Achieving a world-class cancer service in the UK

There are few more emotionally loaded words than cancer. Despite the fact that more people in Britain now survive a diagnosis of cancer than die from it, cancer is still a disease that inspires dread. In a recent
poll, some 25 per cent of people said they feared cancer more than terrorism, Alzheimer’s or a heart attack. With one in three people affected by cancer, everyone knows someone who has had it.

During the 1980s and 1990s, Britain had a shameful record, with one of the poorest cancer survival rates in Western Europe. Patients waited long periods for diagnosis and treatment, and there were widely varying standards of care across the country, with services fragmented and poorly resourced.

In 1999, Professor Mike Richards was appointed as the first cancer “tsar”. He developed the first comprehensive cancer strategy the NHS Cancer Plan. At its launch in 2000, Alan Milburn promised it would mean UK cancer survival rates would be among the best in Europe “within ten years”. Key elements of this
ambitious strategy were improvements to cancer screening, the establishment of cancer networks, improvements in supportive and palliative care and reductions in waiting times.

Two-week referral

Rigorous targets were imposed, which ensured that 99 per cent of suspected cancers were seen by a specialist within two weeks of referral. Some in the medical profession claim such targets distort clinical priorities, incentivising the solution of one problem at the expense of another. The public saw them as lifesavers.

Fast forward five years. It was clear that the plan had succeeded in reducing waiting lists and improving access to services and there had been spectacular progress on some fronts; anti-smoking
legislation for instance. But the landscape had changed more rapidly than anyone had predicted. Inequalities had become more glaringly apparent, the importance of prevention more pressing and patient
experience more variable. Poor awareness of symptoms still meant many presented too late for effective treatment. The need for radiotherapy services had been woefully underestimated.

Moreover the Cancer Plan did not take into account the projected doubling over the next 15 years of those aged over 65. Age is the single greatest risk factor for cancer and, by 2020, there will be 300,000 new
cases of cancer each year instead of 230,000. Nor had the impact of obesity in pushing up cancer rates been appreciated. However, for the public, it was access to the new cancer drugs that had become the
rallying cry.

New drugs

Since the 2000 plan was written, many costly, but very effective new cancer drugs had appeared. The fruits of 20 years of research into the molecular basis of cancer, they include, Glivec, Avastin and of course, Herceptin for breast cancer. Herceptin costs £20,000 for a year’s treatment. These are not one-off treatments – they may need to be taken for years at a time.

Access to these drugs is controlled by the National Institute for Health and Clinical Excellence (NICE), which makes decisions about cost effectiveness. NICE has been much criticised for delay. Even when a
favourable decision on a drug is made, not every patient appears to get access to it. UK survival
In May this year, researchers from the Karolinska Institute in Sweden controversially linked poor cancer
survival in the UK to its poor access to new drugs. France, which spends £900m on cancer drugs, has the highest five-year survival rate in Europe at 71 per cent for women and 53 per cent for men, compared
to 53 per cent and 43 per cent respectively in the UK, which spends less than half this at £400m.

But drugs are not the only cancer treatment. They are just one part of a greater whole, which includes surgery and also radiotherapy, a service in which Britain has been noticeably lacking. Nor are European
comparisons that helpful. The muchquoted 2007 Eurocare study of cancer survival, which ranks Britain so poorly, is based on data from 1999. Access to cancer drugs has to be part of a wider debate about what the NHS can afford.

Demand for new strategy

The cancer charities were in full cry, demanding Cancer Plan 2. Cancer Research UK collected 250,000 signatures to a petition, In December 2006, Patricia Hewitt announced that there would be a new Cancer Reform Strategy but warned that there would be no new money. Cancer had been generously funded already. A year later, Alan Johnson announced the Cancer Reform Strategy (CRS), a five-year plan developed, once again, by Mike Richards. There are four new national initiatives, many new targets and, to the surprise of all, some £400m in additional funding.

There are two firsts; a section on living with cancer (unthinkable in 2000) recognises that many people now survive cancer but may be disadvantaged by it, financially, emotionally and medically; and a two-page patient pledge that sets out what patients should expect of cancer services.

Recognising that half of all cancers could be prevented by changes to lifestyle, there is greater emphasis on prevention through further anti-smoking measures, action on obesity, alcohol and the use of sunbeds. There is emphasis on screening using new technologies to prevent breast, bowel, cervical and lung cancer and, to tackle the problem of late presentation, a national awareness and early diagnosis initiative. On drugs, all new cancer drugs (and 50 per cent of new drugs in the pipeline are anti-cancer treatments) are to be referred to NICE and there are promises to ensure that primary care trusts (PCTs) take up agreed drugs.

Darzi Review

The CRS travels with Lord Darzi, whose recent interim review of the NHS marks a shift from the command and
control of old to localised services. Cancer services are to be centralised where necessary to improve outcomes but locally delivered where possible. It is clear that savings are expected in moving cancer care out of hospitals. More rigorous analysis of variations in service quality will be made possible through a National Cancer Intelligence Network and the inequalities in care caused by deprivation, race and gender will be tackled through a National Cancer Inequality Initiative. The strategy contains much of value, but its success will be judged on implementation. There is great reliance on PCTs to action it and, to many, this requires a greater rather than lesser degree of command and control if services are not to fragment once again.

There are some major NHS workforce issues to address to deliver the diagnostics required and many people are questioning the burden that may be placed on carers as more cancer care takes place in the community.
As the leading cause of premature death in those under 75, cancer demands comprehensive action. Optimism that Britain may indeed have a world-class cancer service by 2012 is at an all-time high.