I was extremely interested to read a report released today in The Lancet Oncology arguing that the cost of treating cancer in the developed world is "heading towards a crisis". In particular, I was drawn to the report's conclusion that solutions to the problem require vision. I too believe we need to be innovative and radical in the way we deliver cancer services in the UK. We need to continue to improve results and experiences while reducing cost.
But I cannot agree with some of what the report says. The authors' use of the word "futile" in relation to late stage chemotherapy is at best unhelpful. It shows little empathy to suggest that life extending drugs should not be offered. At the end of life, as at all stages of a cancer patient's journey, care options should be mutually decided between a clinician and a patient, a paternalistic attitude of "doctor knows best" is out-dated and has no place in today's NHS. One patient might reasonably forego a late stage treatment so as to be as well as possible for their remaining time. Another real example is the patient who wishes to live longer no matter how ill so they can walk their daughter up the aisle.
And it is not drugs that cost most in palliative care. The money spent on unplanned emergency admissions in the UK is extremely high because community cancer services are often unavailable. For example 24/7 community nursing is not standard across the country. Without it we cannot ensure that cancer patients are able to die at home if they wish to do so. Not only is this better for the patient, families and carers, (with the right support, 73% of people with cancer would prefer to die at home1), but Dr Foster and Healthcare at Home estimate that the NHS could save £160m2 a year if it delivered end of life care at home.
What we really need is a vision for the whole cancer journey. There is more we can do to prevent cancers and detect them earlier such as providing targeted information for all groups in society to further help them understand the signs, symptoms and risk factors associated with cancer. Early diagnosis usually offers the best chance of long term survival.
In the treatment phase, I am encouraged by the Government's plans to create a new Value Based Pricing system for medicines. I am hopeful that with input from patients, health professionals, pharmaceutical experts and other key decision-makers, the Department of Health will be able to develop a new approach that will better reflect the overall benefits to patients and society of new drugs and ensure equity of access to effective treatments.
In terms of aftercare, Macmillan would like to see every cancer patient offered a personalised assessment of their on-going physical, emotional, social, practical, financial and spiritual needs which is written up into a care plan. We know that care plans for people with other long term conditions help patients to self-manage their condition, improve survival rates and quality of life, and reduce avoidable and costly hospital admissions.
So yes - the challenge is stark. But the solution is not to remove effective services, treatments or choices from the people who need them. We need policy-makers, the NHS, patients and the private sector to work in partnership to find more efficient ways of delivering high quality cancer care for the long term. We do not need generalisation. We need personalisation.
1. Statistic taken from Macmillan February 2010 online survey of 1,019 UK adults living with cancer. Seventy-three percent of people with cancer said they would prefer to die at home if all their concerns about dying at home (such as access to pain relief, round the clock care, and support for their family and carers) were addressed.
2. Dr Foster Intelligence & Healthcare at Home (2010) Hospital Care at Home. Estimated cost saving for all end of life care, based on existing service models and assumptions from NHS Birmingham East and North.