Cancer: The Survivorship and Inequality Challenges

1. Cancer: The Survivorship and Inequality Challenges Professor Sir Mike Richards July 2010 Leeds

2. Overview • The Coalition Government • Cancer: The Key Challenges • Focus on survivorship and inequalities

3. Coalition Government: Priorities • A patient-led NHS: choice and information. ‘No decisions about me without me!’ • Better health outcomes: Focus on outcomes not process targets • Autonomy and accountability: GP Commissioning • Improved Public Health • Reforming long-term care

4. Coalition Government and Cancer • Improving survival rates • Screening and early diagnosis • Improving patient experience • Survivorship • Cancer Drug Fund • Review of the Cancer Reform Strategy • Announced 6th July 2010 • To be completed by “Winter”

5. Cancer: The Key Challenges • Rising incidence • Poor survival • High mortality • Increasing prevalence • Suboptimal quality of life of survivors • Inequalities • Slow diffusion of cost-effective new technologies • Managing overall expenditure in a cold financial climate

6. Rising Incidence • Incidence of cancer is rising by about 1.5% pa. • This is largely due to demographics – i.e. an ageing population – but some specific cancers are rising much more rapidly (e.g. melanoma; oesophageal adenocarcinoma; HPV-related oral cancer and primary liver cancer) • Well over one half of all cancers could be prevented by adopting healthy lifestyles (not smoking; healthy diet/weight; physical activity; alcohol in moderation). • Specific opportunities: • HPV vaccination • Flexible sigmoidoscopy for colorectal cancer

7. Poor Survival • Evidence from EUROCARE, CONCORD and more recent studies (e.g. Norway vs Sweden vs England) show poor survival rates in England across multiple cancers • One year survival is particularly poor – this is generally taken as a marker of late diagnosis • 10,000 avoidable deaths pa in England • This is the rationale for the National Awareness and Early Diagnosis Initiative (NAEDI) • Note: Survival is improving year on year for most cancers

8. High Mortality • Mortality from cancer clearly reflects both incidence and survival rates • Cancer mortality in the UK (all ages) is worse than the EU average (EU15) and the gap has widened slightly over the past 10 years • Breast and lung cancer contribute heavily to the poor mortality observed in the UK • Mortality rates in the UK are falling well in people under 75, but poorly at older age.

9. Increasing Prevalence • There are around 2 million people alive following a diagnosis of cancer in the UK (1.6 million in England) • Prevalence is rising by over 3% pa and is expected to reach 4 million by 2030 • Breast, colorectal and prostate cancers account for the largest numbers of survivors • Relatively little is known about the quality of life of cancer survivors • Cancer services are not well designed to meet the needs of survivors

10. Inequalities and Cancer • There are multiple types of inequality relating to cancer: e.g. Inequalities in incidence, survival, mortality, early/late diagnosis, treatment and care • These inequalities impact differently on different groups e.g. by race, age, gender, disability, religion, sexual orientation and social deprivation. For example: • BME Groups are in general less likely to develop cancer, but there are notable exceptions – e.g. Prostate cancer; oral cancer; liver cancer • Men have a much higher incidence and mortality for almost all of the cancers which affect both sexes • Older people are much less likely to receive major surgery for cancer • Mortality is much higher in socially deprived groups

11. Gender: Excess cancer in men

12. Major resection rates by age

13. Slow diffusion of new technologies • Diagnostics e.g. Late introduction of PET-CT Molecular Diagnostics? • Surgical Innovations e.g. Total Mesorectal Excision Sentinel node biopsy Laparoscopic colorectal surgery • Radiotherapy e.g. IMRT, IGRT • Systemic therapies

14. Managing Overall Expenditure • Expenditure on Cancer in England is currently around £5bn (excluding prediagnosis costs and voluntary sector care) • Real terms increase over the past 4 years has been around 18% (cf 20% for all programme budget areas combined) • Drugs account for around 20% of total expenditure • Inpatient care is the largest single component - and is higher in the UK than elsewhere • We need to focus more on avoidable emergency admissions and shorter lengths of stay (e.g. acute oncology and Enhanced Recovery Programmes) • If we do this we can deliver substantial improvements in outcomes within the current financial envelope

15. Survivorship: Five Shifts • Cultural shift – emphasis on health and well-being of survivors • Assessment and care planning – especially at the end of primary treatment and at transition points • Supported self management e.g. healthy lifestyles, work and finance. Better education on consequences of treatment • Tailored professional support • Linked to risks of recurrence, consequences, psychological well being etc • Patient choice not ‘one size fits all’ • E.g. Nurse led telephone follow up • Better measurement of outcomes • Patient experience • Patient reported outcomes and QOL

16. Survivorship: Actions • Engaging with professionals and commissioners • Does the vision make sense? • Testing and evaluating new models of care • Adults and children/young people • NHS Improvement • Measurement • Patient experience of care survey in progress (cf 2000 and 2004) • Future: Patient reported outcome surveys (PROMs) • Resources and health economics • Patterns of care evaluation (registries and HES etc) • Health economics: New models vs. doing nothing

17. Inequalities: Actions • The biggest risk is that we do nothing because it is too complex • The new focus on awareness and early diagnosis should reduce inequalities (e.g. for older people, BME groups) • MDTs have a major role in reducing inequalities. They need to ensure that all patients receive appropriate treatments. Recording of stage and frailty/comorbidity should be mandatory and should be demanded by commissioners • MDTs should be able to demonstrate equity of care. They should, for example, be able to benchmark their major resection rates against others

18. Summary • Even though we have made a great deal of progress on cancer over the past 10-15 years, multiple challenges lie ahead • We can and we must tackle these even in a cold financial climate • Survivorship and inequalities are still very high priorities