This is a question that greatly exercises those of us involved in caring for cancer patients, as well as our political masters. The public are also, unsurprisingly, very engaged. Not many healthcare issues attract such global support.
Undoubtedly we do need to improve cancer outcomes in the UK. Benchmarking against those countries with blanket population coverage in their registry data show the UK lagging behind . We have improved survival in many cancers in the past 10 years but there is still a gap. Comparisons across other metrics reveal the UK lagging behind in percentage GDP spent on healthcare, which is likely to explain, at least in part, differences in outcomes.
So then the simple answer becomes to spend more money. But where would one, in the modern vernacular, spend to get the best bang for your buck? Prevention is better than cure but risk reduction is a difficult business that should begin, like the NHS, in the cradle. Better public health feeds through into reduced cancer risk. Those with healthy diets will reduce their risk of developing colorectal and endometrial cancers. Smoking cessation reduces the risk of lung, esophageal, and head and neck malignancies. There is however no such thing as a free lunch. Improved population health improves longevity, which in turn increases the burden of the most prevalent degenerative disease – cancer. The majority of the expected rise in the incidence of cancers in the next few years will be amongst the elderly . So better public health helps, but does not eliminate the problem.
Improved outcomes are, like everything else in healthcare, the result of many interlinked dependencies and can only be tackled by a multifactorial approach. Unfortunately, the current NHS has fragmented patient pathways such that responsibility for these interdependencies often sits with different people, who sometimes have competing budgets. Cancer survival is better in those diagnosed with earlier stages of disease. So, if we improve earlier diagnosis rates the mission will be accomplished. The water becomes muddied when the diagnosis of cancer at an earlier stage (when patients may be asymptomatic) is bundled up with reducing time to achieve diagnosis and treatment in symptomatic cancers. The latter forms the basis of the cancer waiting times targets in England. One could argue that as only a tiny proportion of breast cancer patients present with breast pain, that the resources involved in 2 week waits are not the most evidence based.
Earlier diagnosis for both symptomatic and asymptomatic cancers carries with it the absolute implication of increased investigations. In symptomatic patients, this will be the result of a lowering of the threshold of worrying symptoms referred into secondary care. For asymptomatic patients, screening in some form is the likely mechanism of referral. Most services have adapted to support the current level of referrals, though these are stretched during periodic national ‘early awareness’ campaigns. More referrals mean more diagnostic investigations. This has a significant impact for a number of specialties, of which radiology is one of the most pressed at present.
The past decade has seen an annual increase in the UK of 10–12% in cross-sectional imaging requests . Despite this, the UK still performs fewer scans than most of Europe. This partly results from a technology gap (the average age of CT equipment in the UK has decreased over the past 3 years, but remains the oldest in Europe) , but mainly from a workforce approaching crisis point. The radiology workforce per million of the UK population compares unfavorably with the rest of Europe, with current figures equivalent to those countries not known for good cancer outcomes .
Advances in technology now yield significantly more information per radiological examination, both in terms of volume (164 slices anyone?) but also in terms of functionality (multiparametric imaging doing what it says on the tin). These investigations are becoming increasingly more crucial in the accurate staging of cancer patients, informing and shaping treatment decisions. Interventional radiology underpins a significant proportion of histopathological diagnosis. There are simply too few radiologists in the UK to support a significant safe expansion of diagnostic work. Outsourcing of reporting is happening, often using the current consultant workforce, but this is not a sustainable long-term solution.
More worrying for our radiology colleagues, most strategies to improve diagnosis at an earlier stage of disease will involve radiology screening of some sort. The breast screening programme is well established in the UK, with a recent expansion in the age cohort being actively screened. However, consultant radiology posts with an interest in breast screening are difficult to recruit to. Although only 11% of substantive posts are currently unfilled, 47% of vacant posts have been unfilled for more than 12 months. Add into this an expected 21% of the current established workforce expected to retire by 2018 and the future does not look bright .
So assuming we have diagnosed malignancy at an earlier stage, what are the barriers to delivering appropriate therapy to ensure each patient achieves an optimal outcome? Radiotherapy contributes to the cure of 40% of malignancies (surgery 50% and chemotherapy the remaining 10%) yet it only attracts 5% of the cancer treatment budget. As previously stated, the majority of new cancers occur in the elderly. Although fitter than ever before, they often have comorbidities and if not, their physiological functioning carries a higher risk when delivering curative therapies, especially surgery. Radiotherapy is and will remain the curative treatment of choice for a large number of increasingly elderly patients. Access to radiotherapy, especially advanced radiotherapy techniques, remains lower in the UK than Europe, with only two thirds of those thought to benefit receiving any radiotherapy treatment .
As with imaging services, the gap lies both in technology and in workforce. Delivery of advanced radiotherapy techniques such as intensity-modulated and stereotactic ablative radiotherapy improve survival and reduce morbidity. However, they can only be delivered by modern linear accelerators. In 2012, 10% of linear accelerators in England were beyond the 10 year replacement age. Old machines, in addition to being much more unreliable, cannot deliver modern advanced treatment techniques safely. Without a nationally coordinated rolling programme of machine replacement, the UK will fall further behind comparable countries in the delivery of advanced curative techniques .
Benchmarking against the European workforce shows that the UK clinical oncology workforce per million of the population is not far from average. However, the UK clinical oncology workforce, in addition to delivering all radiotherapy nationally, is also delivering 50% of systemic anticancer therapies in addition, which is not the case in Europe. The clinical oncology workforce shortfall may be difficult to gauge accurately, but current best estimates reveal a gap of 250–320 whole time equivalent consultants by 2018 . Advanced radiotherapy techniques take more clinician time, in terms of planning and supervision, than conventional treatment. Recent achievements in expanding access to intensity-modulated radiotherapy UK wide have often been accomplished with no workforce expansion, but via the erosion of Supporting Professional Activities time. The radiotherapy innovation fund demonstrated that the clinical oncology workforce can rapidly implement changes in service to deliver modern advanced radiotherapy techniques when support is available. The Cancer Drugs Fund in England supports those drugs that have failed the NICE cost–effectiveness hurdle. This resource was made available to improve outcomes for UK patients. Despite the clinical effectiveness of radiotherapy, there is no equivalent for an intervention that is four times more effective.
The UK does need to improve its cancer outcomes and there are undoubted barriers to achieving this aim. Workforce expansion is key, with modern machine replacement programmes not far behind. The national Cancer Taskforce, which will report in the autumn, will hopefully provide recognition of those barriers, ideally with new resource to overcome them . However, the Cancer Taskforce is an English body and has no impact in the devolved nations. That being said, we shall await their final report with interest.
1. De Angelis R.; Sant M.; Coleman M.P. et al on behalf of the EUROCARE-5 Working Group. Cancer survival in Europe 1999-2007 by country and age: resultsof EUROCARE-5-a population-based study Lancet Oncology, 15:23-34 (2014).
2. Cancer Research UK http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age
3. NHS England, NHS Imaging and diagnostic activity 2013 / 2014 release http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/imaging-and-radiodiagnostics-annual-data/
4. Clinical Imaging Board, CIB Equipment survey http://www.sor.org/news/new-survey-finds-need-ct-replacement-plans
5. The Royal College of Radiologists https://www.rcr.ac.uk/media-centre?page=3
6. The Royal College of Radiologists https://www.rcr.ac.uk/clinical-radiology/being-consultant/publications
7. Livens Y, Dunscombe P, Defourny N et al. HERO (Health Economics in Radiation Oncology): A Pan-European Project on Radiotherapy Resources and Needs. Clinical Oncology 27(2), 115–124 (2015).
8. Department of Health, Radiotherapy services in England 2012. London: Department of Health, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213151/Radiotherapy-Services-in-England-2012.pdf
9. The Royal College of Radiologists, Clinical oncology response to HEE Workforce planning 2014/15 Call for evidence https://www.rcr.ac.uk/college/policy/past-consultation-responses
10. The Royal College of Radiologists, Cancer Taskforce: submission of the Royal College of Radiologists 2015 https://www.rcr.ac.uk/media-centre?page=1
No financial conflicts of interest.
Jeanette graduated from Glasgow University in 1991. In 1993, she relocated to Eastbourne to complete her training in general (internal) medicine. Having secured a training post in clinical oncology at the Beatson Oncology Centre in 1994, she recrossed the border. Jeanette completed her training at Mount Vernon Cancer Centre (after two years spent in laboratory research at the Paterson Institute for Cancer Research), taking up a consultant post there in 2002. Her main clinical interest is in the multimodality management of thoracic malignancies with additional minor interest in the radiotherapy of lymphoma and gynecological brachytherapy.
Commitment to providing excellent training to all staff groups has led to Jeanette taking on a number of roles including Clinical Tutor; RCR tutor; TPD, North West Thames and STC chair for Clinical Oncology. She was appointed inaugural and unique Head of School of Clinical Oncology for London / KSS deaneries in 2008. She remains an enthusiastic foundation educational supervisor to three F1 doctors each year and has recently taken on the role of joint module leader (lung cancer) for the MSc organized via the Institute of Cancer Research. Jeanette has held a number of managerial roles including chair of the Mount Vernon Cancer Network lung TSSG and was the Clinical Director for Mount Vernon Cancer Centre for 5 years.
Jeanette’s more formal involvement with the College started in 2010 when she became a member of the national recruitment screening group. She was appointed as a revalidation advisor in 2012. Since September 2013 she has held the office of Medical Director Professional Practice, Clinical Oncology.
Beyond medicine, Jeanette relaxes by taking part in Pilates. She enjoys cooking and baking (the products of which she is more than happy to share) and avidly reads as much as she can fit onto her kindle.