Here is a concept as half baked as it comes. On the big C word. I have pondered for a while on this and wrote what follows a while ago. But that did not go down too well with colleagues and I hesitated to share. A concept should be regarded as a work in progress and hence half baked and should be discussed openly, with respect and restraint. I acknowledge Straight Statistics for much of what follows.
Cancer care statistics are frequently used to bunk or debunk a healthcare system. It is a very complex area and consequently allows sufficient room for the tabloids and politicians to argue their points of view.
Guardian had this headline:
This was based on a study by Prof Colin Pritchard in the British Journal of Cancer that showed that the NHS in England and Wales had achieved “the biggest drop in cancer deaths and displayed the most efficient use of resources among 10 leading countries worldwide.”
This is the conclusion based on mortality data.
Cameron and Lansley’s attack NHS was based on the study in The Lancet by Prof Coleman that was based on the numbers who survive cancer rather than who die, i.e., survival. They had concluded that “survival had improved in all the countries studied, but was persistently higher in Australia, Canada and Sweden, and lower in Denmark, England, Northern Ireland and Wales.”
Many have noted that Denmark also employed GPs as gatekeepers and concluded that as NHS restricts patients from referring themselves directly to specialists it will never be able to match the performance of other systems. This is an inference not directly supported by the data, which needs cautious interpretations.
Consider this graph is from the Lancet paper:
This would suggest that while mortality from lung cancer in falling amongst men, it is worsening in women. And this is not only in UK, but worldwide. Surely we should getting all the feminist groups and women together to protest against sex discrimination!
Indeed, that is not true. Lung cancer mortality in women is rising as the incidence rate in men has fallen rapidly while it is increasing in women. This is because more men than women have stopped smoking. The survival rates remain the same for both sexes around 10% throughout the 25-year period from 1980-2005.
According to Dr Laura Woods and Prof Michel Coleman from the London School of Hygiene and Tropical Medicine, same team whose paper was used to trash NHS, there are 3 main measures in cancer epidemiology:
Screening, early detection, increased awareness are among the factors contributing to increased incidence. Intuitively, catching it early should result in better care, better outcomes. One big disappointment has been that evidence is hazy for most cancer. A lot of people find this upsetting, but that is what the data is suggesting. This “war on cancer” may have resulted in overdiagnosis and overtreatment and there has been a flood of articles on this in BMJ and elsewhere recently. A recent book by GP Dr Margaret McCartney “The Patient Paradox: Why sexed-up medicine is bad for your health” a very readable primer on this topic of great importance.
Indeed, in their BMJ paper, BMJ 2011; 342 doi: 10.1136/bmj.d3399 (Published 9 June 2011)
Coleman et al had concluded:
“The question has long since ceased to be whether such unacceptable differences in cancer survival exist. The question is what the underlying mechanisms are and what can be done to improve the outcomes for patients with cancer in the UK.”
This is clearly a very complex area. Some say science is better at allowing better questions to be asked than providing answers. Some of the questions that arise in my mind are:
- what factors influence cancer care in UK?
- what can I as a GP do to improve care?
- what is the role of deprivation?
- what can be done to reduce the risks of getting cancer?
In The Emperor of All Maladies Siddhartha Mukherjeewrites “Even…‘most fundamental measure of clinical outcome’ – death – was far from fundamental. Death (or at least the social meaning of death) could be counted or recounted with other gauges, often resulting in vastly different conclusions. The appraisal of diseases depends…on our self-appraisal. Society and illness often encounter each other in parallel mirrors, each holding up a Rorschach test for the other.”
Patients presenting with symptoms and red flags need appropriate work up. But, we should still be open to what we might be missing out in the pursuit of diagnosing cancer earlier and earlier. It might be a lot more than what we suspect.