COMMENTARY

Why Does the UK Lag Europe on Cancer Survival and What Can be Done About It?

Karol Sikora, PhD, FRCR, FRCP, FFPM.

Disclosures

December 06, 2018

Hello, my name is Professor Karol Sikora and I'm going to talk to you today about something that was really in the media quite a lot last week and that's the poor cancer survival statistics of Britain compared with the rest of Europe.

I've lived this problem as a consultant for nearly 40 years. We've known that Britain is behind Europe, and we've tried lots of interventions, but we're still at the bottom of the pile. Last week, a report entitled Unfinished Business - An Assessment of the National Approach To Improving Cancer Services was published by the Health Foundation, a health charity. The main author was the previous cancer tsar Mike Richards. I know Mike very well. He's a great chap. I actually examined him for his MD thesis in Cambridge a long time ago, and he's done a tremendous job but under very difficult circumstances.

European Cancer Data

This publication from last week which arose all the publicity was really the history of cancer politics over the last 40 years. And it's a fascinating read, even if you haven't been involved in them.

I think the first thing to say is we really are still behind Europe, and that is clear in the report. The statistics from Eurocare, the latest Eurocare data, shows that for the common cancers we're behind. Ironically, for the rare cancers we're not behind. That's got to be telling us something. We'll come back to that in a minute.

The history goes as follows. In the early 90s, it was clear that we were lagging behind with the first Eurocare studies on cancer across Europe. And then we had the drive, the political drive with the Calman Hine report that came out in 1996. I remember sitting on that, as was Mike Richards, and there was no money to follow. A great concept - primary to secondary care transition, cancer centres, cancer units, a network of cancer expertise with good quality assurance, but absolutely no money to pay for it. And then we got basically the change and the change came with the cancer plan, the NHS Cancer Plan that Mike Richards put together in 1999. And that began things, with a summit with Tony Blair and the Cabinet Office leading to real money being poured, not just into the NHS, but specifically an increase in funding for cancer services. And so we’ve seen over the last 40 years huge amounts of strategy, change, a huge number of funds going into it. We've seen the NHS cancer plan succeeded by the Cancer Reform Strategy, followed more recently by the Five Year Forward View and then the National Cancer Transformation Board. And the conclusion is that although we've improved a bit, the rest of Europe has improved even more in cancer survival.

Key Questions

And so what is it? What’s so different about Britain, and it's all the devolved countries as well, that make it poorer? And you look at everything. Is it the staff? Is it the quality of training? Is it the equipment? We don't have so many doctors, we certainly don't have so much equipment in terms of diagnostic equipment, radiotherapy machines, and so on. Is it surgical access? Is it radiotherapy delays? Is it chemotherapy? Is it the high cost of drugs? We've had the debacle of the Cancer Drugs Fund recently, which really has been a complete mess. Now luckily, it's sorted out on an equitable basis.

The difficulty is knowing where the problem lies. Why are our figures lower? And this report doesn't actually show the key data that I think is the real problem. And that's early diagnosis. Basically, if you look at the 5-year differences, and you compare them with the 1-year differences, the 1-year differences are much bigger than the 5 for the common cancers, especially those that require surgical treatment.

So that means that if the 1-year survival figures are really poor, that means people are presenting with advanced cancer, otherwise, how are they going to die within a year? On the whole cancer doesn't kill you very rapidly unless it's already metastasised. And that's clearly what the problem is.

So why is this? And we start looking at what there is that causes delays in diagnosis.

The Reasons Behind the Numbers

Well, first of all, there's the patient. The patients in the UK are a bit more stoic, men more so than women. There's no doubt they just put up with symptoms. Old boys with a cough, for example, that smoke, they just carry on coughing and don't do anything about it. They accept this as a way of life when they wake up in the morning. Maybe when they get blood in the sputum they start doing something about it. But there's a huge patient driven delay.

Then there's the GP. How do you access your GP? I hear all sorts of stories now, access to GPs being really poor despite 111, and despite all sorts of other outlets providing primary care, urgent care, it's still, for some people, difficult. You may have to take a day off work. You may have to lose money to go and see your GP. And that's fine if you're in a professional job, but if you're in a job that pays you by the hour and you take the day off to go and see your GP, you're losing a lot of money. So it's not so easy.

Then there's delay in access to tests: MRIs, CT scans, PET-CTs, we're the lowest in Europe, there's no doubt. Of all the Western-related economic countries we are down the bottom of the pile in terms of access to them. There just isn't the capacity to access the sort of scanning capacity you can get in France, Germany, or Italy.

And then of course, there's delay in getting pathology. We all know that there are boxes of slides out there that are not reported for 3 months. Now, most of them you can get away with, but some of them will have cancer, and that's part of the delay.

And then of course, you've got delays in secondary care. Less than 25% of patients referred under the 2-week wait will actually be found to have cancer. So, you know, cancer has so many symptoms, it's impossible for even the most experienced GP to identify who's got cancer and who's not. So they can't be fast tracked, you have to fast track everybody.

Cancer and the NHS

So it's interesting how the report goes. It looks at the traditional NHS way of doing things. So, what's improved over the years? Well, survival has improved, of course, but what about patient expectation? How do you measure that? You know, if it was me, I have expectation to be cured. That would be my sole expectation.

But it's looked at bits of data, such as, do know the name of your clinical nurse specialist? Do you get enough information to be involved in your care? Are you always treated with respect and dignity? Did you get diagnosed after one to two visits to your GP? Are you seen as soon as necessary by the hospital? Are different people treating you working well together?

These were six questions that were followed up for a 15-year period, and they show a bit of improvement, but they're pretty nebulous.

Really only hard data, such a survival, is really the way forward.

Radical Rethink

So I think the problem we've got now is how to do it. What we need is not a committee-based structure such as the National Cancer Transformation Board building diagnostic pathways in general hospitals. What we need is a totally separate structure, and it can be outside the whole system, referred by patients, by GPs, by nurse, nurses in the community, of anybody that has symptoms that are getting progressive or persistent for more than 2 to 3 weeks. Whether it's a sore throat, a cough, a tummy ache, a bloated feeling, all these things need to be referred into a funnel.

Patients go at the top of the funnel and they're selected by computer algorithms.

You don't have doctors in these clinics. You have nurse specialists, you have radiographers, and they go through a pathway, which includes scanning, ultrasound, CT, MR, PET-CT if necessary, and then

also endoscopy on the side, skin biopsies, other needle biopsies available.

And it can all be fast tracked. It can all be done within 24 hours. There's no reason not to.

So you go there, you get screened, you have all the tests and you come out with a report, and this is what happens in other countries. You come out with a report saying what's been done, what is the likelihood of cancer, and what you need to do next.

And that's the way into the secondary care services that are most appropriate to you. And only in that way can we actually get moving. Sure, it costs money, but it doesn't actually cost a lot of money because in the end over a 5-year period, you're saving money on the diagnostic capacities of the hospitals that you've got.

GPs and Oncologists

So it strikes me that instead of this traditional spat between GPs and hospital doctors, and believe me last week in the papers, the President of the college of GPs [said] it's not the GPs' fault that cancer patients are coming late. It doesn't matter whose fault it is. What we've got to do is reset the system. We're in the modern world and patients expect to do better than they are now.

The other countries have managed, we need to do it. So even though we're leaving Europe in the next 3 months, maybe, at this time, we should over the next 5 years if we get our diagnostic pathways right, we should be amongst the best in Europe. We've tried lots of reorganisations and not got there yet. I think this time we could actually get there.

I'd really like to hear your views because it's pretty controversial stuff this, and I think everyone's entitled to a view, whether you're a GP, a patient, a hospital consultant, an oncologist, there are different ways to solve the cancer problem, but we have to solve it. We just can't go on doing this.
Thank you.

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