David Cameron, Andrew Lansley and others have frequently invoked our relatively poor cancer outcomes as part of their justification for health reform. But just how bad are we at treating cancer, what are we getting wrong, and will the reforms help?
Our cancer survival rates are improving significantly for most cancers, and for cancer overall. The combined five-year survival rate for all cancers is now over 50 per cent. And while unfortunately some cancers – such as lung and pancreatic cancers – have seen little or no improvement, others – including breast and colorectal cancer – have seen great improvement over time.
In terms of international comparisons, a recent paper in the Lancet provides the best quality and, importantly, most up-to-date comparison of cancer survival rates between eight countries. It shows that survival is best in Canada, Australia and Sweden, intermediate in Norway, and worse in Denmark and the UK nations, with differences particularly significant in older people. And, while our rates are improving, so are everyone else's – and at similar rates; we are not managing to close the gap. In lung cancer, the gap between us and the better performing nations has widened slightly. The gap does seem to be closing in breast cancer, but this is thought to be because the highest performing countries are reaching the 'ceiling' of realistically achievable survival levels.
The evidence as to why we are performing relatively poorly is complex, but points to late diagnosis as one of several factors. So, if the government wants to improve cancer survival rates one of the most important questions is: will it manage to diagnose more cancers earlier? The importance of early diagnosis was recognised in the recently published outcomes strategy for cancer. This included additional funding – not a phrase you expect to hear at the moment – to increase GPs' rapid access to diagnostics, and retained the previous government's cancer waiting time standards, arguing that they are clinically justified and so exempt from the cull of top-down process targets. Both of these decisions could help early diagnosis.
But will the broader health reforms improve early cancer diagnosis? There are arguments on both sides, not least because at this stage in the process it is obviously hard to predict how the reforms will progress through parliament and then play out in practice. On the 'yes' side, the right indicators in the outcomes framework will focus the system more on early diagnosis (such as one-year survival rates and stage at diagnosis), and perhaps transparency on these outcomes will drive providers to improve. On the 'no' side, with financial pressures on the service, there is the risk of a crude response that includes blanket efforts to reduce referrals from primary care, something that we know is already happening from previous research on referral management. The commissioning of cancer care is hugely complex, so with the loss of primary care trusts and the potential loss of associated expertise in cancer networks there's a risk that commissioning for cancer will get worse, not better – at least in the short term. Neither of these risks are adequately addressed in the outcomes strategy.