Editorials

Cancer survival in Britain

Is poorer than that of her comparable European neighbours

Collecting cancer statistics is a dry business. Much effort, dedication, and skill have been put into developing an effective network of cancer registries around Europe. Further work to standardise the datasets and provide efficient quality control now makes the comparison of cancer survival between European countries realistic. Britain does not do well in such a comparison.¹

The clearest outcome indicator for the quality of cancer care is the percentage of patients surviving five years after diagnosis. Most patients can be considered cured after this time, having actuarial survival curves exactly parallel to people of similar age and sex without cancer.² The current analysis comes from 33 cancer registries in 17 countries. The figures cover the period 1978-89 and represent the most recent available, to allow for a five year maturation period and for the subsequent collection, analysis, and quality control. Because data come from cancer registries, they do not always cover the entire populations of all the participating countries. Within the United Kingdom data were available for the whole of Scotland and for almost half (46%) the population of England.

The conclusions for Britain are stark. For all the common cancerslung, breast, colorectal, and prostatethe British survival figures are well below the European average. If Britain could achieve the survival rates of the best country in Europe for each cancer over 25 000 lives a year would be saved. Even if it could just reach the European average, nearly 10 000 lives would be saved. For no cancer does Britain hold top position in the league table. Indeed, it is closer in survival figures to Poland, Estonia, and Slovakia than to countries of similar economic prosperity, such as France, Germany, and Sweden. The reasons underlying Britain's poor performance are not clear. Can we discredit these conclusions as some sort of artefact? Apparently not, as confounding factors have been carefully considered.

The first problem could be delay in diagnosis. This seems unlikely to be a major factor as the stage distribution of cancers in Europe is broadly similar. The quality of primary care is high with reasonable access to secondary diagnostic services, so delays in diagnosis are minimal. The second factor could be delay in starting treatment. The cancer patient's journey is rarely streamlined in the United Kingdom. But delays of more than three months from diagnosis to starting definitive therapy are rare and anything less is unlikely to impact on overall survival. The New NHS sets targets for dealing with patients with symptoms that might be due to cancer.³ From next year such patients will have to be seen within two weeks of referral by their general practitioner. This new target is not based on rational evidence and may be tilting at windmills.

The finger has to point at the quality of cancer care and its integration. Surgery, radiotherapy, and chemotherapy are the main modalities. We know that Britain has fewer radiotherapists per head than Poland and fewer medical oncologists than any country in western Europe.⁴ A study by the Association of Cancer Physicians has shown that 40% of cancer patients never see a specialist oncologist.⁵ Tumour site specialisation has been slow to develop, and is still practised effectively only in the largest cancer centres. Britain is a significantly lower user of chemotherapy than its neighbours. Rationing cancer drugs is commonplace and the lottery of some health authorities being willing to fund certain drugs while others are not leads to patients being treated by the same cancer centre for the same cancer in different ways. A wide variation in clinical outcomes for common cancers in different hospitals has been documented. In some cases this may be due to a volume effect, with some clinicians treating a very small number of patients with a particular cancer type and getting poor outcomes.⁶

Change is taking place, but its pace is slow and variable. The Calman-Hine report led to the concept of a series of interlinked cancer centres and local units covering the entire country.⁷ Although heralded as the way forward by both the previous government and the current administration, central resources to implement the plan have been pitifully small. Semantic changes and endless rounds of discussions with healthcare purchasers will not cure cancer. There is no central audit system for the quality of care. Innovative approaches under way in the United States, such as the widespread use of common care guidelines by the National Comprehensive Cancer Network, have minimised disputes between those who buy and provide care. Evidence based guidelines have been produced by the NHS Executive for breast, colorectal, and lung cancer, but their lack of specificity makes them poor tools for the busy clinician. There is no formal dialogue between cancer centres in the UK and no central control. The National Cancer Foruma derivative group of the Calman-Hine teammeets every six months but has no executive role or resources.

Improving Britain's position in Europe's cancer league will require further investment. The exploitation of recent advances in our understanding of molecular biology is likely to revolutionise chemotherapy. Unless there is an effective organisation in place, however, these advances will not be implemented quickly in routine practice. The public fear cancer more than any other illness. Britain's policymakers need to provide the resources to bring cancer treatment up to the same standards as the rest of Europe.

Karol Sikora, vice president, clinical research (oncology). 

Pharmacia and Upjohn, via Robert Koch, 20152 Milan, Italy