from http://www.england.nhs.uk/wp-content/uploads/2013/12/ccg-ois-1415-at-a-glance.pdf
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Local Picture
People diagnosed with cancer (incidence)
Between 2009 and 2011, 1,924 people were diagnosed with cancer in Kingston. 932 were
female (48.4%) and 992 were male (51.6%)1.
This is an average of 641 people a year or more than 12 a week
The rate in Kingston is similar to the rate in the rest of London, however it is lower
than the rate in England overall
The variation seen may be due to a number of complex and interrelated differences
between London and the rest of the country. These may include lifestyle, socio-
economic, genetic, occupational, environmental and healthcare factors.
People living with cancer (prevalence)
In the latest available data 1.4% of the Kingston population (2,701 people) were registered
to be living with cancer 2.
This is similar to the proportion in London of 1.4%
This is lower than the proportion in England of 1.9%. The difference is probably
connected with the lower incidence of cancer (see above) and the generally younger
population in Kingston compared to England overall.
Deaths from cancer (mortality)
Between 2010 and 2012 cancers caused a total of 816 deaths in Kingston3. 375 of these
people were under 75 years 4 and 195 under 65 years5 meaning cancer is a major cause of
premature death.
Men are significantly more likely to die of cancer than women. This is true in Kingston
and across the country
The death rate is lower in Kingston than in London and England.
Types of Cancer
Table 1 - Percentage of cancer incidence by cancer site
Site 2008-2012
Urology 21.8%
Breast 17.1%
Lower Gastro-Intestinal 13.4%
Lung 11.3%
Haematology 9.5%
Upper Gastro-Intestinal 8.3%
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Gynae 5.2%
Skin 4.1%
Head and neck 2.7%
Other 2.6%
Brain/Central Nervous System 1.7%
Endocrine 1.2%
Sarcoma 0.9%
All sites 100%
Table 2 - Percentage of cancer mortality by cancer site
Site 2008-2012
Lung 21.8%
Upper Gastro-Intestinal 14.7%
Urology 14.1%
Lower Gastro-Intestinal 12.6%
Haematology 8.6%
Breast 8.2%
Other 8.2%
Gynae 5.1%
Brain/Central Nervous System 2.2%
Head and Neck 1.9%
Skin 1.7%
Sarcoma 0.4%
Endocrine 0.3%
All sites 100%
Trends over time
Trend data (see figures 1 and 2) show that incidence (new diagnosis rate) of cancer is slowly
rising in England and London, while mortality (death rate) is falling.
Generally Kingston is following these regional and national trends.
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Figure 1 - Incidence of All Cancer 1993-20116
Figure 2 - Mortalities of All Cancer 1993-20127
There are likely to be several reasons for the falling rate of deaths from cancer
despite more cancers being diagnosed, and these would include earlier detection
and better treatment
The trends seen above are an average for all cancers together. However it is
important to note that the picture is not the same for each type of cancer.
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Figures 3 and 4 show the percentage change in mortality for the top 20 commonest causes
in cancer death in both men and women in the UK.
The most striking feature of the figures for both men and women is the rise in deaths
from liver cancer. The chance of developing liver cancer is related to several factors
linked to lifestyle e.g. sexual behaviour, use of substances (both of which can be
associated with Hepatitis B or C infection), as well as long term alcohol consumption
and smoking.
Figure 3 - Percentage change in European age standardised mortality rates for UK
males 2000-2002 to 2009-20118
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Figure 4 - Percentage change in European age standardised mortality rates for UK
females 2000-2002 to 2009-20118
Survival with Cancer
Cancer survival rates in the UK have doubled in the last 40 years. This can generally be
attributed to faster diagnosis and improvements in treatment9.
Table 3 - One year survival10
Kingston London England
69.2% 68.5% 68.2%
One year cancer survival in Kingston is similar to the London and English average
One year survival rates are a good indicator of whether cancer is being diagnosed
early and whether there is access to optimal treatment available
In general one year cancer survival rates lag behind the best in Europe so there is
room for improvement.
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Table 4 - Five year survival10
Kingston London England
Unavailable 47.8% 47.9%
Five year survival is generally slightly high in women than men
Survival rates continue to fall beyond five years after diagnosis for many types of
cancer.
Deaths at home
In the period 2010 to 2012, 22.9% of people who died from cancer in Kingston did so
at their home address - this does not include people who died in communal
establishments11
The rate is similar to London, but lower than the figure in England overall.
1 Health and Social Care Information Centre. Incidence of all cancers: Directly age-standardised registration rates
(DSR), all ages. Period: 2009-2011 (Pooled rates). V11_V1. Dec 2013. 2 Health and Social Care Information Centre. Prevalence: all cancers, all ages. Period: 2012-13. V13_V1. Dec
2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11E_676PC_13_V1_D.xls.
3 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration
rates (DSR), all ages. Period: 2010-2012 (Pooled rates). V11_V1. Dec 2013.
4 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration
rates (DSR), 75 years. Period: 2010-2012 (Pooled rates). V11_V1. Dec
2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11B_075DR0074_12_V1_D.xls.
5 Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration
rates (DSR), 65 years. Period: 2010-2012 (Pooled rates). V11_V1. Dec
2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11B_075DR0064_12_V1_D.xls
6 Health and Social Care Information Centre. Incidence of all cancers: Directly age-standardised registration rates
(DSR), all ages, annual trend. Period: 1993-2011. V12_V1. Dec
2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11A_077DRT00++_11_V1_D.xls.
7Health and Social Care Information Centre. Mortality from all cancers: Directly age-standardised registration
rates (DSR), all ages, annual trend. Period: 1993-2012. V12_V1. Dec 2013.
8 Cancer Research UK. Cancer mortality for common cancers (figures 2.6 and 2.7) . 2014 . Available
from http://www.cancerresearchuk.org/cancer-info/cancerstats/mortality/cancerdeaths/uk-cancer-mortality-
statistics-for-common-cancers
9 Cancer Research UK. Cancer survival statistics. 2014. Available from http://www.cancerresearchuk.org/cancer-
info/cancerstats/survival/
10 Office for National Statistics. A Cancer Survival index for Clinical Commissioning Groups, Adults Diagnosed
1996-2011 and Followed up to 2012. ONS December 2010.
11 Health and Social Care Information Centre. Deaths at home from all cancers: Percent and Indirectly age-
standardised registration rates (ISR). Period: 2010-2012 (Pooled) V12_V1. Dec
2013.https://indicators.ic.nhs.uk/download/NCHOD/Data/11C_191PC_12_V1_D.xls.
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What Works
Prevention
Prevention offers the most cost-effective long-term strategy for the control of cancer1.
An individual's risk of developing cancer depends on many factors, including age,
lifestyle and genetic make-up
Some of these factors may be modified to reduce the risk of getting cancer
Although there are some things we can’t control about our cancer risk, decades of
research have clearly shown that by living a healthy life, people can reduce the risk
of developing the disease
Figure 5 shows the number of cancer cases in the UK that could be prevented by
eliminating known lifestyle and environmental factors, like being a non-smoker,
keeping ahealthy weight, drinking less alcohol, eating a healthy, balanced diet, and
avoiding being exposed to certain infections or radiation2
Cigarette smoking is the single most important cause of preventable cancer in the UK
Cancer Research UK estimates that that more than four in ten cancer cases could be
prevented by lifestyle changes.
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Figure 5 - Lifestyle factors affecting the incidence of cancer
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Early detection of cancer
Early detection of cancer greatly increases the chances for successful treatment. There are
two major components of early detection of cancer: education to promote early diagnosis
and screening.
Education
National public education campaigns are underway to encourage people to present to their
GP earlier with possible symptoms of cancer. The best recognised of these from recent
years are the Be Clear on Cancer Campaigns. These are yet to be fully evaluated but further
information for patients can be found at the NHS website and for professionals at the Cancer
Research UK website.
Screening
Screening refers to the use of simple tests across a healthy population in order to identify
individuals who have disease, but do not yet have symptoms.
Great care must be taken when developing and implementing screening programmes
that they do not result in more harm than good
UK policy is led by the UK National Screening Committee
There are currently three national screening programmes for cancer:
o Breast cancer screening
o Cervical cancer screening
o Bowel cancer screening
Treatment of cancer
The main goals of a cancer diagnosis and treatment programme are to cure or considerably
prolong the life of patients and to ensure the best possible quality of life to cancer survivors.
The most effective and efficient treatment programmes are those that:
are provided in a sustained and equitable way
are linked to early detection, and
adhere to evidence-based standards of care and a multidisciplinary approach4.
Diagnosis
The first critical step in the management of cancer is to establish the diagnosis. The national
cancer waiting times standard is for urgent referrals for suspected cancer to be seen within
two weeks5.
Major treatment modalities
Choice of treatment requires careful consideration of each individual case. Major treatment
modalities include surgery, radiotherapy and systemic therapy (chemotherapy). Individual
patients may be suitable for one of, a combination of, or none of these options. The national
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cancer waiting times standard is for first treatment to be given within 31 days of diagnosis of
cancer and a maximum of 62 days from the initial GP referral5.
End of life care
Palliative care improves the quality of life of patients and families who face life-threatening
illness, by providing pain and symptom relief, spiritual and psychosocial support from
diagnosis to the end of life and bereavement6. The National Institute for Health and Care
Excellence (NICE) has issued best practice guidance on supportive and palliative care
services for patients with cancer.
1 World Health Organisation. Cancer prevention. 2014. Available from http://www.who.int/cancer/prevention/en/
2 Cancer Research UK. All cancers combined Key Facts .2014. Available
from http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/Allcancerscombined.
3 Adapted by the author from: Cancer Research UK. Attributable risk - comparing the causes of cancer poster.
Cancer Research UK. December 2011.
4 World Health Organisation. Treatment of cancer .2014. Available from http://www.who.int/cancer/treatment/en/
5 NHS Commissioning Board. Everyone counts: Planning for Patients 2013-14. NHS England December 2012.
Available from: http://www.england.nhs.uk/wp-content/uploads/2012/12/everyonecounts-planning.pdf
6 World Health Organisation. Palliative care is an essential part of cancer control. 2014. Available
from http://www.who.int/cancer/palliative/en/
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Current Services
Prevention
A range of primary prevention initiatives available locally focus on promoting a
healthy lifestyle, by stopping smoking, tackling obesity, encouraging a healthy
diet and increasing physical activity.
Screening
Breast cancer screening– Coordinated in Kingston by The South West London
Breast Screening Service.
Cervical cancer screening – All women aged between 25 and 64 are invited for
cervical screening.
Bowel cancer screening – St George’s Healthcare is the southwest London Bowel
Cancer Screening Centre.
Primary Care Services
Primary care practitioners are usually responsible for the recognition of symptoms
and signs that could relate to cancer. The role of GPs often continues beyond a
diagnosis of cancer to include follow up, the management of coexisting conditions,
involvement in end of life care and wider psychological and social support
(See Community Voice)
Kingston Clinical Commissioning Group (CCG) has appointed a Lead GP with
responsibility for improving early diagnosis of cancer within primary care. It has also
worked with the Cancer Commissioning Team to encourage education sessions for
GP practices in the borough using practice profiles to highlight areas where there is
variation from the norm
High numbers of patients diagnosed as an emergency may indicate late diagnosis
and is associated with poor survival1. 20% of patients in Kingston are diagnosed with
cancer through emergency routes. This is similar to the England average 2
The ‘Be Clear on Cancer’ campaign has been promoted within the borough to
encourage patients to visit their GP for assessment if they have symptoms which
could be related to cancer.
Secondary Care Services
Kingston patients have a choice of where to be referred for management of their suspected
cancer.
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There are cancer services available from Kingston Hospital which includes inpatient
surgery, day case surgery and chemotherapy treatments
The Sir William Rous Unit in Kingston Hospital opened to patients in June 2008. It
provides a specialist service for those with cancer or those concerned they may have
cancer (Also see community voice)
Kingston hospital links with tertiary services provided at the Royal Marsden
Hospital and at St Georges Hospital
Occasionally, people with cancer will need to be admitted to manage their condition.
In 2013 -14:
there were 1,120 cancer related admissions for patients registered in Kingston
59.9% of admissions were to Kingston Hospital
20.8% were admitted to the Royal Marsden Hospital
12.9% were admitted to St Georges Hospital3 .
End of life care
Various organisations provide end of life care, advice and support for patients, families and
carers. This subject was covered in detail in the 2013 Kingston Annual Public Health Report
(See Chapter 4.6 for more information).
The Five year Cancer commissioning Strategy for London outline how commissioning
responsibilities from April 2013 brought changes to the NHS:
CCGs have responsibility for the commissioning of common cancer services as well
as early diagnosis, services for patients living with and after cancer as well as end of
life care
NHS England has responsibility for the direct commissioning of specialist services
including chemotherapy and radiotherapy, primary care and cancer screening
Public Health teams within Local Authorities take on responsibility for prevention and
population awareness of cancer signs and symptoms.
1 National Cancer Intelligence Network. Routes to Diagnosis - NCIN Data Briefing. National Cancer Intelligence
Network. 2014 . Available from: http://www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis
2 Cancer Commissioning Toolkit
3 Secondary Users Service information.
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Community Voice
A patients experience is an integral part of an individual’s diagnosis, treatment and ongoing
care and support when looking at cancer. In Kingston, there are few specific pieces of work
that have focused solely on Kingston residents and their views and/or experiences of cancer
prevention or treatment. The National Cancer Patient Experience Survey 2015 for Kingston
Hospital NHS Foundation Trust revealed that respondents gave an average rating of 8.4 for
their care (on a scale of zero - very poor to 10 - very good). The following questions are
included in phase 1 of the Cancer Dashboard developed by Public Health England and NHS
England:
74% of respondents said that they were definitely involved as much as they wanted
to be in decisions about their care and treatment
87% of respondents said that they thought the GPs and nurses at their general
practice would support them through their treatment
When asked how easy or difficult it had been to contact their Clinical Nurse Specialist
respondents said that it had been ‘quite easy’ or ‘very easy’
83% of respondents said that, overall, they were always treated with dignity and
respect they were in hospital
60% of respondents said that hospital staff told them who to contact if they were
worried about their condition or treatment after they left hospital definitely did
everything they could to support them while they were having cancer treatment.
As Kingston works collaboratively within the South West London Cancer Network (SWLCN)
there are a number of wider surveys that have captured the Kingston voice. All of these are
used collectively to highlight the issues that are key for individuals when considering how to
commission services locally.
The Cancer Awareness Measure (CAM) Survey in South West London 20101 looks at
cancer awareness amongst the residents of South West London between May and August
2010. A total of 5,009 resident people were interviewed across South West London.
The majority of South West London residents report having been affected by cancer in some
way, either personally or through friends or family having the disease. One in ten residents
(12%) has personally had cancer themselves. Female residents aged 45 to 54 from white
ethnic groups working in managerial, higher administrative or professional occupations have
been found to be more likely to have been affected by cancer. Over half of residents (54%)
reported having a close family member having had cancer.
Cancer impacts far wider than just the individual with the condition, the reach it has on family
and friends is significant. This highlights the importance of raising awareness and support
within the wider community. Public awareness of signs and symptoms and readiness to seek
help are discussed in the individual cancer chapters: Breast, Bowel, Prostate, and Lung.
A Primary Care Audit was undertaken in 2010 across South West London. The purpose of
this was to inform decisions about how best to support primary care professionals and
ensure the earliest diagnosis. During the period April to June 2010 the SWLCN undertook
such an audit as part of the National Awareness and Early Diagnosis Initiative.
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A person’s cancer pathway begins when they recognise and then act on signs and
symptoms. A person who has a type of cancer with easily recognisable symptoms will
present sooner. For example, breast cancer signs are more recognisable than those of colon
cancer. Sometimes, despite recognising symptoms, people are reluctant to present to
primary care. This report highlights the percentages of patients that were diagnosed at
different stages as well as avoidable delays across all cancers. These are areas that could
warrant further exploration to understand the barriers that prevent people from earlier
diagnosis and seeking help earlier.
A number of national surveys provide useful insight into a number of issues surrounding
cancer services and treatment. The 2014 National Cancer Experience Survey highlights that
patients in London consistently describe a lower quality of patient experience than the UK as
a whole.
1IPSOS MORI CAM reports in: Baseline Assessments of Breast, Lung, Colorectal and Urology Related Cancers
South West London Cancer Network 2010 NOTE Information presented in this section from Ipsos MORI is to be
treated as confidential and is subject to copyright.
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Recommendations
Kingston Public Health, Royal Borough of Kingston
1. Promote healthy lifestyles across all public health activities to prevent cancer and
support a reduction in health inequalities
2. Commission evidence-based primary prevention programmes focussed on the key
risk factors linked to cancer, with particular focus on vulnerable groups
3. Promote local awareness of the signs and symptoms of cancer using consistent key
messages
4. Support Kingston Clinical Commissioning Group (Kingston CCG) in commissioning
high quality cancer services services in the borough
Kingston CCG
5. Work with London Cancer Alliance (West and South) to improve local cancer
services
6. Promote healthy lifestyles through primary care to prevent cancer and support a
reduction in health inequalities
7. Implement measures to improve the early detection of cancer. This may include GP
education and commissioning services in line with South West London and national
best practice commissioning guidance to reduce variation and improve overall quality
8. Continue to invest in the Kingston GP cancer lead that provides local leadership and
co-ordination for early detection activities
9. Work with NHS England screening commissioners to facilitate the pathway from
screening to treatment and to achieve the 62 day pathway
10. Work with local acute trusts and community service providers to improving patient
experience
11. Improve support to people living with and beyond cancer as a long term condition
Kingston Health and Wellbeing Board
12. Work with local community groups and the local CCG to target hard to reach groups.
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GLOSSARY
CCG Clinical Commissioning Group
CCT Cancer Commissioning Toolkit
Other Needs Assessments
Cancer needs assessment: Joint Strategic Needs Assessment for Kingston (2010-11)
http://www.kingston.gov.uk/downloads/file/736/cancer_needs_assessment_joint_strategic_n
eeds_assessment_for_kingston_2010-11
SWLCN Baseline Assessment links
Baseline Assessment of Breast Cancer South West London Cancer Network 2010
Baseline Assessment of Colorectal Cancer South West London Cancer Network 2010
Baseline Assessment of Urology related Cancer South West London Cancer Network 2010
Baseline Assessment of Lung Cancer South West London Cancer Network 2010
Useful links for professionals:
National Cancer Strategy
https://www.gov.uk/government/publications/the-national-cancer-strategy
The National Cancer Intelligence Network
http://www.ncin.org.uk
Office for National Statistics: Cancer Statistics
http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Cancer
National Awareness and Early Diagnosis Initiative for England – NAEDI
http://www.cancerresearchuk.org/cancer-info/spotcancerearly/naedi/
Local Authority Health Profiles
http://www.apho.org.uk/default.aspx?QN=P_HEALTH_PROFILES
Help and Information:
Kingston CCG Website
http://www.kingstonccg.nhs.uk/
NHS Choices
http://www.nhs.uk/conditions/Cancer/Pages/Introduction.aspx
Cancer Research UK
http://www.cancerresearchuk.org/cancer-help/
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Macmillan Cancer Support
http://www.macmillan.org.uk/Cancerinformation/Cancerinformation.aspx
Many different organisations support those who are affected by cancer. Many of these
specialise in certain types of cancer. Speak to your GP if you have concerns about your
health or need more information on a specific problem.