British people die unnecessarily, according to World Health Organisation cancer chief Karol Sikora. If the British health system were as good at treating cancer as the best elsewhere in Europe, up to 25,000 lives would be saved each year, 10,000 if we merely hit the average.
Move to France for the best chance of surviving lung cancer, the Eurocare II study implies(1). For those diagnosed with breast and prostate cancer Switzerland offers most hope. Top of the league for treating bowel cancer is the Netherlands, while the Austrians have the highest success rates in stomach cancer. Britain languishes at the bottom of the league alongside countries of much lower socio-economic status such as Poland and Estonia.
The picture isn't uniformly bad. In some British centres, patients receive treatment as good as anywhere in the world and their chances are as high as they can be given in the current state of knowledge. But distressingly for patients, cancer care in this country is patchy, in some areas below standard. It's hard for patients to find out whether they are getting the best care - or the worst.
Why? At a recent Paris conference a simple explanation was proffered: our low spending on powerful tumour-killing drugs was to blame. There is more to it than that. How care is organised, shortage of specialist oncologists, non-implementation of agreed reforms, a conservative medical culture and lack of money are all implicated.
Two decades ago most European countries picked up and ran with a WHO directive which recommended specialist multidisciplinary teams which would focus on specific types of cancer. Britain did not follow suit. Professor Gordon McVie, director of the Cancer Research Campaign, says cancer simply wasn't considered a priority. Doctors took the view that 'cancer was something anyone could have a crack at'.
British cancer patients are traditionally diagnosed and treated by general physicians and surgeons, who may deal with only a handful of cases a year. European patients are fast-tracked to specialists. Cancer charities tell patients that the first question they have to ask, in judging the quality of the care they about to receive, is whether the doctor they are referred to specialises in their kind of cancer. The chances are that he will not.
Yet research has proven over and again the benefits of specialist care in reducing delays in diagnosis, improving the effectiveness of treatment and boosting the odds on survival. A woman with ovarian cancer, for example, has 50 per cent less risk of dying within five years if her removal operation is done by a surgeon who does more than five such procedures a year, rather than by one who does fewer than five.
In 1995, recognising the need for change, the chief medical officers for England and Wales (Sir Kenneth Calman and Dr Deidre Hine) recommended a radical restructuring of cancer care. This was intended to introduce dedicated cancer units in district hospitals for more common cancers and create cancer centres providing high standard comprehensive, specialised and multidisciplinary care for most cancers, including rare ones, in regional centres(2).
Optimists say this sea-change in cancer organisation make Karol Sikora's figures on cancer survival - which cover only the period 1978-89 - well out-of-date. But in reality the Calman/Hine changes are proving agonisingly slow and uneven. While for example Birmingham has forged ahead in developing specialist cancer care, others, such as Oxford, have barely started.
It's a matter of culture: the highly-opinionated professionals running cancer care have been steeped in a thick brew of attitudes and expectations. The Bristol heart babies case demonstrated the absolute autonomy that senior hospital doctors have enjoyed. But the more urgent problem is the shortage of cancer specialists. Britain has fewer oncologists per patient than any equivalent European country.
According to the Joint Council for Clinical Oncology (JCCO), representing radiologists, surgeons and physicians, there are currently the equivalent of 365 whole-time oncologists (85 medical oncologists - specialists in drug therapy - and 280 clinical oncologists, that is specialists in radiotherapy). With 183,000 people newly diagnosed with cancer a year, this means each specialist sees about 500 new patients a year.
Compare this, the JCCO chairman, Dr Mike Cullen, says, to the 75 new patients per specialist in Norway, 100 in Belgium, 140 in Germany, 150 in Austria, 200 in France, Spain and the US, 250 in the Netherlands and 270 in Switzerland. 'These figures speak for themselves. They mean consultants in other countries can devote more time per patient and, very importantly, that they can become more specialised in just one or two types of cancer. It's like snooker, the more you practise the better you get. An oncologist seeing 400 to 500 patients can't do that. This is a key contributing factor to poorer overall survival.'
The reasons for this shortfall include bad planning (it takes five years to train a specialist) and lack of money which means trusts have to wait to convert, say, a post in rheumatology to oncology when the incumbent retires rather than increasing posts overall. We lack a co-ordinated force to drive change through a fragmented NHS.
Money shortages are evident again when it comes to drug treatment - chemotherapy. Drugs such as Taxol which are rationed by health authorities in the United Kingdom, have been proved to offer months, sometimes years of extra life to cancer patients. But Britain spends less than any equivalent Western country on cancer medicines. In the year to March 1998, Britain spent £58m or £1.01 per head of population on anti-cancer drugs while Italy spent £1.24 per head, Germany £2.31, France £2.93 and the US £4.93.
For the sake of comparison, note that in the same 12 months, Britain spent £41 million on acne treatments, £78 million on laxatives, £87 million on AIDS/HIV therapy, £420 million on antibiotics, £660 million on ulcer therapy and £774 million on medication to lower blood pressure. Dr Cullen says 'I don't think we should be spending as much on drugs as the US, but we are clearly behind the times in these treatments. Cancer isn't rare: a quarter of us will die from it and a third of us will get it at some time, yet we are not spending anywhere near as much as we should on it.'
Therapeutic radiotherapy is suffering from a similar lack of investment. An audit last year by the Royal College of Radiologists found access to linear accelerators severely limited - these are the modern machines which have made it possible to direct radiation more accurately to tumours while sparing normal tissues and minimising complications, both of key factors in survival. Fewer than 7 per cent of the population are served by the recommended level of four accelerators per million people(3). In 22 radiology departments, treatment is still delivered with Cobalt-60 machines abandoned in other parts of Western Europe.
The royal college believes a minimum of 48 new accelerators - at a cost of £1 million each - and 44 replacements along with supporting staff are needed to bring Britain level with European standards. 'Almost every department in the country is short of one machine, and at least another of their machines needs replacing,' Dr Norman Howard says on behalf of the radiologists. 'Most of Europe is better off and one always goes to Scandinavia with one's tongue hanging out.'The college has put together one of the few sets of statistics that give an indication of how variable treatment is around the country. It has measured health authorities against the good practice guidelines it put together for the maximum length of time patients should have to wait for radiotherapy. Its report showed that the North West topped the league, with 40 per cent of patients waiting an unacceptably long time for treatment, followed by Trent (37 per cent) and Northern and Yorkshire (36 per cent)(4). Best was the West Midlands, with 7 per cent.
The Department of Health's league tables for the first time last December gave a break-down by health authority of death rates from breast cancer(5). Mortality figures can easily be skewed, critics say. Although they were adjusted for the age of the local population, they did not take into account factors like poverty and smoking. That said, there were marked variations. With 100 as the average, the Isle of Wight came out best with a standardised mortality ratio of 81, followed by Gateshead, South Tyneside and Morecambe Bay on 82. Worst was Solihull on 119 and Walsall on 118.
The Thames Cancer Registry offers a glimpse of the variations in London and the South-east. Breast cancer five-year survival is slightly above the national average at 68.7 per cent. But some addresses are significantly better than others. Five year survival rates for breast cancer in Kensington, Chelsea and Westminster are 73.7 per cent, while in Bexley and Greenwich, they are only 66 per cent. The contrast between the boroughs is more marked when it comes to prostate cancer. In Kensington, a man has a 59.8 per cent chance of living for five years. In Bexley, his chances are only 34 per cent.
What is to be done? The Calman-Hine reforms need to be pushed through faster, and with more money behind them. The Government has recently announced extra sums for lung and breast cancer, but welcome as they are, they are not directed at improving the organisation of cancer care. Professor Sikora would also like to see a national cancer centre from which excellence, best practice and high standards could be disseminated around the country.
Some hope that the National Institute for Clinical Excellence, which starts work next month, will end some of the patchiness around the country. Its experts will make value for money judgments on, say, Taxol in ovarian cancer, which is used almost universally in Europe and the US but is still available here only in areas where the health authority has decided to pay for it.
If things are to get better, attitudes need to change on the part of doctors, for example to new therapies. And patients. Patient support groups such as CancerBACUP say the public should challenge the prevailing culture. If patients and their relatives were more demanding, more assertive the chances of surviving cancer in Britain would stand a chance of approaching the European norm.
Sources: (1) Eurocare II: European Journal of Cancer, Vol 34, No 14, 1998 - from where the graphics also come; (2) Department of Health, report by the expert advisory group to the chief medical officers; (3) Royal College of Radiologists, Equipment, Workload and Staffing for Radiotherapy in the UK 1992-1997; (4) RCR, A National Audit of Waiting Times for Radiotherapy, June 1998; (5) DoH performance indicators, December 1998
