Equal access to correct diagnosis, specialist care, and newer more effective therapies is key to better cancer survival and mortality rates, says Dr Gerard Panting
Across the European Union, approximately two million people will be diagnosed in 2008 with one of more than 200 different forms of cancer.1 The four major types (breast, lung, large bowel [colorectal], and prostate) will account for almost 50% of cases.2 Cancer of the bladder, stomach, mouth, kidney, uterus, pancreas, and non-Hodgkins lymphoma and the leukaemias will account for another 26%, with the 190 rarer cancers making up the remaining 25% of cases.3
Even over the past decade, the incidence of many of these cancers has changed, with recorded cases of lung, cervical, stomach, and bladder cancers falling by around 30% in each case, while incidence of liver, uterine, renal, and prostate cancers has risen by about 30% each, and occurrence of breast cancer has increased by 12% (data presented at the European Cancer Conference [ECCO 14] in Barcelona, 2007).
However, some of these figures need to be interpreted with caution. Over the past 30 years, the use of the prostate-specific antigen (PSA) blood test has resulted in a huge increase in the number of patients being diagnosed with prostate cancer. It has been estimated that in the case of well-differentiated prostate cancers, the diagnosis using the PSA test can be made up to 14 years before there would be any form of clinical presentation, and that many patients in this category will not require treatment for prostate cancer, their disease being best managed by an active surveillance programme.4
Nevertheless, there are some genuine trends in the statistics, which reflect success in reducing the risk of cancer, particularly reductions in lung and bladder cancer through stop-smoking programmes and encouraging healthier diets. However, an estimated 1 million people will die from cancer in Europe this year, many of them unnecessarily. Late presentation, delayed diagnosis, a lack of cancer specialists, or no access to modern treatments all play their part and all need addressing if the death toll is to be reduced.
Public awareness of risk factors and risky behaviour, as well as being on the alert for the presence of red flag symptoms and signs is obviously important; unfortunately, sensible health messages tend not to capture the public imagination, perhaps because individuals think it cannot happen to them. However, some methods of getting the message across are more successful than others; for example, when lead characters in soap operas are depicted with cancer or other illnesses, consultations with GPs about these conditions significantly increase. Likewise, news that a celebrity has been diagnosed with cancer always makes the news and increases consultation rates.
Screening programmes are very effective for detecting certain forms of cancer and have had a considerable impact on earlier diagnosis of breast and cervical cancer. In Germany, all patients over 55 years of age have access to a free colonoscopy,5,6 but take up is low.6 This is despite the fact that the relationship between early diagnosis and survival is well known and is something that most people believe intuitively, even where there is no concrete evidence to that effect.
Diagnostic error and delay
Not all patients who present early to their doctor are diagnosed correctly. Over 50% of all clinical negligence claims involve an allegation of some delayed diagnosis.
A review was carried out for the Medical Protection Society of 1000 claims against UK GPs. This identified several common clinical scenarios.7 Altogether a total of 631 of these cases (63%) could be described as resulting from a delay in reaching the correct diagnoses. A delay in diagnosing malignancy was the most common reason for a claim, especially in the case of carcinoma of the breast and carcinoma of the cervix (albeit the data on the incidence of cervical cancer was changing over the course of the study period).7
The most frequent diagnostic error in breast carcinoma occurred when a breast lump was categorised as benign, either on clinical or mammographic grounds, when it later turned out to be malignant. In these claims, the defence frequently fails as taking no further action to determine the true nature of the breast lump can rarely, if ever, be justified.7
In the case of colorectal cancer, the common misdiagnoses are irritable bowel syndrome, colitis, or haemorrhoids. Although these conclusions may have been plausible in the first instance, failure to reassess the patient when the symptom complex changed should have cast doubt on the original diagnosis and resulted in re-assessment.7
Cancer is the leading cause of premature mortality in the UK, with 200,000 new cases diagnosed each year, costing £4.5 billion, mainly in drugs and hospital care (data from ECCO 14, rarer cancers forum). But even after the possibility of malignancy has been recognised, the direction of the patient’s care is still uncertain. The first problem is gaining access to recognised specialists—medical and radiation oncology suffer from poor staff recruitment in the UK. In the case of a rare form of cancer, finding a centre with the right expertise may require some help, in which case the Rarer Cancers Forum (www.rarercancers.org.uk) may be able to suggest appropriate centres and specialists.
The ‘postcode lottery’
There have been enormous advances in therapy in recent years. Newer treatments include:
- imatinib, which has changed the treatment of chronic myeloid leukaemia
- trastuzumab, which has changed the outlook for the 20% of breast cancer patients who are HER2/neu positive
- sunitinib, which has not yet been appraised by NICE, but it holds out fresh hope for patients with gastric intrastromal cancer and renal cell cancer.
However, these new drugs are expensive and not available to everyone. It is the responsibility of the National Institute for Health and Care Excellence (NICE) to appraise new treatments and issue guidance on their use, but until that appraisal is released, use of new treatments is at the discretion of the commissioning PCT. This delay inevitably leads to inconsistency, with patients in different postcode areas facing noticeable differences in cost of care. Those who live at the ‘wrong’ postcode can face the prospect of large bills for their preferred treatment.
Despite a statement from the NHS Cancer Plan in September 2000,8 which said, ‘It is unacceptable that getting access to new and effective drugs has depended on where people live rather than their clinical need’, there are many well publicised examples of how the postcode lottery lives on.
Patients in some parts of Western Europe do not seem to face these problems at present, but as the number of expensive new drugs rises, so the prospect of NICE type appraisals and rationing loom.
As the EUROCARE-4 study showed, the UK lags behind other European countries in 5-year survival rates for colorectal, ovarian, and female breast cancer. It falls short of the standards achieved in the Nordic and Central European countries, being on a par with Ireland and positioned just above the Eastern European states. The study concluded that if all European countries achieved the survival rates of Norway, Sweden and Finland, there would be 12% fewer cancer deaths in Europe.9
As we all live longer and the incidence of many cancers increase with age, the burden of cancer treatment on the NHS is set to increase. Survival rates are not uniform across the EU; committing resources to public health measures to reduce exposure to risk factors, public awareness campaigns and a drive to early medical diagnosis, should all beneficially affect survival rates. Once diagnosed, patients with access to appropriate specialists and the right combination of modern therapies will fare best, and while that is not solely a financial issue, the necessary resources have to be funded.
- Office for National Statistics. Cancer registration statistics England 2005. www.statistics.gov.uk
- Parker C, Muston D, Melia J, Moss S, Dearnaley D. A model of the natural history of screen-detected prostate cancer, and the effect of radical treatment on overall survival. Br J Cancer 2006; 94 (10): 1361–1368.
- Heintze C, Matysiak-Klose D, Kröhn T et al. Diagnostic work-up of rectal bleeding in general practice. Br J Gen Pract 2005; 55 (510): 14–19.
- Panting G. Personal risk management—with case histories. Hong Kong Med J 2003; 9 (3): 227–229.
- Department of Health. The NHS Cancer Plan: a plan for investment, a plan for reform. London; DH, 2000.
- Berrino F, De Angelis R, Sant M et al; EUROCARE Working group. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995–99: results of the EUROCARE-4 study. Lancet Oncology 2007; 8 (9): 773–783.G