Everyone who reads this will have been touched by cancer - whether personally or through friends and family. It remains a stigmatising illness and it is likely that the constant stream of worrying statistics or stories of missed and delayed diagnosis will amplify existing anxieties. All of the nurses and doctors in my cancer centre detect an erosion of trust, or at least a heightened suspicion that many of our decisions not to treat might be underpinned by some economic sub-plot, rather than a rational response to the patient's needs. We are increasingly asked: "But if I was insured, could you treat me then?" So between which extremes does the truth lie?
It is apparent that our cancer survival figures fall short of those of our neighbours in Europe and the United States; however, closer inspection of the data suggests that they are open to misinterpretation. In this country we are especially skilled at collecting information on the dead, unlike France, say, where it is more difficult to derive death rates which reflect the whole population.
At a recent meeting of experts gathered to discuss the international survival disparity, it did seem as if patients in the UK presented with more advanced cancer - there is a rule of thumb that there is greater potential to cure a cancer the size of a grape rather than a grapefruit - which should lead us to promote strategies for greater health awareness.
There is also a strong inverse relationship between deprivation and cancer survival, with poorer sections of society surviving least well, which we need to understand more fully in order to develop corrective policies. Another factor which is likely to contribute to differential survival is inequity of access to quality cancer care.
It is useful to conceive a sequential pathway of care, starting with referral to hospital by the GP, followed by diagnosis, staging (how far has the cancer spread?) and treatment (which could be surgery, radiotherapy or chemotherapy, singly or in combination). A retrospective audit of waiting times (October, 1997) showed that it took six months for 90% of bowel cancer patients to proceed from the point of GP referral to surgery. This is far too long. There are patients whose cancer will grow, perhaps to the extent that their chance of cure or prolonged survival will be significantly reduced, while waiting for treatment.
Rather than singling out the initial bit of the cancer pathway - the push to get patients referred by GPs seen by hospital consultants within two weeks - I believe that we will see increasing focus on the time to first treatment as a target, which is likely to return greater health gain.
There is a consensus emerging that if we could streamline the system so that the majority of cancer patients were treated within two months from the point of GP referral, lives would be saved. What are the bottlenecks that are preventing us from achieving this goal? When we examined our process of referral from consultant surgeon to medical oncologist, it involved 26 steps and took seven weeks. By rearranging our appointment system we reduced this to 10 days. Hardly rocket science, but it saved time towards getting the patient treated promptly. We are also understaffed: there are 100 consultant chemotherapy experts in the UK compared to 7-8,000 in the US. In some centres, the waiting time for a CT scan (necessary to estimate tumour burden), is in excess of three months. The waiting time for a CT scan in the Mayo clinic is probably closer to three hours.
If there is a war on cancer and a front line, it often feels like wading through the mud of the Somme. Chemotherapy drugs are the tools of my trade and yet I am sometimes denied access to the latest drugs through the arbitrariness of post-code prescribing. If a cancer fails to respond to initial treatment, patients ask what else can be done, and if that involves a novel drug which is not "funded" I have to explain that I have to engage in a round of "begging" letters to health authorities to try to come up with the money (usually in the range of a couple of thousand pounds). It is impossible to imagine the feeling of worthlessness which my patients feel while waiting for funding to come through. The drug might buy them only an extra six months of life, but that could be a baby born or an anniversary realised. They say: "Am I not worth that few thousand pounds? Who would deny me that chance of extra time?"
I feel diminished by the system and often angered by the uncaring responses from the funding bodies.
We are currently writing a national cancer plan, which will take account of workforce planning and provide a kit to relieve bottlenecks in the process of care. The National Institute of Clinical Excellence should improve the flow of worthwhile drugs into the clinic. We also hope to make shorter-term gains through the DoH-funded Cancer Services Collaborative, which will redesign the care pathway to deliver timely treatment, by a multidisciplinary, site-specialised team.
• David Kerr is professor of clinical oncology at the CRC Institute for Cancer Studies, Birmingham university.
