COMMENTARY

Why is the UK Bottom of the Global Cancer Survival League Table?

Karol Sikora, PhD, FRCR, FRCP, FFPM

Disclosures

September 16, 2019

This transcript has been edited for clarity.

Hello. My name is Professor Karol Sikora and I'm talking today about survival in the UK from cancer, and a study that came out last week in The Lancet Oncology studying seven countries, seven cancers. The study was called Progress in cancer survival, mortality and incidence in seven high-income countries.

A fascinating study, really well done, 3.9 million people. The seven countries were Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the UK. The interesting thing about those countries is they all have universality in health care. No one goes without, no matter how poor you are. It's a mixture of tax- and insurance-based schemes but universality is ensured. So you wouldn't expect resource to be the real problem here.

Poor Prognosis

The cancers considered were mainly poor prognostic groups. I suppose that's right. Prostate cancer and breast cancer, were left out because they are, on the whole, a good prognosis. And the authors wanted to see how things would work out for these poorer prognosis tumours. So oesophagus, stomach, colorectal, pancreas, lung, and ovary.

The key measurements were 5 year survival. And lost in the appendix is the 1 year survival. And we'll come back to that in a moment.

Let's talk about the 5 year survival. You don't need to be an expert statistician, or understand any statistics, to see there are major differences. On all seven cancers, Britain is bottom of the pile. And the differences are really quite staggering.

I won't go through them all, you can look at it, but for 2010-2014, approximately:

  • Oesophagus 23% in Australia, 16% in the UK

  • Stomach 32% in Australia, 20% in the UK

  • Lung 21% Australia, 14% UK

  • Ovarian 43% in Australia, 37% in the UK

Australia tends to come top or very close to the top for all the cancers.

Diagnostic Pathway

So what does it all mean? The 5 year survival is a complex measurement which takes into account the diagnostic pathway, the staging of the primary cancer when it's first diagnosed and treated, and the quality of treatment. Not just the fancy stuff: immunotherapy, CAR-T cell therapy, proton beam therapy, that's irrelevant to the 5 year survival statistic. The majority is access to basic good surgery, good radiotherapy, and good chemotherapy, for those diseases where it's appropriate.

Now, when we go back and look in the appendix, not discussed in the text, is the age standardised 1 year survival. And there, the differences are even bigger, much bigger in fact. So, for 2010-2014 approximately:

  • 52% in Australia versus 46% in the UK for oesophageal cancer

  • 40% in Australia, 26% in the UK for pancreatic cancer

Massive differences. And it's the same across the board: we're way behind.

One Year Survival

Now the 1 year survival is a much more complex statistic ironically than the 5 year survival. It takes into account the diagnostic pathway, the stage of the tumour, and whether during the staging, during the diagnostic pathway, the stage advances and a tumour goes from a curable tumour to an incurable tumour.

And that is the problem. We have been consistently behind since the beginning of the study in 1995. If we're consistently behind on the 1 year statistics, that means we're not going to do well on the 5 year statistics.

So what are the reasons for this? We can only surmise what's going on here: of seven countries [with] roughly the same total spend on health care; everyone has some form of insurance, national scheme, National Health Service scheme. So why the differences?

Also, what's ironic, the Australians and New Zealanders, Canadians, a lot of them were trained here as oncologists, so it can't just be that, it must be that 1 year survival that's the problem.

So is it the patients that are different? Of course, they're different. People tolerate symptoms to differing degrees. Women less so than men. Men tend to be stoic; jobs come in the way, they don't want to bother to go to the doctor. So patients are one factor. And that's remedial with education: the right messages that persistent symptoms that don't go away with simple remedies need attention.

The second is primary care. What's different? We have a gatekeeper in our system. And you either do two things, you make the gatekeeper rigid, and try and let him or her access the system when they can or you open up the beginnings of the diagnostic pathway to that gatekeeper. And that's by far the best thing to do. And it's so surprising, we haven't done it. Why not give GPs access to CT scans, to ultrasound, and to MRI?

Now, some do have, and they do it very well. But some don't have access. They have to make a consultant referral.

Fast Track, Slow Track

The 2 week wait target for urgent referral has been a bit of a red herring. Less than 25% of patients are referred with cancer through the 2 week wait. So what's the other 75% doing?

If you have a fast track, just like at an airport, slow tracks are going to get slower, because people are working out the penalties they're going to have to pay if they slow down the fast track. So that's very different here.

The problem we've got then, is referral to hospital. Now we know there's waiting lists for scanning, there's waiting lists for surgical appointments, most patients with cancer will get through a surgical pathway to get a biopsy of the relevant organ with the relevant specialist. And that takes time, and there just aren't the slots available.

And you predict the obvious rise in cancer incidence as we go through an ageing population. It's not going to work unless we get more capacity in the system. So it's that diagnostic capacity, that capacity to get biopsies, and then the capacity to get started on treatment within a realistic timeframe.

Sixty-two days, which is the NHS England target is simply not fast enough.

In all these other countries, you'd get next day service with your GP. The day after that - the scan. The day after that you see the specialist, and that includes Saturdays.

If you look around Europe: France, Italy, Germany, it's the same pattern. Why can't we do it here? We just haven't got the capacity. There aren't enough doctors, there aren't enough machines, the number of scanners of whatever type, is much lower.

Sure, they're always going to be specialist scanners that you're going to have to reserve for secondary care, PET CT, I'm thinking of. But simple CT scanning and MRI are cheap. A CT, actual cost about £200. An MRI, actual cost about £500 pounds. Ultrasound about £100 pounds, including the interpretation.

We know the costs from the independent sector. So that could be applied here. And you could get a decent funnel for the diagnosis of cancer, which would get rid of this huge discrepancy between different countries.

Conclusion

So the conclusion is: smarten up the front end of diagnosis of cancer; not worry about high cost therapies, that's not the cause of the problem. Interestingly, Cancer Research UK, who funded the study, stress the fact that it's improved in Britain over successive 5 year cohorts since 1995. But it's appalling that it should be like this. NHS England, predictably, just said: 'Well, we've done protons, we've done immunotherapy, CAR-T cell therapies' - the same catechism these people reiterate. The reality is, the system doesn't work. It's letting down British cancer patients and the only way to improve it is to smarten up the front end, not just for the 2 week wait patients but for everybody that has any symptom that could possibly be related to cancer.

This is Karol Sikora. Thank you for listening. Any comments please let me know.

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