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Treating colorectal cancer: chances in front of goal

BMJ 2000; 320 doi: (Published 01 April 2000) Cite this as: BMJ 2000;320:949
  1. Nigel A Scott, consultant colorectal surgeon
  1. Salford

    The provision and more importantly the politics of colorectal cancer treatment often feature in the press. The UK prime minister's cancer summit to cut cancer deaths by one fifth over the next decade concluded that the 150 specialist oncologists in Britain should be doubled. A spokesman for a cancer charity said, “we could switch spending on acne and constipation to fighting cancer.” We can't get into the cancer premier league without more money, more investment—the chant from the terraces—let's buy a new striker, let's buy 150 specialist oncologists.

    Before buying or selecting a new striker, a football manager needs a measure of effectiveness. How often is a chance in front of goal converted into a score by the proposed signing? A striker that puts away one chance in three is worthy of investment. If he needs 20 chances in front of goal to score then I think not. Andy Cole fell victim to this assessment in Glen Hoddle's England team—Cole being judged as wasting too many goal scoring opportunities.

    The politics of cancer and sport are the same

    Sitting in a clinic that deals with the symptomatic presentation of colorectal cancer it is tempting to explore the Cole-Hoddle model for the treatments offered to patients with colorectal cancer. If the health service is presented with 100 chances in front of goal (elective new patients with colorectal cancer) how many goals (cures at five years) does it score with its three strikers—surgery for the primary tumour, radiotherapy for rectal cancer, and adjuvant chemotherapy for Dukes's C cancers.

    Thus of the 100 chances in front of goal 40 cures hit the back of the net

    Kick off—and the first 35 of the 100 chances in front of goal are fluffed—35 of the new patients present with advanced systemic metastatic disease. They cannot be cured, no goals scored. After curative surgery the remaining 65 chances all seem goal bound. But 25 of these are blocked, hit the woodwork, or are tipped over the bar as 25 patients develop recurrent or metastatic disease. Thus of the 100 chances in front of goal 40 cures hit the back of the net.

    Post-match analysis looks at the goals scored by each of our three strikers. Adjuvant radiotherapy in the 30 patients with rectal cancer presenting without metastatic disease avoids local recurrence in 10%—radiotherapy scores three goals. Adjuvant chemotherapy in the 30 Dukes's C patients presenting without metastatic disease delivers cure in 5%—1.5 goals. So how do our NHS strikers in colorectal cancer stack up? A hundred chances in front of goal—adjuvant radiotherapy, three goals, adjuvant chemotherapy, 1.5 goals, and primary surgery, 36 goals.

    Surgical excision of localised disease at presentation is the only genuinely effective striker in colorectal cancer, putting one chance in three in the back of the net. A better supply of early chances up front from midfield and the wingbacks would increase the strike rate and goals scored. Screening the asymptomatic population is the only way to achieve this, but screening carries the risk of a massive own goal—the health service impact of the worried well.

    Cancer laboratories and oncologists talk a good game. Investment in these areas may at some unspecified time deliver a better strike rate, but who knows. As someone on the pitch now, dealing with hundreds of new and follow up patients with colorectal cancer, I need practical political leadership of cancer medicine. This leadership has to be divorced from the pressures and self interests of cancer laboratories and oncology pressure groups. The political promise that investment in cancer laboratory research and oncologists will increase cures in colorectal cancer by one fifth in the next 10 years falsely raises public expectations. You do not buy the unproven striker just because his agent has a good video.

    The politics of sport and cancer are the same—satisfaction among the paying public is equal to results divided by expectation. If you tell the fans that you are investing in a terrific new striker (expectation massive—20 goals in 100 chances) and the striker's actual impact is only 4.5 goals in 100 chances then football manager or politician you are in trouble because the fans' satisfaction quotient will be “sick as a parrot.”

    They think it's all over—it is now.


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