1. Fogarty, Mary

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LIVERPOOL-Speaking here at a plenary session at the National Cancer Research Institute Conference, Sir Mike Richards, England's Clinical Director for Cancer and End-of-Life Care, outlined the government's plans for tackling the issue of poor survival rates and unfavorable comparisons with other countries.


Professor Richards titled his presentation "Improving Cancer Survival in England: Driving for the Best," and began by saying there were three important headline metrics in cancer-incidence, survival and mortality. All three are very important from the point of view of forming cancer strategies, but his talk would focus "only on the most important for now-survival rates."


Survival data are measured, he explained, by looking at how likely patients diagnosed with cancer are to survive, say, one or five years: included in this is the impact of early versus late diagnosis and the impact of treatment, both of which are influenced by health service delivery.


But how accurate is this survival data? Professor Richards referred to the paper by Beral and Peto (BMJ 2010 Aug 11;341:c4112. doi: 10.1136/bmj.c4112) that drew attention to the unreliability of survival data in England. The study found that some patients are not being registered at the time of diagnosis, that registries have been over-reliant on death certification, and that the omission of patients with a good prognosis artificially lowered reported survival rates. Also, the inadequate tracing back of patients identified through death certification could result in these patients being inaccurately recorded as short survivors.


However, he said, although registries have historically missed some cancers and wrongly attributed the date of diagnosis for others, the impact on survival estimates appears to be small. And further, the deficiencies detected in cancer registration do not explain the differences in survival rates observed between England and other countries.


A review of cancer registration by the Department of Health and Cancer Research in England has now been set up, advised by independent experts Professors David Jones and Bruce Armstrong.


Professor Richards also discussed the EUROCARE studies from 1991 to 2002, for colorectal and breast cancer, which do show an improvement in the five-year survival period in England but did not lead to a narrowing of the gap between England and most of northern and central Europe (and even southern, as Spain was also ahead).


The headline fact, Prof. Richards said, was that if England were to match the best in Europe for survival, 10,000 lives a year might be saved, including 2,000 in breast cancer, 1,700 in colorectal cancer, and 1,300 in lung cancer.


The latest position on survival comparisons has been shown by the International Cancer Benchmarking Partnership, a study by Professor Michel Coleman, conducted in Australia, Canada, Denmark, Norway, Sweden, and the UK (England, Wales, and northern Ireland). The study looked at breast, colorectal, lung, and ovarian cancers, and consisted of five modules: survival comparisons; public awareness and beliefs about cancer (ABC); primary care; routes to diagnosis and delays; and high resolution studies (treatment, pathology etc.)


In the five-year survival comparisons, Canada, Australia, and Sweden came out way on top, with both England and Denmark at the bottom. And the pattern in the one-year comparisons was pretty much the same, with the UK the worst by far.


Three Main Reasons

Why does England compare so unfavorably? Professor Richards said this was due to three main reasons:


* Late presentation by patients to general practitioners, possibly owing to lack of awareness.


* Late investigation and/or onward referral to the hospital, followed then by


* Suboptimal treatment at the hospital-for example, variable access to lung cancer surgery.



A survey of adult awareness of cancer symptoms (Robb et al, BJC 2009;101, S18-S23), showed that while about 65% were aware that a lump could be a sign of cancer, there was quite low recognition of most other symptoms. As for GPs, they might be slow in referring because perhaps they don't recognize the cancer, or they don't want to worry the patient or they have poor access to diagnostic tools. It may also be they are under pressure to limit referrals.


One shocking statistic was that 14% of patients said they had never been to see a GP before their diagnosis. And more than 17% of patients had seen their GP three to four times before being diagnosed-there was a wide variation in GPs' use of diagnostic measures, as shown by a survey of chest x-ray referrals by GP practices in Leeds.


The National Cancer Intelligence Network (NCIN) "Routes to Diagnosis" study has shown that about 25% of all new cancer patients present as emergencies and that they have particularly low one-year survival, unsurprisingly. They consist of three subgroups: those sent by the GP as an emergency; those never seen by the GP who present to A&E (Accident and Emergency Department); and those seen by GPs but who then present to A&E.


5-Point Action Plan

To help improve the poor survival rates, Professor Richards presented a five-point action plan, consisting of (1) extending screening; (2) raising public awareness; (3) supporting GPs; (4) improving access to diagnostics; and (5) improving treatment.


The second, raising public awareness, has already begun with a pilot in the east and southwest of England giving early warning signs for bowel cancer in ads on TV and radio, and in newspapers and leaflets. The results showed a definite increase in awareness, with increased attendance in primary care with relevant symptoms, and a large increase in referrals during the campaign for colonoscopies. Although it is too early to evaluate the diagnoses, the campaign has clearly been successful enough to roll out across the country early in 2012.


Professor Richards also pointed to a regional pilot awareness initiative for lung cancer earlier this year, which will be followed early in 2012 with local awareness campaigns for esophageal/stomach, kidney/bladder, and breast cancers in people over age 70.


He also noted the thrust towards, as he called it, centralization of complex surgery, which is nearly complete. The aim is also to improve access to and the quality of surgery; radiotherapy; and systemic therapies-i.e., chemotherapy and targeted therapies.


According to the 2010 study by the International Atomic Energy Agency, surgery was the largest contributor to cancer cure at 49%, followed by radiotherapy at 40%, and chemotherapy at 11% (IAEA 2010).


Another awareness campaign, making 2011 the Year of Radiotherapy, he said, was an NHS campaign to raise awareness of the benefits and cost-effectiveness of radiotherapy.


'Improving Outcomes: Strategy for Cancer 2011' Report

Professor Richards reminded the audience of the government's aim as detailed in the "Improving Outcomes: A Strategy for Cancer 2011" report to save an additional 5,000 lives a year from cancer by 2014/5. Since there is always a time lag in measuring survival-i.e., the one-year survival rates for patients diagnosed in 2012 will probably not be known until 2014-proxy measures are needed to get a sense now of the progress: for example, an increase in the percentage of patients presenting with early-stage disease; a decrease in the percentage of patients presenting as emergencies; an increase in the percentage of people receiving potentially curative treatment; and an increase in uptake of diagnostic tests such as colonoscopies.


Regarding colonoscopies, he showed some international comparisons: The rate in Canada is twice as high as in England; in Australia, the rate is almost the same as in England; and even Poland scores higher than the highest rate in England.


Professor Richards said that the main cost in improving survival would come from running new screening programs, such as that for flexible sigmoidoscopy, as well as more publicity campaigns to promote earlier presentation. Then there would be increased use of diagnostic tests by GPs and an increased use of surgery and radiotherapy.


However, he noted, these costs could be recovered to a certain extent by a reduction in other costs such as less chemotherapy, fewer days in bed, and palliative care. And health economic studies have suggested that both screening and earlier diagnosis of symptomatic cancer are highly cost effective, efforts that the government has already allocated funds for in the Cancer Outcomes Strategy.