A breast cancer cell (in pink) seen through an electron microscope; around it is an artist’s rendition of the molecules of the drug Herceptin
On each working day of this year, over 1,000 people in Britain will be told for the first time that they have cancer. More than one in three of us will get the disease and the incidence is rising dramatically as our population ages. Cancer predominantly affects the over-60s, although it can strike at any age and there are more over-65s in the world today than ever before. An ageing population means that the incidence of cancer worldwide will inevitably rise.
The success of modern medicine at treating infection, heart disease and other illnesses has led to more people living well beyond retirement—this is certainly a cause for celebration. But this longevity brings new epidemics: cancer, dementia, arthritis, diabetes, frailty, multiple co-morbidity and the inability to cope with independent living. For this reason, we need to restructure our health and social care systems if we are to deal with this rapid transition. The current round of deck-chair shuffling will not stop the ship from sinking.
The first hint that British cancer survival rates were slipping came in 1989, when a series of European comparators, which measured access to cancer treatment and its efficacy, put Britain in last place. I remember a cross civil servant calling me when my colleagues and I at Hammersmith Hospital pointed this out in our launch for the Cancer Centre Appeal. Kenneth Clarke, the then health minister was seething, as I had spoiled his weekend.
A series of reports by Eurocare, a pan-European cancer research project, were published three months later and these compared survival rates in different nations. The reports concluded that Britain had the worst rates of the wealthier EU countries. A good measure of progress is the number of patients alive five years after initial diagnosis. Different cancers have different five-year survival rates, depending on the effectiveness of treatment. The range is wide: from 98 per cent in testicular cancer to 3 per cent in pancreatic cancer. Britain’s results were consistently below the EU average for the four main common cancers: lung, breast, prostate and colon. Since then, Eurocare has reported similar findings. Britain is still the poor man of Europe, while treatments and results in other countries continue to improve. If Britain could achieve even the western European average survival rate, it would save the equivalent number of lives as preventing a fully laden jumbo jet crashing at Heathrow every other day. We are still far from being world class (see chart, right).
Cancer care became increasingly politicised in the early 1990s; the initial response of the Conservative government was to form committees. Of these only the Calman-Hine Committee, chaired by the chief medical officer, proved effective, by creating the cancer network that still exists. The others just met for coffee and biscuits.
When Labour came to power in 1997 it was determined to bolster the NHS’s cancer capacity. The Cancer Plan, launched in 2000, was driven by a huge cash injection into the public sector—the NHS budget tripled and for cancer care it increased fivefold. Mike Richards, a distinguished oncologist was appointed as the “cancer tsar,” and though his work was admirable, the bureaucracy and politics of the NHS constrained him. Undoubtedly there were improvements, but these have been over-run by increased demand for care, and technological advances in treatments.
Cancer patients are becoming more sophisticated in their choices, and the drive is now towards providing a personalised style of medicine. They are pushing for better care and are travelling to get it. The key issue is how to maintain equity in choice and access, both geographically and between different socio-economic groups.
It is essential that all patients should have access to the best new treatments. Powerful new technologies can turn cancer into a chronic disease, which can then be controlled, as with diabetes. A consequence of this is that more people with cancer are living longer, thereby increasing the prevalence of the disease in the population. Rising numbers, increased consumerism and innovation come with a hefty price tag. The current climate of national austerity further compounds the problem.
Advances in the imaging technology used during surgery to remove primary tumours have minimised the damage done to surrounding tissue and the increasing use of robotics and keyhole devices means that lengthy stays in hospital are no longer necessary. Radiotherapy has been revolutionised by a combination of sophisticated imaging and computing systems that can contour a tumour accurately. Intensity modulated radiotherapy (IMRT) and image guided radiotherapy (IGRT) are becoming standard. But in Britain, less than 15 per cent of eligible patients have access these technologies, compared to nearly 100 per cent in France and Germany.
The problem with cancer is that it can spread through metastasis (the meaning comes from meta, next and stasis, place). But the molecular revolution has brought a pipeline of new drugs that target receptors and also the molecular cogs that malfunction and which lead to the abnormal growth patterns of a cancer cell. Herceptin was the first drug of this type and has been used to treat breast cancer for the last decade—there are now 700 targeted drugs at the trial stage. But, over the last six months, the average monthly cost of each of the eight cancer drugs approved in the United States was over $10,000 (£6,000). If this trend continues it could bankrupt the healthcare systems of rich countries and never be affordable by the poor.
Some drugs selectively block tumour blood vessel growth, thereby strangling cancer cells by depriving them of nutrients. Once a cancer has been treated, a new generation of computed tomography and magnetic resonance imaging scanners allows us to monitor progress. Techniques such as positron emission tomography can even provide information on the biochemical changes inside a patient’s cancer cells and the new era of cheap DNA and protein analysis of both cancer and normal cells in an individual provides clues as to the best way to treat a cancer.
Computer algorithms, constructed from data from thousands of patients can indicate the best way to reduce disease recurrence. These can suggest appropriate times to administer drugs, hormones and vaccines even when there is no evidence of spread on imaging. The old military metaphors such as the war on cancer, tumour sterilisation and avoiding collateral damage in victims are being replaced by the more peaceful language of disease stabilisation, symbiosis and chronic control with gentle therapies in people living with cancer.
These many improvements have undoubtedly saved lives. But can Britain keep pace with this new world? To do so, we need to look more closely at the fundamental structure of our services to make them more convenient for our customers in the context of their daily lives. The costs of the diagnostics for personalised medicine may be high but the potential for savings enormous. No payer of healthcare is going to ignore this. The days of marketing cancer drugs like a supermarket commodity are over. It is now going to be essential to develop ways to optimise responses through companion diagnostics and by closely monitoring the effectiveness of treatment. Can Britain keep up?
The new Cancer Drugs Fund, for example, is an annual £200m bonanza that disburses funds for drugs that are not approved by Nice (the National Institute for Health and Clinical Excellence). The aim is to provide access to drugs not available on the NHS, but which have been recommended by a consultant. In practice it is a bureaucratic nightmare administered by staff who know little about cancer. Inevitably, getting funding requires patience and persistence by both doctor and patient alike. Postcode lotteries abound as different decisions are made by different sets of bureaucrats. Although no data has been published, most of my colleagues have the impression that better-off patients are more successful at making use of the fund—inequity bedevils all of the NHS’s more complex services.
Ultimately there are only three ways to pay for healthcare—tax, insurance, or cash. Being honest with patients about what is available and ensuring equal access is crucial. Honesty about the limits of the NHS’s capabilities remains politically sensitive.
Until now, patients’ voices have been drowned out by the noise of the system. The only real way for them to be heard is through choice and competition. But our NHS generates an almost religious fervour, and resistance to reform is intense. A combination of strong commissioning, realistic tariffs and effective regulation is needed to create an orderly market in which old and new providers can compete. Different providers can create unique services and provide real choice of care for cancer patients. Innovation in service delivery will require the creation of new clinics that can readily adopt novel technology. The existing model is simply unsustainable because of workforce shortages, demotivation and top down bureaucracy.
Getting the right treatment to the right patient using new diagnostics will increase the cost-effectiveness of our care. Increased efficiency by the better use of expensive equipment, targeting expensive drugs to those that will really reap the benefits and keeping patients out of hospital has to be part of our plan. We need to develop the excellent work of the major cancer charities, to make it easier for people to understand their treatment and make the best choices for themselves. Public, private and voluntary providers and payers working together have a vital role in developing innovative strategies to drive access, quality and value. Public education on healthy lifestyle change has never been more important to reduce the burden of disease.
It is essential that efficiency savings throughout cancer care delivery are ploughed back into service improvements. Our spending on new cancer drugs and high quality radical radiotherapy is falling far behind comparable countries. Yet the per capita total amount spent on cancer is similar. Only by efficiency savings can funding be made available for innovation.
Healthcare must become a true service industry. It must provide a wide range of services. It is inevitable that some high cost, but not very worthwhile treatments will have to be purchased outside the NHS, however unpopular this may be. Honesty, transparency and tenacity are essential but rare commodities in politicians who have to broker future policies. Today, despite an enormous effort in time and money, we are still at the bottom of the European tables in terms of survival. No political propaganda can ever correct this. A radical new approach is urgently needed if we are to be world class in cancer care.
On each working day of this year, over 1,000 people in Britain will be told for the first time that they have cancer. More than one in three of us will get the disease and the incidence is rising dramatically as our population ages. Cancer predominantly affects the over-60s, although it can strike at any age and there are more over-65s in the world today than ever before. An ageing population means that the incidence of cancer worldwide will inevitably rise.
The success of modern medicine at treating infection, heart disease and other illnesses has led to more people living well beyond retirement—this is certainly a cause for celebration. But this longevity brings new epidemics: cancer, dementia, arthritis, diabetes, frailty, multiple co-morbidity and the inability to cope with independent living. For this reason, we need to restructure our health and social care systems if we are to deal with this rapid transition. The current round of deck-chair shuffling will not stop the ship from sinking.
The first hint that British cancer survival rates were slipping came in 1989, when a series of European comparators, which measured access to cancer treatment and its efficacy, put Britain in last place. I remember a cross civil servant calling me when my colleagues and I at Hammersmith Hospital pointed this out in our launch for the Cancer Centre Appeal. Kenneth Clarke, the then health minister was seething, as I had spoiled his weekend.
A series of reports by Eurocare, a pan-European cancer research project, were published three months later and these compared survival rates in different nations. The reports concluded that Britain had the worst rates of the wealthier EU countries. A good measure of progress is the number of patients alive five years after initial diagnosis. Different cancers have different five-year survival rates, depending on the effectiveness of treatment. The range is wide: from 98 per cent in testicular cancer to 3 per cent in pancreatic cancer. Britain’s results were consistently below the EU average for the four main common cancers: lung, breast, prostate and colon. Since then, Eurocare has reported similar findings. Britain is still the poor man of Europe, while treatments and results in other countries continue to improve. If Britain could achieve even the western European average survival rate, it would save the equivalent number of lives as preventing a fully laden jumbo jet crashing at Heathrow every other day. We are still far from being world class (see chart, right).
Cancer care became increasingly politicised in the early 1990s; the initial response of the Conservative government was to form committees. Of these only the Calman-Hine Committee, chaired by the chief medical officer, proved effective, by creating the cancer network that still exists. The others just met for coffee and biscuits.
When Labour came to power in 1997 it was determined to bolster the NHS’s cancer capacity. The Cancer Plan, launched in 2000, was driven by a huge cash injection into the public sector—the NHS budget tripled and for cancer care it increased fivefold. Mike Richards, a distinguished oncologist was appointed as the “cancer tsar,” and though his work was admirable, the bureaucracy and politics of the NHS constrained him. Undoubtedly there were improvements, but these have been over-run by increased demand for care, and technological advances in treatments.
Cancer patients are becoming more sophisticated in their choices, and the drive is now towards providing a personalised style of medicine. They are pushing for better care and are travelling to get it. The key issue is how to maintain equity in choice and access, both geographically and between different socio-economic groups.
It is essential that all patients should have access to the best new treatments. Powerful new technologies can turn cancer into a chronic disease, which can then be controlled, as with diabetes. A consequence of this is that more people with cancer are living longer, thereby increasing the prevalence of the disease in the population. Rising numbers, increased consumerism and innovation come with a hefty price tag. The current climate of national austerity further compounds the problem.
Advances in the imaging technology used during surgery to remove primary tumours have minimised the damage done to surrounding tissue and the increasing use of robotics and keyhole devices means that lengthy stays in hospital are no longer necessary. Radiotherapy has been revolutionised by a combination of sophisticated imaging and computing systems that can contour a tumour accurately. Intensity modulated radiotherapy (IMRT) and image guided radiotherapy (IGRT) are becoming standard. But in Britain, less than 15 per cent of eligible patients have access these technologies, compared to nearly 100 per cent in France and Germany.
The problem with cancer is that it can spread through metastasis (the meaning comes from meta, next and stasis, place). But the molecular revolution has brought a pipeline of new drugs that target receptors and also the molecular cogs that malfunction and which lead to the abnormal growth patterns of a cancer cell. Herceptin was the first drug of this type and has been used to treat breast cancer for the last decade—there are now 700 targeted drugs at the trial stage. But, over the last six months, the average monthly cost of each of the eight cancer drugs approved in the United States was over $10,000 (£6,000). If this trend continues it could bankrupt the healthcare systems of rich countries and never be affordable by the poor.
Some drugs selectively block tumour blood vessel growth, thereby strangling cancer cells by depriving them of nutrients. Once a cancer has been treated, a new generation of computed tomography and magnetic resonance imaging scanners allows us to monitor progress. Techniques such as positron emission tomography can even provide information on the biochemical changes inside a patient’s cancer cells and the new era of cheap DNA and protein analysis of both cancer and normal cells in an individual provides clues as to the best way to treat a cancer.
Computer algorithms, constructed from data from thousands of patients can indicate the best way to reduce disease recurrence. These can suggest appropriate times to administer drugs, hormones and vaccines even when there is no evidence of spread on imaging. The old military metaphors such as the war on cancer, tumour sterilisation and avoiding collateral damage in victims are being replaced by the more peaceful language of disease stabilisation, symbiosis and chronic control with gentle therapies in people living with cancer.
These many improvements have undoubtedly saved lives. But can Britain keep pace with this new world? To do so, we need to look more closely at the fundamental structure of our services to make them more convenient for our customers in the context of their daily lives. The costs of the diagnostics for personalised medicine may be high but the potential for savings enormous. No payer of healthcare is going to ignore this. The days of marketing cancer drugs like a supermarket commodity are over. It is now going to be essential to develop ways to optimise responses through companion diagnostics and by closely monitoring the effectiveness of treatment. Can Britain keep up?
The new Cancer Drugs Fund, for example, is an annual £200m bonanza that disburses funds for drugs that are not approved by Nice (the National Institute for Health and Clinical Excellence). The aim is to provide access to drugs not available on the NHS, but which have been recommended by a consultant. In practice it is a bureaucratic nightmare administered by staff who know little about cancer. Inevitably, getting funding requires patience and persistence by both doctor and patient alike. Postcode lotteries abound as different decisions are made by different sets of bureaucrats. Although no data has been published, most of my colleagues have the impression that better-off patients are more successful at making use of the fund—inequity bedevils all of the NHS’s more complex services.
Ultimately there are only three ways to pay for healthcare—tax, insurance, or cash. Being honest with patients about what is available and ensuring equal access is crucial. Honesty about the limits of the NHS’s capabilities remains politically sensitive.
Until now, patients’ voices have been drowned out by the noise of the system. The only real way for them to be heard is through choice and competition. But our NHS generates an almost religious fervour, and resistance to reform is intense. A combination of strong commissioning, realistic tariffs and effective regulation is needed to create an orderly market in which old and new providers can compete. Different providers can create unique services and provide real choice of care for cancer patients. Innovation in service delivery will require the creation of new clinics that can readily adopt novel technology. The existing model is simply unsustainable because of workforce shortages, demotivation and top down bureaucracy.
Getting the right treatment to the right patient using new diagnostics will increase the cost-effectiveness of our care. Increased efficiency by the better use of expensive equipment, targeting expensive drugs to those that will really reap the benefits and keeping patients out of hospital has to be part of our plan. We need to develop the excellent work of the major cancer charities, to make it easier for people to understand their treatment and make the best choices for themselves. Public, private and voluntary providers and payers working together have a vital role in developing innovative strategies to drive access, quality and value. Public education on healthy lifestyle change has never been more important to reduce the burden of disease.
It is essential that efficiency savings throughout cancer care delivery are ploughed back into service improvements. Our spending on new cancer drugs and high quality radical radiotherapy is falling far behind comparable countries. Yet the per capita total amount spent on cancer is similar. Only by efficiency savings can funding be made available for innovation.
Healthcare must become a true service industry. It must provide a wide range of services. It is inevitable that some high cost, but not very worthwhile treatments will have to be purchased outside the NHS, however unpopular this may be. Honesty, transparency and tenacity are essential but rare commodities in politicians who have to broker future policies. Today, despite an enormous effort in time and money, we are still at the bottom of the European tables in terms of survival. No political propaganda can ever correct this. A radical new approach is urgently needed if we are to be world class in cancer care.
