There is a mismatch between great British research and less impressive care
In Baroness Jowell’s final speech to the House of Lords she drew attention to the fact that just 2 per cent of British cancer research funding is spent on brain tumours. She would no doubt be pleased that the government is increasing that amount by £65 million in her name. Her accomplishments on many fronts are themselves a memorial to a life well lived and the extra money will be a capstone on that memorial. It is not, however, a strategy for bearing down on the most stubbornly lethal cancers and driving up survival rates, and a strategy is what the country needs.
There is a stark divergence between the quality of cancer research in Britain, which is genuinely world-class, and the quality of treatment and outcomes, which continue to lag behind those in other developed countries. One of only two top-rated cancer research centres in Europe is in Cambridge. Cancer Research UK works with 13 centres in all and they are among the world’s most prolific publishers of peer-reviewed papers. By contrast a recent study ranked Britain on average 17th out of the 28 EU countries by five-year survival rates for nine common types of cancer.
This underachievement on cancer treatment is not new. Nor is it simply a result of limits on resources available to the NHS. It is largely a result of delays in diagnosis and treatment, and all-too-frequent failures to make new therapies available to those who need them. These failures may be explained by the need to save money, only to cost more in the long run.
With no operational proton beam therapy machines of its own, for example, the health service now pays for patients to have the treatment abroad or privately. Or leaves them to go without. A systematic effort to speed up diagnosis and treatment might not have saved Lady Jowell, but it would save thousands of others.
Part of the challenge is to boost uptake of screening programmes already available on the NHS. There are well-known risks attached to excessive cancer screening, including false positive results and unnecessary but debilitating treatment. These risks have been taken into account in setting current screening guidelines for breast, prostate and cervical cancer. Despite this, the number of women attending recommended breast cancer screenings fell last year to its lowest level in a decade, while 25 per cent of those booked to attend a cervical cancer screening did not.
When diagnosis is late the best treatment in the world may not be enough. Even when it is not, a simple lack of specialist staff and equipment may delay treatment. Of 20 rich countries in a recent King’s Fund study, Britain ranked last by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.
Prevailing in the battle against cancer requires choices. It will be galling for some if the government now allows brain cancer patients to take part in more than one clinical trial at a time, at Lady Jowell’s suggestion, while denying other cancer patients, such as those with leukaemia, access to drugs approved as clinically and cost-effective on the false basis that they are still experimental. Surviving cancer patients deserve a coherent strategy to bring British care up to standards taken for granted elsewhere in the developed world.
Sir, The problems identified in your leading article (May 15) on cancer survival rates in Britain are very real. We are a persistently poor performer relative to countries that we would like to see as our peers. But this is a complicated problem, and simple solutions will not work. Studies suggest that British patients are more reluctant than their counterparts on the Continent to go to their GP with symptoms, and GPs in turn are less likely to refer people for testing.
Although there would be advantages to spending more on cutting-edge drugs, the high cost could come only from other NHS treatments, and the evidence suggests that the overall effect would be relatively small compared with improving other aspects of prevention and care. This is not a problem unique to cancer: the NHS needs to improve outcomes across a wide range of conditions. It is very seductive to focus on particular diseases but experience in other countries suggests that strengthening the overall system will be more effective.
CEO, Nuffield Trust
Sir, Your leading article succinctly describes how the UK lags behind most of Europe in terms of cancer survival rates. But it (perhaps inadvertently) creates the impression that the solution lies in narrowly focusing on improving cancer care.
This is doubtful. The NHS is a laggard in terms of health outcomes in general, not just cancer survival. It is also a laggard in terms of stroke survival, measures of avoidable premature deaths, mortality rates for respiratory diseases, and almost any indicator for which we have comparable data. It would be odd if cancer were the exception.
The health systems that achieve the best outcomes tend to be competitive, pluralistic systems with a mix of municipal, regional, private for-profit and private non-profit providers. Not wholly unlike the one sub-sector in which, as your leading article notes, the UK excels: medical research.
Dr Kristian Niemietz
Institute of Economic Affairs
Sir, Chronic lymphocytic leukaemia (CLL) is one of more than 130 types of blood cancer (reports, May 12, and letter, May 15). A recent report by the all-party parliamentary group on blood cancer found that unlike the treatment of solid tumour cancers, blood cancer is often not treatable using surgery or radiotherapy. This means that it is even more dependent on drugs being available.
People affected by CLL will often be monitored under “watch and wait” until their cancer reaches a certain stage, when they will undergo chemotherapy with all of its associated side-effects. Even then, many people will relapse. Approximately 200 people a year, whose CLL has relapsed, will be denied the drug — ibrutinib — that offers them a lifeline.
It is not acceptable that guidance by the National Institute for Health and Care Excellence (Nice) on the use of ibrutinib is being reinterpreted by NHS England, particularly if this is for anything other than what is in the best interests of people with CLL.
Henry Smith, MP
Chairman, all-party parliamentary group on blood cancer
Sir, Ibrutinib is an innovative treatment and alternative to conventional chemotherapy and can improve quality of life for patients. On January 25, 2017, Nice approved the use of ibrutinib for previously treated CLL patients. We are dismayed that ibrutinib will not be offered to these patients if they have relapsed more than three years after treatment. It is unclear how NHS England could implement such an arbitrary restriction without evidence or guidance from Nice.
NHS Wales and NHS Scotland have made no further restrictions to Nice’s guidance. This is creating a health equity issue. It is a cross-border postcode lottery, unfairly penalising English patients and their families.