A comparison of lung cancer and tuberculosis m

Biology Depth Study

Did lung cancer cause more deaths in England and Wales than tuberculosis between
1995-2020?

Introduction
This report aims to determine whether a non-infectious disease can cause more deaths than an
infectious disease by comparing the mortality rates of lung cancer and tuberculosis in England and
Wales (E&W) over the 25-year period of 1995-2020. An infectious disease is a disease that may be
transmitted from an infected host to others, while a non-infectious disease is a disease that cannot
be spread between organisms. Both types of disease negatively affect the health and function of an
individual’s body, may cause death especially if untreated, and can have severity and mortality
affected by factors such as age, sex, and genetics. However, while the cause of infectious diseases is
contact with pathogens such as bacteria or viruses that enter the body to damage cells and tissues,
development of non-infectious diseases is usually due to a combination of environmental and
genetic factors and lifestyle choices. Additionally, infectious diseases can be spread between
organisms through direct or indirect contact, such as bodily fluids or airborne droplets that
introduce the disease-causing pathogen to an uninfected organism, while non-infectious diseases
cannot be transmitted through any kind of contact since no pathogens are involved. The infectious
disease that will be the focus of this report is tuberculosis, a bacterial lung infection, and the non-
infectious disease will be lung cancer, a group of carcinomas originating in and mainly affecting the
lungs.

Materials and Method

This study was conducted using secondary sourced data from the NHS England website on death
rates from tuberculosis and lung cancer. The NHS Digital database was used due to the availability of
detailed datasets for public access, allowing easy data collection and analysis, as well as its high
reliability as a source due to NHS England being a UK-government affiliated non-departmental
public body. Datasets from two compendiums were obtained, and directly age-standardised death
rates per 100,000 European Standard Population for all sexes and age groups for lung cancer and
tuberculosis were extracted. These data were entered into Microsoft Excel in table format, including
each year between 1995-2020 inclusive and the corresponding death rates. A separate table was
created for each disease. Separate line graphs were then created using the graphing function in Excel
for tuberculosis and lung cancer, showing years on the horizontal axis as the independent variable
and death rates per 100,000 as the dependent variable. Another table was then created including
years and death rates for both diseases, and made into a chart using the same process. This chart
showed two line graphs, one for tuberculosis and the other for lung cancer, to facilitate comparison
of death rates over time between the two diseases. A legend was added to indicate which coloured
line graph represented which disease, with orange used for lung cancer and blue for tuberculosis.
The death rates for the diseases were finally compared using the graphs to determine which was
higher, and UK-based information sources from the internet such as government guidelines were
consulted to ascertain reasons for why mortality differed.
Results

Lung cancer refers to tumours originating in the trachea, bronchus or lung tissue. It is believed to
be a result of repeated exposure to carcinogens such as cigarette smoke or asbestos, which leads to
dysplasia of lung epithelium. This can develop into carcinoma with continued exposure that results
in genetic mutations and affects protein synthesis, disrupting the cell cycle and causing uncontrolled
cancer cell growth. Growth of tumours in the lungs can lead to airway blockages, pleural effusion,
and inflammation. Lung cancer may also metastasise especially in advanced stages, spreading to
other parts of the lung, lymph nodes, bones, the brain, or other organs. Causes of mortality vary,
however the most common include tumour burden, lung infections, pulmonary haemorrhage and
pulmonary embolism. Tumours may enlarge and spread, causing organ failure or compromising
organ function (e.g. breathing), which can lead to mortality since bodily functions crucial to survival
cannot be performed. Lung cancer also compromises the immune system and physical barriers,
leading to a higher risk of developing lung infections such as pneumonia or sepsis that can then
contribute to mortality, since the body’s immune system is unable to effectively eradicate the
pathogen to minimise damage. Pulmonary haemorrhage originating from tumours or due to erosion
of nearby blood vessels may cause mortality because of excessive blood loss or pulmonary oedema
meaning gas exchange cannot occur at a sufficient rate, leading to hypoxia and death if homeostasis
cannot be maintained. Pulmonary embolism occurs when tumour cells obstruct the pulmonary
artery, interrupting blood flow and impairing gas exchange, leading to hypoxemia which can be fatal
if blood oxygen levels become too low to support brain function. The chance of mortality increases
with progression through the stages of lung cancer, especially if treatment is lacking or unsuccessful.
Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis usually impacting
the lungs. Latent TB is asymptomatic and untransmissible, while active TB causes adverse symptoms
and is transmitted from person-to-person when an infected person coughs, speaks, or sings,
releasing bacteria into the air which can be inhaled by another person and enter the lungs. Latent TB
may be reactivated to become active TB, with most cases arising from this. Generally, TB is most
commonly spread to those who regularly spend time with people with active TB or have a weakened
immune system, since regular exposure is required for infection to occur. When lung tissue is
infected, apoptosis occurs, producing tubercles that contain the bacteria. A cell-mediated immune
response is only effectively developed after 2-10 weeks, during which time the bacteria may
continue to replicate. This can lead to necrosis, especially if the immune response and tissue repair
are impaired, as cytotoxic T cells kill infected cells in the lungs to attempt to contain the spread. If
necrosis is extensive, respiratory failure can occur, resulting in respiratory arrest followed by coma
due to lack of oxygen to the brain, then death. Disseminated TB occurs when bacteria cannot be
contained in the lungs and spread to other organs through the vascular system. Septic shock, when
the immune response damages vital organs, may occur with extended hypotension leading to
serious organ damage or failure and death due to loss of crucial bodily functions. Deaths in TB
patients are also often a result of comorbidities such as cancers or HIV, with TB exacerbating the
damage caused by the other condition or vice versa. Generally, TB is most fatal in
immunocompromised individuals, if left untreated, or if bacteria are multidrug-resistant. Otherwise,
it is usually curable using an extended course of antibiotics.
Discussion
This study found that lung cancer caused more deaths than tuberculosis in E&W during 1995-2020
due to higher death rates per 100,000 individuals from lung cancer. Fig. 3 shows a large distance
between line graphs for lung cancer and mortality, as lung cancer mortality rates consistently
remained much higher than tuberculosis, with an average difference of 61.65 individuals/100,000.
The significant difference in death rates is related to differences in ease and timing of diagnosis and
treatment of tuberculosis and lung cancer in E&W. Tuberculosis can be easily diagnosed using chest
scans (e.g. X-rays, CT) or mucus sample testing in symptomatic people, and a Mantoux test in
asymptomatic or suspected TB individuals, resulting in earlier diagnosis and treatment which
improves prognosis since less lung damage is caused in the early stages of the disease. Most cases
can be cured using a combination of antibiotics taken for at least 6 months, and incur costs to the
NHS of under £1000 per patient. Only a small proportion of TB cases (medically complex or drug-
resistant) require higher expenses and more intensive care. Additionally, treatment for TB is free for
UK residents, increasing the likelihood of patients seeking care and decreasing deaths from
untreated disease. These factors would have all contributed to tuberculosis’ low mortality rates (Fig.
2), which stayed below 1.00 for all years but one (1995) with an overall decreasing trend from a high
of 1.03 in 1995 to 0.29 in 2020. Conversely, lung cancer diagnosis is more difficult since early stages
are often asymptomatic, with many patients in E&W only being diagnosed in later stages (Stage 3 &
4) when symptoms cause physical discomfort. Later diagnosis complicates treatment, as the cancer
has often metastasised and affected multiple organs by this point, contributing to higher mortality. A
combination of surgery, chemotherapy, and chemo-radiotherapy may be used, depending on the
stage and characteristics of the cancer, with advanced stages being more difficult to treat – treating
Stage 3 cancer is often problematic, with 5-year survival rates of 20%, and Stage 4 cancer is
incurable. Due to the higher proportion of Stage 3 and 4 cancer diagnoses in E&W, treatment is thus
less likely to be successful. Therefore, mortality per 100,000 population from lung cancer was
comparatively very high (Fig. 1), remaining above 50 individuals for all but one year (2020) of the
25-year period, though a consistent decrease was observed, from a peak of 73.32 in 1995 to 49.20 in
2020.

Conclusion
The findings of this study indicate that between 1995-2020, the non-infectious disease lung cancer
did cause more deaths in E&W than the infectious disease tuberculosis. This is most clearly seen in
Fig. 3, where a large gap was observed between the line graphs for each disease since age-
standardised death rates per 100,000 individuals ranged between 49.20-73.32 for lung cancer (Fig.
1) and only 0.27-1.03 for tuberculosis (Fig. 2), a much lower range of values. The difference in death
rates was shown to be influenced greatly by the increased difficulty of treating lung cancer due to
delayed diagnosis in populations in E&W compared to the relative simplicity of tuberculosis
diagnosis and treatment, since more advanced progression of disease is directly linked to greater
mortality. This has implications for future plans to improve the health of E&W residents, with a focus
on faster diagnosis and treatment of non-infectious diseases such as lung cancer recommended due
to its higher death rate.
My new inquiry question is:
“Does lung cancer cause more deaths in China than tuberculosis?”
My reasoning for new inquiry question is:
I have narrowed the scope of the original inquiry question by naming a specific non-infectious
disease (“lung cancer”) and an infectious disease (“tuberculosis”). I have also named a country
(“China”) to try to limit the population I will be investigating due to time and resource constraints
as a student making it too difficult to do research on a larger scale (e.g. worldwide).
To do list

What are my next steps?

1. Further refine question to identify a time range to focus on (to enable focus on data from a
specific time period) – this will make the scope more appropriate for a Year 12 Biology
student with limited time and access to resources.
2. Conduct further research on both lung cancer and tuberculosis to understand the diseases
better, and how they cause mortality. May need to research pathophysiology, disease
progression etc.
My new inquiry question is:
“Did lung cancer cause more deaths in England and Wales than tuberculosis between 1995-
2020?”
My reasoning for new inquiry question is:
Due to a lack of data on lung cancer mortality rates in China, I decided to change the focus region
to England and Wales due to greater access to a wide range of data processed using the same
standardisation methods from NHS England. This will make comparison of data easier and obtain
more valid results. A time period of 25 years (“1995-2020”) was also identified to ensure data
could be compared over a consistent time range for both diseases – this period was chosen
because there was data available on mortality rates for both diseases in England and Wales for
these years. Due to the narrower scope and availability of matching data, this inquiry question
should be appropriate for a Year 12 student’s level of research.
To do list

What are my next steps?

1. Start formatting scientific report; identify headings and sections based on marking
criteria.
2. Find more sources (e.g. reports, journal articles) on how tuberculosis and lung cancer
affect the body in order to understand progression of diseases better, and find links to
mortality. Also, look for information on these diseases in England and Wales specifically
(or the UK).
Logbook
Date Logbook Entry
06/06/24 Attended a Biology class excursion to UNSW’s Museum of Human Disease. A
Depth Study Primer booklet and workbook were handed out to aid with our
research on the day. There was an extensive collection of specimens present
at the Museum for both infectious and non-infectious diseases, which
allowed me to gain a deeper insight into the observable effects of diseases
on parts of the body. Of special interest were examples of various lung
cancers, including mesothelioma. There was also an interesting factsheet on
why tuberculosis bacteria are difficult to kill using antibiotics, which was
used in an activity in the workbook. Overall, this excursion was useful for
seeing a variety of manifestations of different diseases up close and was
good inspiration for finding an infectious and non-infectious disease to
research further for my depth study.
07/06/24 Started researching some diseases of interest, first using some lists of
common infectious diseases in Australia. However, I did decide that I
wanted to look at lung cancer for my non-infectious disease, partly due to
its prevalence in many countries and partly because of my own cultural
background (in my experience, China has a very significant smoking culture,
especially among male businessmen, so I was interested in how this cultural
phenomenon impacted mortality from lung cancer). I also decided that I
would choose China as my country of focus, however a year range has not
been decided yet. Infectious disease yet to be determined, but I am thinking
about choosing something also affecting the lungs to compare between two
different diseases that affect the same organ.
12/06/24 I discovered that China also has fairly high rates of tuberculosis, so this was
a possible option for the infectious disease. With both my infectious and
non-infectious diseases of focus decided, I started looking for data on
mortality rates. I found some research papers on lung cancer in China and
glanced through them for usable data, however most seemed to have
summarised and analysed existing data from the 2021 Global Burden of
Disease (GBD) Study. When this was accessed, I realised that it required a
subscription for use, so raw data from this source was not realistically
accessible for my level of research. I continued looking for data for both TB
and lung cancer, and did find a graph from Our World In Data based on
statistics from the GBD Study for tuberculosis mortality in China.
18/06/24 Following on from my research in the previous session, I refined my inquiry
question for the first time, specifying tuberculosis and lung cancer as the
diseases I was focused on and China as the location/population. I continued
looking for data on lung cancer in China, but could not find any reliable
sources with comprehensive datasets. Due to this setback, I decided to shift
my focus and look for different countries with more data available for the
same diseases. While doing this, I discovered that NHS England had easily
accessible datasets on tuberculosis and lung cancer mortality rates for
England and Wales that were standardised using the same processes. The
UK also has an abnormally high number of lung cancer deaths compared to
many European countries, so this appeared to be worth investigating. I was
then able to find multiple sources with information on lung cancer and TB
in the UK, so I refined my inquiry question again, this time changing the
location/population to England and Wales and identifying a time period of
1995-2020 based on data availability.
21/06/24 Using the datasets obtained from NHS England, I created tables in Excel
then used them to make charts. I decided to use line graphs as these are
able to show both data points and trends over time well. After editing the
formatting of the graphs for the individual diseases, I realised that since the
 scales on these graphs were different, comparison would be slightly more
difficult. Hence, I created another graph with both diseases shown as
different coloured line graphs, which immediately made clear the huge
difference in mortality rate between the two.

Using information on infectious vs. non-infectious diseases from the

Pearson Biology 12 textbook, I wrote the Introduction for my depth study
and also formatted the document by adding headings and changing some
fonts and colours.
22/06/24 I wrote the Materials and Method section, including some information on
how data is age-standardised since NHS processed their data in this way.
This required some generalised research to gain an understanding of
statistical analysis techniques used in epidemiology. I also made sure to
include a description of how I turned the raw data into graphs using Excel.
The reliability of the data source was commented on following research on
what a non-departmental public body was.
23/06/24 I began the Results section by inserting the graph I had made in Excel for
lung cancer death rate into my depth study document and adding a label. I
then researched the pathophysiology of lung cancer and what it can do to
the body, as well as the most common reasons for mortality due to lung
cancer. This information was used in the first paragraph, where I explained
how lung cancer causes mortality. The graph for TB was then also added to
the document and labelled. The effect of tuberculosis disease on the body
and how it causes mortality were researched, with this information
summarised in the second paragraph. The graph showing death rates for
both diseases was then added below this and labelled in the same manner.
24/06/24 I reviewed the Results section since I was aware of its relatively high word
count so I removed a few sentences that were repetitive or not directly
related to mortality. I then began writing the Discussion section by starting
with the main takeaways and trends shown in the graphs. In relating to
features of the population that resulted in lung cancer mortality being
higher, I decided to focus on diagnosis and treatment as the main
contributing factors and thus researched how England and Wales diagnosed
and treated patients with these diseases. A definitive link was found
between the tendency for lung cancer patients to be diagnosed in later
stages and higher mortality, while in TB patients, diagnosis and treatment
was mostly easy and inexpensive due to NHS subsidies. These points were
linked to the data in the graphs to show the link between the and the higher
mortality of lung cancer vs. tuberculosis.
25/06/24 I spent some time cutting down on word count in the Discussion as I had
already approached 1500 words and did not yet have a Conclusion. After
this, I had more leeway so wrote a fairly short Conclusion restating the
findings of my depth study and linking the final conclusion, the results
obtained, and reasons for mortality. Unfortunately, this resulted in word
count increasing again so I had to go back and rephrase some sentences to
shave a few words off.
26/06/24 During class, I consulted my teacher on whether an explanation of age-
standardisation was required in the Materials and Method section even
though I had not standardised the data myself. I was informed that this was
not needed, allowing me to remove a short paragraph on the age-
standardisation method used by NHS England and reducing word count.
27/06/24 Since I was over the word limit by approximately 30 words, I decided to
read through the depth study again to try and cut down on any unnecessary
repetition or redundant phrases. This took a while, and I mainly focused my
efforts on the Introduction and Materials and Methods sections at first, due
to their relative simplicity. I was able to identify and remove some
repetitive sentences that did not add much to meaning. I also condensed
some phrases.

I created the reference list using MyBib to autogenerate most of the

references in Harvard style (some had to be written manually) and made
sure to check each reference by hand to ensure consistency. Sometimes
missing information (e.g. author, date published) had to be added. The
references were ordered alphabetically and the list inserted into a Word
document.
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